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Noring K, Carlsten M, Sonnevi K, Wahlin BE. The value of complete remission according to positron emission tomography prior to autologous stem cell transplantation in lymphoma: a population-based study showing improved outcome. BMC Cancer 2021; 21:500. [PMID: 33947353 PMCID: PMC8097884 DOI: 10.1186/s12885-021-08225-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background Chimeric antigen-receptor T-cell and bispecific antibody therapies will likely necessitate a reconsideration of the role of autologous stem-cell transplantation (ASCT) in lymphoma. Patients who are likely to profit from ASCT need to be better identified. Methods Here, we investigated the value of positron emission tomography/computerized tomography (PET/CT) before ASCT. All 521 patients transplanted for lymphoma 1994–2019 at Karolinska (497 conditioned with BEAM) were included. Results Outcome improved over three calendar periods 1994–2004, 2005–2014, 2015–2019 (2-year overall survival [OS]: 66, 73, 83%; P = 0.018). Non-relapse mortality (NRM) at 100 days over the three periods were 9.8, 3.9, 2.9%, respectively. The OS improvement between 1994 and 2004 and 2005–2014 was due to lower NRM (P = 0.027), but the large OS advance from 2015 was not accompanied by a significant reduction in NRM (P = 0.6). The fraction of PET/CT as pre-ASCT assessment also increased over time: 1994–2004, 2%; 2005–2014, 24%; 2015–2019, 60% (P < 0.00005). Complete responses (PET/CT-CR) were observed in 77% and metabolically active partial responses (PET/CT-PR) in 23%. PET/CT-CR was a predictor for survival in the entire population (P = 0.0003), also in the subpopulations of aggressive B-cell (P = 0.004) and peripheral T-cell (P = 0.024) lymphomas. Two-year OS and progression-free survival (OS/PFS) for patients in PET/CT-CR were in relapsed/refractory aggressive B-cell lymphoma 87%/75% and peripheral T-cell lymphoma 91%/78%. The corresponding figures in PET/CT-PR were 43%/44 and 33%/33%. Patients with solitary PET/CT-positive lesions showed acceptable outcome with ASCT followed by local irradiation (2-year OS/PFS 80%/60%). CT was less discriminative: 2-year OS/PFS: CT-CR, 76%/66%; CT-PR, 62%/51%. Outcome was inferior after BEAC compared with BEAM conditioning. Conclusions We conclude that the improved outcome reflects better, PET/CT-informed, identification of patients who should proceed to ASCT. The excellent survival of patients in PET/CT-CR indicates that ASCT should remain part of standard therapy for lymphoma.
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Affiliation(s)
- Kristina Noring
- Division of Hematology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Hematology Unit, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Mattias Carlsten
- Hematology Unit, Karolinska University Hospital, Solna, Stockholm, Sweden.,Center for Hematology and Regenerative Medicine, Department of Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - Kristina Sonnevi
- Division of Hematology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Hematology Unit, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Björn Engelbrekt Wahlin
- Division of Hematology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden. .,Hematology Unit, Karolinska University Hospital, Solna, Stockholm, Sweden.
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A Primary Retroperitoneal Diffuse Large B-Cell Lymphoma: A Challenging Diagnosis. CURRENT HEALTH SCIENCES JOURNAL 2018; 44:392-396. [PMID: 31123618 PMCID: PMC6421481 DOI: 10.12865/chsj.44.04.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 12/03/2018] [Indexed: 01/02/2023]
Abstract
Although quite rare, retroperitoneum can harbour malignant limphomas. On the grounds that the anatomical location is uncommon and the symptoms are scarce, the diagnosis is usually late and challenging. Imaging methods such as magnetic resonance imaging, computed tomography (CT) and positron emission tomography-computed tomography (PET-CT), can characterize and locate the tumor while endoscopic ultrasound fine needle aspiration (EUS-FNA) may provide pathological confirmation. We present the clinical case of a fifty-five-year-old female that is admitted to our hospital with epigastric discomfort, nausea and vomiting. CT showed a homogenously enhancing mass lesion that encased the pancreas, in contact with the portal vein, inferior vena cava, invading splenomesenteric confluence. To investigate further, EUS-FNA was decided and it revealed lymphocyte proliferation suggestive for the diagnosis of lymphoma. Hereinafter, surgical intervention was performed and immunohistochemical analysis and sub classification of lymphoma was obtained. The final diagnosis was non-Hodgkin lymphoma, Diffuse Large B-Cell Lymphoma (DLBCL). Poly-chemotherapy with R-CHOP was initiated. At the end of the treatment fluorodeoxyglucose positron emission tomography (FDG-PET) was performed and no pathological findings were found. A brief review of literature is also provided.
