Circle) None Fever Night Sweats Wt Loss Laboratory Studies Hgb WBC Plate

LYMPHOMA STAGING DIAGRAM Instructions: boxed items must be completed History B Sx (Circle) none fever night sweats wt loss Laboratory studies Hgb WBC Plate ECOG performance status g/L x109/L x109/L LDH (patient/upper normal) / CERVICAL PRE-AURICULAR HIV antibody pos neg WALDEYER'S RING UPPER CERVICAL MEDIAN OR LOWER CERVICAL HBsAg pos neg POSTERIOR CERVICAL SUPRACLAVICULAR INFRACLAVICULAR MEDIASTINAL HBcoreAb pos neg PARATRACHEAL MEDIASTINAL AXILLARY Hep C Ab pos neg AXILLARY HILAR RETROCRURAL SPE monoclonal protein pos neg type____________ SPLEEN PARA AORTIC PARA AORTIC MESENTERIC For Hodgkin lymphoma only CELIAC COMMON ILIAC SPLENIC (HEPATIC) HILAR EXTERNAL ILIAC PORTAL Albumin g/L INGUINAL MESENTERIC Lymphs x 109/L INGUINAL FEMORAL OTHER EPITROCHLEAR POPLITEAL Treatment Largest tumor diameter (nearest whole cm) Treatment plan Initial biopsy site Date (d/m/y) / / Histologic diagnosis Doctor in Charge 1 _________________________________________ 2 Reason for referral Bone marrow pos neg not done New Recurrent Follow-up Completed by _______________ Date____________ List all other extranodal sites here 1 2 Complete if diagnosis or stage subsequently changed 3 4 Diagnosis/Stage amended to _________________________ 5 Reason__________________________________________ 6 By_______________________ Date______________ Stage (circle) 0 1 2 3 4 A B E This staging diagram can be found on NOTIFY PATIENT INFORMATION IF STAGE OR H:lym_docs\staging\lymphoma.doc DIAGNOSIS IS AMENDED Form #TH-41 Revised 26 March 2007 LYMPHOMA AND CHRONIC LYMPHOCYTIC LEUKEMIA STAGING SYSTEMS BCCA LYMPHOMA, HODGKIN AND CHRONIC LYMPHOCYTIC LEUKEMIA NON-HODGKIN 1982 STAGE FINDINGS STAGE INVOLVEMENT 0 Lymphocyte count > 5.0 x 109 /L 1 Single lymph node region (1) or one Bone marrow contains 40% extralymphatic site (1E). lymphocytes 2 Two or more lymph node regions, 1 Stage 0 + lymphadenopathy same side of the diaphragm (2) or 2 Stage 0 + hepatomegaly or local extra lymphatic extension plus splenomegaly one or more lymph node regions 3 Stage 0 + anemia (Hgb < 100 g/L) same side of the diaphragm (2E). 4 Stage 0 + thrombocytopenia 3 Lymph node regions on both sides of (Platelets < 100 x 109/L) the diaphragm (3) which may be Blood, 1975;46:219 accompanied by local extralymphatic extension (3E). 4 Diffuse involvement of one or more extralymphatic organs or sites. International prognostic factors SYMPTOMS Large cell lymphoma Hodgkin lymphoma A = no B symptoms Age > 60 y Age > 44 y B = presence of at least one of these: Perform 2-4 Gender male stat 1 – unexplained weight loss Stage 3,4 Stage 4 > 10% baseline during 6 # of e- > 1 Albumin < 40 g/L months prior to staging nodal 2 – unexplained fever > 38 0C LDH > normal WBC > 15 x 3 – night sweats 109/L Hemoglo < 105 g/L Canc Research, 1971;31:1860-1 bin Lymphs <0.6 x ECOG Performance status definitions 109/L 0 Well, asymptomatic or < 8% 1 Symptoms, no disability NEJM,1993;329:987-94 NEJM,1998;339:1506-14 2 Up to 1/2 waking time at rest, unable to do usual work 3 More than 1/2 waking time at rest Follicular Lymphoma International 4 Moribund Prognostic Index (FLIPI) Factors Age >60 y Stage III-IV Hemoglobin <120 g/L LDH >normal # Nodal Sites >4 Blood,2004;104:1258-65 Note: The number of nodal sites for the FLIPI is calculated by adding up the number of “Boxes” with nodal involvement in the nodal diagram Additional Information (optional) .

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