Staging of Follicular Lymphoma (FL)

In addition to identifying the subtype of FL, an estimation of patient prognosis requires the determination of the disease stage.1 The Lugano classification is the current staging system used for patients with FL. It is a modification of the Ann Arbor staging system originally developed in 1971.1,2 The Lugano classification is based on nodal involvement and incorporates the use of PET imaging.1

FL Stages 1-41


Patients with earlier-stage disease at diagnosis (eg, Stage l lymphoma) have a higher likelihood of survival than those with a more advanced stage at diagnosis.3

FL Stage* Description1
Stage I FL involves:

  • 1 lymph node or a group of adjacent nodes

Extranodal status: single extranodal lesions without nodal involvement

Stage II FL involves:

  • 2 or more nodal groups on the same side of the diaphragm

Extranodal status: stage I or II by nodal extent with limited contiguous extranodal involvement

Stage II bulky FL involves:

  • Stage II as above with “bulky” disease
Stage III FL involves:

  • Nodes on both sides of the diaphragm
  • Nodes above the diaphragm with spleen involvement
Stage IV FL is in its most advanced stage, with:

  • Additional non-contiguous extranodal involvement

*The suffix "E" is used if limited extranodal extension is documented; more extensive extranodal disease is designated stage IV. The suffix "X" previously was used in the Ann Arbor staging system to designate the presence of bulky disease. Instead of using the designation "X," the Lugano classification requires a recording of the largest tumor diameter. For treatment purposes, criteria for bulky disease vary by histology and no cutoff has been validated. However, cutoffs of 6 cm and 6 cm to 10 cm have been used for follicular lymphoma and diffuse large B-cell lymphoma.1

References: 1. Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano Classification. J Clin Oncol. 2014; 32(27):3059-3068. 2. Zucca E, Pavanello F; Oncology Institute of Southern Switzerland (IOSI). The Lugano Classification recommendations for Hodgkin’s and non-Hodgkin’s lymphoma: staging, response assessment and follow-up [e-learning presentation]. ESMO website. http://oncologypro.esmo.org/Education-Library/ESMO-E-Learning-and-V-Learning/The-Lugano-Classification-recommendations-for-Hodgkin-s-and-non-Hodgkin-s-lymphoma-Staging-Response-Assessment-and-Follow-Up. Updated May 4, 2016. Accessed September 20, 2018. 3. National Institutes of Health. Cancer stat facts: non-Hodgkin lymphoma. https://seer.cancer. gov/statfacts/ html/nhl.html. Accessed January 5, 2019.