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Sawan P, Rebeiz K, Schoder H, Batlevi C, Moskowitz A, Ulaner GA, Dunphy M, Mannelli L. Specialized second-opinion radiology review of PET/CT examinations for patients with diffuse large B-cell lymphoma impacts patient care and management. Medicine (Baltimore) 2017; 96:e9411. [PMID: 29390562 PMCID: PMC5758264 DOI: 10.1097/md.0000000000009411] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To identify discrepancies in fludeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) reports generated by general radiologists and subspecialized oncological radiologists for patients with diffuse large B-cell lymphoma (DLBCL), and to assess if such discrepancies impact patient management.Two radiologists retrospectively reviewed 72 PET/CT scans of patients with DLBCL referred to our institutions between 2009 and 2011, and recorded the discrepancies between the outside and second-opinion reports regarding multiple preset criteria using kappa statistic (Κ), including the disease stage. A multidisciplinary staging that considered all patient clinical data, pathology, and follow up radiological scans, was considered as standard of reference. A hemato-oncologist, blinded to the reports' origin, subjectively graded the quality and structure of these reports for each patient to determine if clinical stage and disease activity could be derived accurately from these reports.Agreement was not, or slightly, achieved between the reports regarding the binary and multilevel criteria (Κ < 0-0.2 and weighted Κ = 0.082, respectively). Second-opinion reviews of PET/CT scans were concordant with the multidisciplinary staging in 78% of cases with an almost perfect agreement (Κ = 0.860). A change in staging was demonstrated in 36% of cases. In addition, 68% of second-opinion reports were assigned the highest grades on quality (grades 4 and 5) by the hemato-oncologist, compared with 15% of outside reports, with no noted agreement (weighted Κ = -0.007).Second-opinion review of PET/CT scans by sub-specialized oncological radiologists increases accuracy of initial staging, posttreatment evaluation and also the clinical relevance of the radiology reports.
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Affiliation(s)
- Peter Sawan
- Department of Radiology
- Department of Molecular Imaging and Therapy
| | | | | | - Connie Batlevi
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, York Avenue, New York, NY
| | - Alison Moskowitz
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, York Avenue, New York, NY
| | | | | | - Lorenzo Mannelli
- Department of Radiology
- Department of Molecular Imaging and Therapy
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The role of fluorine-18 fluorodeoxyglucose PET in prognosis evaluation for stem cell transplantation of lymphoma: a systematic review and meta-analysis. Nucl Med Commun 2016; 37:338-47. [PMID: 26741290 DOI: 10.1097/mnm.0000000000000468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The role of fluorine-18 fluorodeoxyglucose PET (F-FDG PET) in prognostic evaluation of pre-stem cell transplantation (SCT) and post-SCT is still uncertain. A systematic review and meta-analysis were carried out to detect the prognostic power of F-FDG PET. 'PubMed', EMBASE, and Springer were searched for relevant articles. Subgroup analysis was carried out to evaluate the F-FDG PET in predicting the prognosis between Hodgkin lymphoma (HL) and non-Hodgkin lymphoma. Finally, 17 studies that included 1192 patients were eligible, 16 studies for progression-free survival (PFS) and 12 studies for overall survival (OS). For the pre-SCT PET or PET/computed tomography scan, the combined hazard ratios (HRs) of PET for PFS and OS were 2.32 and 2.64, respectively. Subgroup analysis showed that the HRs of PFS for HL and non-Hodgkin lymphoma were 3.28 and 2.00, respectively. For the post-SCT PET scan, the combined HR for PFS was 4.61. The sensitivity analysis showed that exlcusion of any single study had no significant effect on HR. We found that F-FDG PET was especially effective in predicting pre-STC and post-STC prognosis. The patients with a negative PET scan had a better prognosis compared with those with a positive scan in PFS and OS. In the subgroup analysis, F-FDG PET had a higher value in predicting prognosis before SCT for HL patients.
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Kostakoglu L, Cheson BD. State-of-the-Art Research on "Lymphomas: Role of Molecular Imaging for Staging, Prognostic Evaluation, and Treatment Response". Front Oncol 2013; 3:212. [PMID: 24027671 PMCID: PMC3762124 DOI: 10.3389/fonc.2013.00212] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 08/02/2013] [Indexed: 12/11/2022] Open
Abstract
Lymphomas are heterogeneous but potentially curable group of neoplasms. Treatment of lymphomas has rapidly evolved overtime with significant improvement in the cure rate and reductions in treatment-related toxicities. Despite excellent results, treatment programs are continued to be developed to achieve better curative and safety profiles. In these patients individualized therapy schemes can be devised based on a well-defined risk categorization. The therapy efficacy can be increased early during therapy in non-responding patients with escalated therapy protocols or with the addition of radiation therapy, particularly, in advanced-stage or unfavorable risk patients. The increasing availability of positron emission tomography using 18F-fluorodeoxyglucose, particularly fused with computed tomography (FDG-PET/CT) has lead to the integration of this modality into the routine staging and restaging for lymphoma with convincing evidence that it is a more accurate imaging modality compared with conventional imaging techniques. FDG-PET/CT is also is a promising surrogate for tumor chemosensitivity early during therapy. This review will summarize published data on the utility of FDG-PET/CT imaging in the staging, restaging, and predicting therapy response in patients with lymphoma.
