Lugano classification

The Lugano staging system is a lymphoma staging classification system resulting from recommended changes to the Cotswolds-modified Ann Arbor classification following meetings in 2011.

The goal was to simplify and standardize the response assessment enabling better understanding and communication among professionals. The Lugano staging system has an excellent inter-observer agreement in staging (k=0.90, percent agreement=94.9%) and treatment response assessment (k=0.91, percent agreement=95.8%) 3.



  • stage I: one node or group of adjacent nodes
  • stage II: two or more nodal groups, same side of diaphragm


  • stage III: nodes on both sides of the diaphragm; nodes above the diaphragm with spleen involvement
    • stage III(1): involvement of the spleen or splenic, hilar, celiac, or portal nodes
    • stage III(2):  involvement of the para-aortic, iliac, inguinal, or mesenteric nodes
  • stage IV: diffuse or disseminated involvement of one or more extranodal organs or tissue beyond that designated E, with or without associated lymph node involvement
  1. all cases to indicate the absence (A) or presence (B) of systemic symptoms (fever/night sweats/unexplained weight loss)
  2. designation of (E) refers to extranodal contiguous extension that can still be encompassed within a irradiation field appropriate for nodal disease of the same anatomic extent (if more extensive than that, label as IV)
  3. designation of (bulky) if a single nodal mass >10 cm or >1/3 of transthoracic diameter
Changes to the Cotswolds-modified Ann Arbour classification
  • anatomic description of disease extent: previously Ann Arbor stage I or II are now categorized as having “limited” disease and previously Ann Arbor stage III or IV are now categorized as having “advanced” disease
  • tumor bulk: a single nodal mass, in contrast to multiple smaller nodes, of 10 cm or greater than a third of the transthoracic diameter at any level of thoracic vertebrae as determined by CT is retained as the definition of bulky disease for Hodgkin lymphoma. For follicular non-Hodgkin lymphoma we should consider 6 cm and for large B-cell non-Hodgkin lymphoma from 6 to 10 cm
  • update of Cotswolds modifications: as the presence of B symptoms affects only Hodgkin lymphoma treatment, the modifier “B” should be used in patients with this lymphoma type. The associated “X” modifier is no longer applied in Hodgkin or non-Hodgkin lymphoma, instead, the longest diameter of a mass is simply recorded for staging purposes

The Lugano classification also has a system for response to treatment and lesion measurement guidelines outline below:

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Cases and figures

  • Figure 1: Lymph node regions
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