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Childhood Non-Hodgkin Lymphoma Treatment (Professional) (cont.)

Stage Information for Childhood NHL

The most widely used staging scheme for childhood non-Hodgkin lymphoma (NHL) is that of the St. Jude Children's Research Hospital (Murphy Staging).[1]

Stage I Childhood NHL

In stage I childhood NHL, a single tumor or nodal area is involved, excluding the abdomen and mediastinum.

Stage II Childhood NHL

In stage II childhood NHL, disease extent is limited to a single tumor with regional node involvement, two or more tumors or nodal areas involved on one side of the diaphragm, or a primary gastrointestinal tract tumor (completely resected) with or without regional node involvement.

Stage III Childhood NHL

In stage III childhood NHL, tumors or involved lymph node areas occur on both sides of the diaphragm. Stage III NHL also includes any primary intrathoracic (mediastinal, pleural, or thymic) disease, extensive primary intra-abdominal disease, or any paraspinal or epidural tumors.

Stage IV Childhood NHL

In stage IV childhood NHL, tumors involve bone marrow and/or central nervous system (CNS), regardless of other sites of involvement.

Bone marrow involvement has been defined as 5% malignant cells in an otherwise normal bone marrow with normal peripheral blood counts and smears. Patients with lymphoblastic lymphoma with more than 25% malignant cells in the bone marrow are usually considered to have leukemia and may be appropriately treated on leukemia clinical trials.

CNS disease in lymphoblastic lymphoma is defined by criteria similar to that used for acute lymphocytic leukemia (i.e., white blood cell count of at least 5/ÁL and malignant cells in the cerebrospinal fluid [CSF]). For any other NHL, the definition of CNS disease is any malignant cell present in the CSF regardless of cell count. The Berlin-Frankfurt-Munster (BFM) group analyzed the prevalence of CNS involvement in NHL in over 2,500 patients.[2] Overall, CNS involvement was diagnosed in 6% of patients. Involvement by cell type was as follows:

  • Burkitt lymphoma/leukemia: 8.8%
  • Precursor B-cell lymphoblastic lymphoma: 5.4%
  • T-cell lymphoblastic lymphoma: 3.7%
  • Anaplastic large cell lymphoma: 3.3%
  • Diffuse large B-cell lymphoma: 2.6%
  • Primary mediastinal large B-cell lymphoma: 0%

Mature B-cell NHL (Burkitt lymphoma and diffuse large B-cell lymphoma) patients have been treated based on features of the disease, other than stage.

Table 3. FAB/LMB and BFM Staging Schemas for B-cell NHL

StratumDisease Manifestation
ALL = acute lymphoblastic leukemia; BFM = Berlin-Frankfurt-Munster; CNS= central nervous system; FAB = French-American-British; LDH = lactate dehydrogenase; NHL = non-Hodgkin lymphoma.
FAB/LMB International Study[3,4,5]ACompletely resected stage I and abdominal stage II
BMultiple extra-abdominal sites
Nonresected stage I and II, III, IV (marrow <25% blasts, no CNS disease)
CMature B-cell ALL (>25% blasts in marrow) and/or CNS disease
BFM Group[6]R1Completely resected stage I and abdominal stage II
R2Nonresected stage I/II and stage III with LDH <500 IU/L
R3Stage III with LDH 500–999 IU/L
Stage IV, B-ALL (>25% blasts), no CNS disease, and LDH <1,000 IU/L
R4Stage III, IV, B-cell ALL with LDH >1,000 IU/L
Any CNS disease


  1. Murphy SB, Fairclough DL, Hutchison RE, et al.: Non-Hodgkin's lymphomas of childhood: an analysis of the histology, staging, and response to treatment of 338 cases at a single institution. J Clin Oncol 7 (2): 186-93, 1989.
  2. Salzburg J, Burkhardt B, Zimmermann M, et al.: Prevalence, clinical pattern, and outcome of CNS involvement in childhood and adolescent non-Hodgkin's lymphoma differ by non-Hodgkin's lymphoma subtype: a Berlin-Frankfurt-Munster Group Report. J Clin Oncol 25 (25): 3915-22, 2007.
  3. Patte C, Auperin A, Gerrard M, et al.: Results of the randomized international FAB/LMB96 trial for intermediate risk B-cell non-Hodgkin lymphoma in children and adolescents: it is possible to reduce treatment for the early responding patients. Blood 109 (7): 2773-80, 2007.
  4. Cairo MS, Gerrard M, Sposto R, et al.: Results of a randomized international study of high-risk central nervous system B non-Hodgkin lymphoma and B acute lymphoblastic leukemia in children and adolescents. Blood 109 (7): 2736-43, 2007.
  5. Gerrard M, Cairo MS, Weston C, et al.: Excellent survival following two courses of COPAD chemotherapy in children and adolescents with resected localized B-cell non-Hodgkin's lymphoma: results of the FAB/LMB 96 international study. Br J Haematol 141 (6): 840-7, 2008.
  6. Reiter A, Schrappe M, Tiemann M, et al.: Improved treatment results in childhood B-cell neoplasms with tailored intensification of therapy: A report of the Berlin-Frankfurt-Münster Group Trial NHL-BFM 90. Blood 94 (10): 3294-306, 1999.
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