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Affiliation(s)
- Lale Kostakoglu
- Department of Radiology, Mount Sinai Medical Center , New York, NY , USA
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Qiao W, Zhao J, Xing Y, Wang C, Wang T. Predictive value of [¹⁸F]fluoro-2-deoxy-D-glucose positron emission tomography for clinical outcome in patients with relapsed/refractory diffuse large B-cell lymphoma prior to and after autologous stem cell transplant. Leuk Lymphoma 2013; 55:276-82. [PMID: 23617323 DOI: 10.3109/10428194.2013.797974] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We evaluated the predictive value of [(18)F]fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) for clinical outcome such as progression-free survival (PFS) and overall survival (OS) in patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) prior to and after autologous stem cell transplant (ASCT). FDG-PET/computed tomography (CT) was performed in 39 consecutive patients with relapsed/refractory DLBCL scheduled for ASCT. The median follow-up of surviving patients was 3 years (range 19-66 months). Both pre- and post-ASCT, FDG-PET findings were strongly correlated with PFS and OS (p < 0.005). The 2-year PFS estimates for FDG-negative versus -positive patients were 84.8% vs. 36.8% (pre-) and 81.1% vs. 13.3% (post-). The 2-year OS estimates in these groups were 95.5% vs. 68.3% (pre-) and 92.7% vs. 57.1% (post-). Patients were classified into three groups according to FDG-PET results before and after ASCT. The median PFS was significantly lower in the +/+ group (13.0 months) as compared with the +/- group (31.0 months, p = 0.021) and the -/- group (p = 0.000). The regression model showed that the predictive value of FDG-PET before ASCT owed its significance to a very high hazard ratio between patients with positive and negative imaging (p < 0.01). FDG-PET prior to and following ASCT in patients with relapsed or refractory DLBCL contains prognostic information on long-term clinical outcome.
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Sohn BS, Yoon DH, Kim KP, Kim S, Lee KM, Park JS, Lee DH, Ryu JS, Huh J, Hong IK, Suh C. The role of 18F-fluorodeoxyglucose positron emission tomography at response assessment after autologous stem cell transplantation in T-cell non-Hodgkin’s lymphoma patients. Ann Hematol 2013; 92:1369-77. [DOI: 10.1007/s00277-013-1782-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 05/02/2013] [Indexed: 11/28/2022]
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The role of transplantation in diffuse large B-cell lymphoma: the impact of rituximab plus chemotherapy in first-line and relapsed settings. Curr Hematol Malig Rep 2011; 6:47-57. [PMID: 21190142 DOI: 10.1007/s11899-010-0075-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rituximab has improved the prognosis of patients with diffuse large B-cell lymphoma, but a high proportion of patients with advanced disease will relapse or will fail to achieve a remission with front-line treatment. Salvage chemotherapy, followed by high-dose chemotherapy or radiation therapy and autologous stem cell transplantation, remains the best treatment option for such patients, especially those who retain chemosensitivity. Allogeneic transplantation is under investigation in this setting, often as a treatment for relapse after autologous transplantation. Treatment-related mortality due to graft-versus-host disease, preparative regimen toxicity, and poor immune recovery often limits its benefits. This article reviews the role of hematopoietic stem cell transplantation in the treatment of diffuse large B-cell lymphoma, the incorporation of rituximab, and avenues of clinical investigation in this rapidly evolving field.
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Mocikova H, Pytlik R, Markova J, Steinerova K, Kral Z, Belada D, Trnkova M, Trneny M, Koza V, Mayer J, Zak P, Kozak T. Pre-transplant positron emission tomography in patients with relapsed Hodgkin lymphoma. Leuk Lymphoma 2011; 52:1668-74. [DOI: 10.3109/10428194.2011.573889] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Qiao W, Zhao J, Wang C, Wang T, Xing Y. Predictive value of (18)F-FDG hybrid PET/CT for the clinical outcome in patients with non-Hodgkin's lymphoma prior to and after autologous stem cell transplantation. ACTA ACUST UNITED AC 2010; 15:21-7. [PMID: 20132658 DOI: 10.1179/102453310x12583347009739] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Evaluation of therapeutic response in non-Hodgkin's lymphoma (NHL) patients with autologous stem cell transplantation (ASCT) is of great clinical significance. But the exact role of (18)F-fluorodeoxyglucose (FDG) imaging in NHL associated with ASCT is unclear. This study assessed the predictive value of (18)F-FDG hybrid PET/CT imaging for the clinical outcome such as progression-free survival (PFS) in patients with NHL prior to and after ASCT. METHODS (18)F-FDG hybrid PET/CT was performed in 31 patients (24 male and 7 female) with pathologically confirmed NHL prior to and after ASCT. Mean age was 43.1+/-13.8 years. No patients were lost to follow-up earlier than 1 year from ASCT. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of (18)F-FDG hybrid PET/CT before ASCT were compared to the results after ASCT. The results of pre- and post-ASCT FDG hybrid PET/CT findings were correlated to PFS using Kaplan-Meier survival analysis. Regression analyses were employed to test for independence of established prognostic factors. RESULTS Sixteen of 31 patients (52%) progressed/relapsed or died after a median follow-up of 7 months, the remaining 15 patients (48%) were disease free after a median follow-up of 24 months. Both pre- and post-ASCT, (18)F-FDG hybrid PET/CT findings showed high PPV, NPV and accuracy (85.7 versus 92.3%, 76.5 versus 77.8% and 80.6 versus 83.9%). Both pre- and post-ASCT, (18)F-FDG hybrid PET/CT findings were strongly correlated with PFS (P<0.0005, significant). Of pre- ASCT FDG finding, the 1-year PFS rate for FDG-negative and FDG-positive patients was 88.2 and 28.6%. Of post-ASCT FDG finding, the 1-year PFS rate for FDG-negative patients and FDG-positive patients was 88.9 and 23.1%. The regression model showed that the predictive value of FDG imaging owed its significance to the very high hazard ratio between patients with positive FDG imaging and negative FDG imaging (P<0.005) both pre- and post-ASCT. CONCLUSIONS (18)F-FDG hybrid PET/CT imaging prior to and following autologous stem cell transplantation in NHL contains predictive information on the long-term clinical outcome.
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Affiliation(s)
- Wenli Qiao
- Department of Nuclear Medicine, The First People's Hospital, Shanghai Jiaotong University, China
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Dickinson M, Hoyt R, Roberts AW, Grigg A, Seymour JF, Prince HM, Szer J, Ritchie D. Improved survival for relapsed diffuse large B cell lymphoma is predicted by a negative pre-transplant FDG-PET scan following salvage chemotherapy. Br J Haematol 2010; 150:39-45. [PMID: 20507301 DOI: 10.1111/j.1365-2141.2010.08162.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The utility of ([18F])fluoro-2-deoxy- d-glucose positron-emission tomography (FDG-PET) for predicting outcome after autologous stem cell transplantation (ASCT) for diffuse large B cell lymphoma (DLBCL) is uncertain - existing studies include a range of histological subtypes or have a limited duration of follow-up. Thirty-nine patients with primary-refractory or relapsed DLBCL with pre-ASCT PET scans were analysed. The median follow-up was 3 years. The 3-year progression-free survival (PFS) for patients with positive PET scans pre-ASCT was 35% vs. 81% for those who had negative PET scans (P = 0.003). The overall survival (OS) in these groups was 39% and 81% (P = 0.01), respectively. In a multivariate analysis, PET result, number of salvage cycles and the presence of relapsed or refractory disease were shown to predict a longer PFS; PET negativity (P = 0.04) was predictive of a longer OS. PET is useful for defining those with an excellent prognosis post-ASCT. Although those with positive scans can still be salvaged with current treatments, PET may useful for selecting patients eligible for novel consolidation strategies after salvage therapies.
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Affiliation(s)
- Michael Dickinson
- Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
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Nguyen XC, Lee WW, Amin AM, Eo JS, Bang SM, Lee JS, Kim SE. Tumor Burden Assessed by the Maximum Standardized Uptake Value and Greatest Diameter on FDG-PET Predicts Prognosis in Untreated Diffuse Large B-cell Lymphoma. Nucl Med Mol Imaging 2010; 44:39-44. [PMID: 24899936 DOI: 10.1007/s13139-009-0009-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 11/02/2009] [Accepted: 11/16/2009] [Indexed: 11/26/2022] Open
Abstract
PURPOSE It is uncertain whether the tumor burden as assessed using FDG-PET has prognostic significance in newly diagnosed diffuse large B-cell lymphoma (DLBCL). The authors undertook this study to determine whether a parameter that reflects both FDG uptake magnitude and the greatest tumor diameter is a prognostic indicator in DLBCL. MATERIALS AND METHODS Forty-two DLBCL patients (age, 57.4 ± 15.5 years; male/female = 25/17; stage I/II/III/IV=5/17/10/10) who underwent FDG-PET before chemotherapy were enrolled. A lesion with the highest maximum standardized uptake value (MaxSUV) on the PET image was selected, and size-incorporated MaxSUV (SIMaxSUV) of mass was calculated as MaxSUV × greatest diameter (mm) on the transaxial PET image. Median follow-up duration was 20.0 months. RESULTS Twelve (28.6% = 12/42) patients experienced disease progression, and 10 (23.8% = 10/42) died during follow-up. Among six variables [Ann Arbor stage, %Ki-67 expression, International Prognostic Index (IPI), MaxSUV, greatest diameter, and SIMaxSUV] investigated, only SIMaxSUV was found to be a single determinant of progression-free and overall survivals by multivariate analyses (p < 0.05). CONCLUSION These results suggest that SIMaxSUV, a new FDG-PET parameter that incorporates FDG uptake magnitude and the greatest tumor diameter, may be a useful indicator of prognosis in untreated DLBCL.
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Affiliation(s)
- Xuan Canh Nguyen
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707 Korea ; Department of Nuclear Medicine, Cho Ray Hospital, Ho Chi Minh City, Viet Nam
| | - Won Woo Lee
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707 Korea ; Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
| | - Amr Mohamed Amin
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707 Korea ; Department of Nuclear Medicine Diagnosis and Therapy, Cairo University, Cairo, Egypt
| | - Jae Seon Eo
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707 Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Seok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Eun Kim
- Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707 Korea ; Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, Korea
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Durán C, Infante JR, Serrano J, Rayo JI, García L, Domínguez ML, Sánchez R. [Neurolymphomatosis: diagnosis of extension and assessment of response to treatment with PET-CT]. ACTA ACUST UNITED AC 2009; 28:295-8. [PMID: 19864049 DOI: 10.1016/j.remn.2009.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 07/03/2009] [Indexed: 11/25/2022]
Abstract
Neurolymphomatosis is a rare neurological manifestation of non-Hodgkin's lymphoma (NHL) and it may be its first and sole manifestation. Diagnosis is often difficult and nerve biopsy is generally required. However, this it is not always possible to perform or is not conclusive. We present the case of a 66-year-old woman diagnosed with giant B-cell NHL. After 6 cycles of chemotherapy, imaging and molecular biology techniques showed complete remission. At four months after treatment, the patient complained of low back pain of radicular distribution. CT and MRI imaging showed signs of lymphoproliferative activity of L5 and also lesions to thoracic nerve roots. A PET-CT was requested in order to complete the diagnosis and plan the treatment. Imaging confirmed the presence of tumor recurrence with neurolymphomatosis and also indicated lesions on the chest and abdominal level. Thus, it was decided to start a new line of chemotherapy, without performing the histological study through biopsy. This case illustrates the important role played by PET-CT imaging in neurolymphomatosis diagnosis. This technique can help the patient avoid more aggressive procedures, such as a biopsy, and can also be useful in the follow-up and assessment of the treatment response to NHL-diagnosed patients.
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Affiliation(s)
- C Durán
- Servicio de Medicina Nuclear, Complejo Hospitalario Universitario de Badajoz, Badajoz, España.
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Poulou LS, Thanos L, Ziakas PD. Unifying the predictive value of pretransplant FDG PET in patients with lymphoma: a review and meta-analysis of published trials. Eur J Nucl Med Mol Imaging 2009; 37:156-62. [DOI: 10.1007/s00259-009-1258-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Accepted: 07/31/2009] [Indexed: 11/28/2022]
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Terasawa T, Lau J, Bardet S, Couturier O, Hotta T, Hutchings M, Nihashi T, Nagai H. Fluorine-18-fluorodeoxyglucose positron emission tomography for interim response assessment of advanced-stage Hodgkin's lymphoma and diffuse large B-cell lymphoma: a systematic review. J Clin Oncol 2009; 27:1906-14. [PMID: 19273713 DOI: 10.1200/jco.2008.16.0861] [Citation(s) in RCA: 215] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To systematically review the prognostic accuracy of fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) for interim response assessment of patients with untreated advanced-stage Hodgkin's lymphoma (HL) or diffuse large B-cell lymphoma (DLBCL). METHODS MEDLINE, EMBASE, SCOPUS, and Biologic Abstracts were searched for relevant studies. Two assessors independently reviewed studies for inclusion and extracted data. Relevant unpublished data were requested from the investigators if unavailable from publications. A meta-analysis of the prognostic accuracy was performed. RESULTS Thirteen studies involving 360 advanced-stage HL patients and 311 DLBCL patients met our inclusion criteria. Advanced-stage HL studies included few unfavorable-risk patients. DLBCL studies were heterogeneous. FDG-PET had an overall sensitivity of 0.81 (95% CI, 0.72 to 0.89) and a specificity of 0.97 (95% CI, 0.94 to 0.99) for advanced-stage HL, and a sensitivity of 0.78 (95% CI, 0.64 to 0.87) and a specificity of 0.87 (95% CI, 0.75 to 0.93) for DLBCL. Meta-regression and subgroup analyses did not identify factors that affect prognostic accuracy. CONCLUSION For low- to intermediate-risk advanced-stage HL, FDG-PET performed after a few cycles of standard chemotherapy seems to be a reliable prognostic test to identify poor responders, warranting prospective studies to assess PET-based treatment strategies. For DLBCL, no reliable conclusions can be drawn due to heterogeneity. Interim PET remains an unproven test for routine clinical practice. Its use should be reserved for research settings where treatment regimens and imaging conditions are standardized.
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Affiliation(s)
- Teruhiko Terasawa
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, USA.
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Hoppe BS, Moskowitz CH, Zhang Z, Maragulia JC, Rice RD, Reiner AS, Hamlin PA, Zelenetz AD, Yahalom J. The role of FDG-PET imaging and involved field radiotherapy in relapsed or refractory diffuse large B-cell lymphoma. Bone Marrow Transplant 2009; 43:941-8. [PMID: 19139730 DOI: 10.1038/bmt.2008.408] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We examined the role of fluorodeoxyglucose-positron emission tomography (FDG-PET) and the addition of involved field radiotherapy (IFRT) as potential modifiers of salvage therapy. From January 2000 to June 2007, 83 patients with chemosensitive relapsed or primary refractory diffuse large B-cell lymphoma (DLBCL) underwent FDG-PET scans following second-line chemotherapy before high-dose therapy with autologous stem cell rescue (HDT/ASCR). We evaluated the prognostic value of having a negative FDG-PET scan before HDT/ASCR and whether IFRT improved the outcomes. Median follow-up was 45 months, and the 3-year PFS, disease-specific survival (DSS) and OS were 72, 80 and 78%, respectively. Multivariate analysis revealed that a positive FDG-PET scan had worse PFS (hazard ratio=(HR) 3.4; P=0.014), DSS (HR=7.7; P=0.001) and OS (HR=5.4; P=0.001), and that patients not receiving IFRT had worse PFS (HR=2.7; P=0.03) and DSS (HR=2.8, P=0.059). Patients who received IFRT had better local control with fewer relapses within prior involved sites compared with those that did not receive IFRT (P=0.006). These outcomes confirm the important prognostic value of FDG-PET scans before undergoing HDT/ASCR. It also suggests that the role of IFRT should be evaluated further.
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Affiliation(s)
- B S Hoppe
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Pinilla I, Rodríguez-Vigil B, Gómez-León N. Integrated FDG PET/CT: Utility and Applications in Clinical Oncology. Clin Med Oncol 2008; 2:181-98. [PMID: 21892279 PMCID: PMC3161686 DOI: 10.4137/cmo.s504] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Accurate diagnosis and staging are essential for an optimal management of cancer patients. Positron emision tomography with 2-deoxy-2-fluorine-18-fluoro-D-glucose (18FDG-PET) and, more recently, 18FDG-PET/computed tomography (18FDG-PET/CT) have emerged as powerful imaging tools in oncology, because of the valuable functional information they provide. The combined acquisition of PET and CT has synergistic advantages over its isolated constituents and minimizes their limitations. It decreases examination times by 25%–40%, leads to a higher patient throughput and unificates two imaging procedures in a single session. There is evidence that 18FDG-PET/CT is a more accurate test than either of its components for the evaluation of various tumors. It is a particularly valuable tool for detection of recurrence, especially in asymptomatic patients with rising tumor markers and those with negative or equivocal findings on conventional imaging tests. Yet, there are some limitations and areas of uncertainty, mainly regarding the lack of specificity of the 18FDG uptake and the variable 18FDG avidity of some cancers. This article reviews the advantages, limitations and main applications of 18FDG-PET/CT in oncology, with especial emphasis on lung cancer, colorectal cancer, lymphomas, melanoma and head and neck cancers.
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Alousi AM, Saliba RM, Okoroji GJ, Macapinlac HA, Hosing C, Korbling M, Samuels BI, Popat U, Kebriaei P, Anderlini P, Qazilbash MH, de Lima M, Giralt SA, Champlin RE, Khouri IF. Disease staging with positron emission tomography or gallium scanning and use of rituximab predict outcome for patients with diffuse large B-cell lymphoma treated with autologous stem cell transplantation. Br J Haematol 2008; 142:786-92. [PMID: 18564354 DOI: 10.1111/j.1365-2141.2008.07277.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Tumor status, as determined by positron emission tomography or gallium scanning (PET/G), may be an important predictor of outcome for patients with diffuse large B-cell lymphoma (DLBCL) undergoing autologous stem cell transplantation (ASCT). ASCT conditioning regimens that include rituximab may reduce the rate of relapse. We evaluated the influence of rituximab on overall and progression-free survival in patients with DLBCL based on PET/G status before ASCT. A retrospective review of all patients with chemosensitive DLBCL who underwent ASCT in the context of research protocols at our institution between 1995 and 2005 was performed. Our study included 174 patients. Disease status before ASCT, according to PET/G, was negative in 136 patients (78%), positive in 29 patients (17%), and unknown in nine patients (5%). PET/G status and rituximab use were the only factors predictive of progression-free survival in multivariate analyses: the hazard ratios for relapse were 2.9 for PET/G-positive versus -negative patients (P < 0.001) and 0.4 for rituximab versus no rituximab use (P = 0.001). We conclude that evidence of disease on PET/G scanning prior to transplantation is associated with an increased risk for relapse after ASCT. Transplantation regimens containing rituximab can reduce this risk, regardless of PET/G status.
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Affiliation(s)
- Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA.
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19
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Abstract
The majority of patients with Hodgkin lymphoma (HL) can now expect to be cured with conventional chemo- and/or radio-therapy. However, a subgroup still exists that have poor outcomes, even following dose escalation and autologous stem cell transplantation. Furthermore, patients relapsing after autografting have limited therapeutic options available. Whilst the application of allogeneic transplantation strategies has historically been limited by prohibitive transplant-related mortality, the exploration of reduced intensity approaches has demonstrated the feasibility of delivering allogeneic immunotherapies with more acceptable mortality rates. Although its role remains controversial, we are beginning to re-evaluate the use of allogeneic transplantation in the management of patients with HL and to address a number of critical questions. These include whether a clinically relevant graft-versus-tumour response occurs in HL, and whether subgroups of patients who might benefit from allogeneic approaches can be identified in order to inform development of rational clinical studies. This review focuses on evaluating recent experience with reduced intensity allogeneic approaches in HL in order to inform opinion on its current role and to highlight areas for future investigation.
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Affiliation(s)
- Karl S Peggs
- Department of Haematology, University College London Cancer Institute, London, UK.
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20
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Yoshimi A, Izutsu K, Takahashi M, Kako S, Oshima K, Kanda Y, Motokura T, Chiba S, Momose T, Ohtomo K, Kurokawa M. Conventional allogeneic hematopoietic stem cell transplantation for lymphoma may overcome the poor prognosis associated with a positive FDG-PET scan before transplantation. Am J Hematol 2008; 83:477-81. [PMID: 18266206 DOI: 10.1002/ajh.21158] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A positive scan in pretransplantation fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) has been shown to be associated with a poor prognosis in patients with lymphoma undergoing high-dose chemotherapy followed by autologous stem cell transplantation (ASCT). For those with a positive FDG-PET scan, treatment that includes allogeneic stem cell transplantation (allo-SCT) may be an alternative. However, it is uncertain whether allo-SCT can overcome a poor prognosis. Therefore, we conducted a retrospective analysis of 14 patients with lymphoma who had undergone FDG-PET scan within one month before allo-SCT at our institution. Eleven patients were FDG-PET-positive and three were negative. With a median follow-up of 17 months (range: 6-44) after allo-SCT, the cumulative incidence of progression was 29.3% in FDG-PET-positive patients and 0% in the FDG-PET-negative patients. Four of the 11 patients who had post-transplantation FDG-PET showed FDG-avid lesions on the first post-transplantation scan. In two of the four, regression of the lesions was observed during the scheduled reduction of immunosuppressant without donor lymphocyte infusion and remained without progression at the last follow-up (34 and 8 months). Durable responses after allo-SCT, at least with conventional conditioning regimens, can be expected in patients with FDG-PET-positive lesions before transplantation. Thus, conventional allo-SCT could be an attractive modality compared to ASCT for patients with positive FDG-PET after the completion of conventional salvage chemotherapy, and particularly for patients with T and NK-cell lymphomas.
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Affiliation(s)
- Akihide Yoshimi
- Department of Hematology and Oncology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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21
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Seshadri T, Kuruvilla J, Crump M, Keating A. Salvage therapy for relapsed/refractory diffuse large B cell lymphoma. Biol Blood Marrow Transplant 2008; 14:259-67. [PMID: 18275892 DOI: 10.1016/j.bbmt.2007.11.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Accepted: 11/30/2007] [Indexed: 11/26/2022]
Abstract
Diffuse large B cell lymphoma (DLBCL), the most common subtype of aggressive lymphoma, has considerable biologic and clinical heterogeneity. Despite recent therapeutic advances, up to 50% of patients relapse after standard chemoimmunotherapy. The International Prognostic Index (IPI) at relapse is of value in providing prognostic information on response to salvage chemotherapy and outcome after autologous hematopoietic cell transplantation (aHCT). Predictive biologic and gene expression markers, however, remain undefined, and require further clarification from additional molecular studies. To date, the standard of care in the management of relapsed/refractory DLBCL is salvage chemotherapy followed by an aHCT for those with chemotherapy-sensitive disease. Currently, there is no standard salvage chemotherapy regimen, and the use of immunotherapy for relapsed disease requires further evaluation. This review focuses on prognostic markers, current salvage therapies, and discusses the role of novel treatment in the management of relapsed/refractory DLBCL.
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Affiliation(s)
- Tara Seshadri
- Autologous Blood and Marrow Transplant Program, Princess Margaret Hospital, Toronto, Ontario, Canada.
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22
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Abstract
PURPOSE OF REVIEW The prognostic utility of midtreatment fluorine-18 fluorodeoxyglucose positron emission tomography (F-FDG PET) has become widely appreciated in aggressive B-cell non-Hodgkin's lymphoma and, more recently, in Hodgkin's lymphoma. Outcomes based on midtreatment FDG PET performed during primary and salvage therapy are reviewed and management strategies considered, with a focus on treatment intensification for poor-risk disease as identified by metabolic imaging. RECENT FINDINGS PET, when performed after as few as two cycles of primary chemotherapy, is strongly prognostic in certain aggressive lymphomas and provides information independently from validated prognostic indices. What constitutes a positive or negative scan is not always clear, particularly if there is minimal tracer uptake, and the causes of false positive and false negative scans must be considered. How to tailor therapy based on the midtreatment PET result is the focus of current trials and is presently being defined for both Hodgkin's and non-Hodgkin's lymphoma. SUMMARY Early PET has the strong potential to improve clinical outcomes by sparing good-risk patients from overly aggressive treatments, and by more accurately identifying poor-risk patients so as to guide changes in management. Treatment modifications on the basis of midtreatment PET are presently best made in clinical trial settings.
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23
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Positron Emission Tomography and Cancer. Oncology 2007. [DOI: 10.1007/0-387-31056-8_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Abstract
Positron emission tomography (PET)/computed tomography (CT) has a growing role in the imaging of many cancers. As our experience has grown over the past number of years so has our understanding for which cancers it is particularly useful. The value of PET/CT at each stage of the cancer journey is different for each cancer. This review attempts to tease out the role of PET/CT in the common cancers with particular emphasis on where it is the imaging investigation of choice.
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Abstract
Early assessment of response to chemotherapy with fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is becoming a routine part of management in patients with Hodgkin lymphoma (HL) and histologically aggressive non-Hodgkin lymphoma (NHL). Changes in FDG uptake can occur soon after the initiation of therapy and they precede changes in tumour volume. Recent studies in uniform populations of aggressive lymphomas (predominantly diffuse large B cell lymphomas) and HL have clarified the value of early response assessment with PET. These trials show that PET imaging after 2-3 chemotherapy cycles is far superior to CT-based imaging in predicting progression-free survival and can be at least as reliable as definitive response assessment at the end of therapy. This information is of great potential value to patients, but oncologists should be cautious in the use of early PET response in determining choice of therapy until some critical questions are answered. These include: When is the best time to use PET for response assessment? What is the best methodology, visual or quantitative? (For HL at least, visual reading appears superior to an SUV-based assessment). Can early responders be cured with less intensive therapy? Will survival be better for patients treated more intensively because they have a poor interim metabolic response? In the future, early PET will be crucial in developing response-adapted therapy but without further carefully designed clinical trials, oncologists will remain uncertain how best to use this new information.
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26
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Herishanu Y, Perry C, Braunstein R, Metser U, Goor O, Rogowski O, Berliner S, Polliack A, Naparstek E. Early-mid treatment C-reactive protein level is a prognostic factor in aggressive non-Hodgkin's lymphoma. Eur J Haematol 2007; 79:150-4. [PMID: 17635239 DOI: 10.1111/j.1600-0609.2007.00894.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND In the light of an emerging role for early-mid treatment 18 F-deoxyfluoroglucose positron emission tomography (FDG-PET) as an important prognostic indicator in aggressive non-Hodgkin's lymphoma (NHL) , we attempted to determine whether a simple parameter, such as the early-mid treatment CRP (C-reactive protein) level, could also be utilized as a significant prognostic factor in aggressive NHL. PATIENTS AND METHODS Serum CRP levels were monitored in 55 patients with aggressive NHL. The lowest value of the early mid-term CRP levels recorded was compared with the interim PET-CT results, as well as with the clinical course and eventual outcome. RESULTS During chemotherapy, the lowest value of early-mid treatment CRP levels significantly predicted the results of the interim FDG-PET (P = 0.04 with an odds ratio of 1.13). Patients who did not achieve an early-mid treatment CRP level of <5 mg/L, had a shorter time to disease progression or relapse (P = 0.001) as well as a reduced overall survival (OS) (P = 0.016). CONCLUSIONS The early-mid treatment serum CRP level is a prognostic factor in aggressive NHL. Patients who do not achieve an early-mid treatment level of <5 mg/L have quicker disease progression or earlier relapse and also appear to have an inferior OS.
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Affiliation(s)
- Yair Herishanu
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
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27
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Bar-Shalom R. Normal and Abnormal Patterns of 18F-Fluorodeoxyglucose PET/CT in Lymphoma. Radiol Clin North Am 2007; 45:677-88, vi-vii. [PMID: 17706532 DOI: 10.1016/j.rcl.2007.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In spite of the high performance of 18F-fluorodeoxyglucose (FDG) PET for the evaluation of lymphoma, inherent limitations of this modality underscore the additional value of PET/CT as an important tool in the assessment of this disease. Accumulating data on the use of PET/CT in lymphoma indicate the contribution of hybrid imaging to improved interpretation accuracy of PET using FDG and CT. Knowledge of the normal and abnormal patterns of FDG-PET/CT imaging and their variability in patients with lymphoma is important to provide a comprehensive clinically significant interpretation that has an impact on patient management and potentially on outcome.
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Affiliation(s)
- Rachel Bar-Shalom
- Division of Positron Emission Tomography, Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, 35254 Israel.
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28
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Kirby AM, Mikhaeel NG. The role of FDG PET in the management of lymphoma: what is the evidence base? Nucl Med Commun 2007; 28:335-54. [PMID: 17414883 DOI: 10.1097/mnm.0b013e3280895e23] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
[18F]Fluorodeoxyglucose positron emission tomography (18F-FDG PET) is playing an increasing role in the management of both Hodgkin and non-Hodgkin lymphoma, offering potential advantages in the accuracy of disease assessment at a number of points in the management pathway. This review evaluates the current level of confidence in the use of PET technology in (1) initial staging, (2) the assessment of early response to chemotherapy, (3) the assessment of residual masses at completion of initial treatment, (4) follow-up, and (5) radiotherapy planning.
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Affiliation(s)
- Anna M Kirby
- Department of Clinical Oncology, Guy's and St Thomas' NHS Trust, London, UK.
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29
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Juweid ME, Stroobants S, Hoekstra OS, Mottaghy FM, Dietlein M, Guermazi A, Wiseman GA, Kostakoglu L, Scheidhauer K, Buck A, Naumann R, Spaepen K, Hicks RJ, Weber WA, Reske SN, Schwaiger M, Schwartz LH, Zijlstra JM, Siegel BA, Cheson BD. Use of positron emission tomography for response assessment of lymphoma: consensus of the Imaging Subcommittee of International Harmonization Project in Lymphoma. J Clin Oncol 2007; 25:571-8. [PMID: 17242397 DOI: 10.1200/jco.2006.08.2305] [Citation(s) in RCA: 983] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To develop guidelines for performing and interpreting positron emission tomography (PET) imaging for treatment assessment in patients with lymphoma both in clinical practice and in clinical trials. METHODS An International Harmonization Project (IHP) was convened to discuss standardization of clinical trial parameters in lymphoma. An imaging subcommittee developed consensus recommendations based on published PET literature and the collective expertise of its members in the use of PET in lymphoma. Only recommendations subsequently endorsed by all IHP subcommittees were adopted. RECOMMENDATIONS PET after completion of therapy should be performed at least 3 weeks, and preferably at 6 to 8 weeks, after chemotherapy or chemoimmunotherapy, and 8 to 12 weeks after radiation or chemoradiotherapy. Visual assessment alone is adequate for interpreting PET findings as positive or negative when assessing response after completion of therapy. Mediastinal blood pool activity is recommended as the reference background activity to define PET positivity for a residual mass > or = 2 cm in greatest transverse diameter, regardless of its location. A smaller residual mass or a normal sized lymph node (ie, < or = 1 x 1 cm in diameter) should be considered positive if its activity is above that of the surrounding background. Specific criteria for defining PET positivity in the liver, spleen, lung, and bone marrow are also proposed. Use of attenuation-corrected PET is strongly encouraged. Use of PET for treatment monitoring during a course of therapy should only be done in a clinical trial or as part of a prospective registry.
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Affiliation(s)
- Malik E Juweid
- Department of Radiology, University of Iowa, Iowa City, IA 52242, USA.
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30
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Abstract
This review attempts to discuss the role of positron emission tomography (PET) imaging for staging, treatment response and follow-up of patients with lymphoma. The pitfalls and impact of PET imaging on the clinical management are also addressed.
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31
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Schot BW, Zijlstra JM, Sluiter WJ, van Imhoff GW, Pruim J, Vaalburg W, Vellenga E. Early FDG-PET assessment in combination with clinical risk scores determines prognosis in recurring lymphoma. Blood 2006; 109:486-91. [PMID: 17003382 DOI: 10.1182/blood-2005-11-006957] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study was set up to demonstrate whether prognostic classification based on the secondary age-adjusted International Prognostic Index (sAA-IPI) for recurring aggressive non-Hodgkin lymphoma (NHL) or the prognostic score for recurring Hodgkin lymphoma (HL) can be improved by including the midtreatment results of fluorine-18-fluorodeoxy-glucose-positron emission tomography (FDG-PET). Clinical data on patients with recurring lymphoma who were treated with second-line chemotherapy (DHAP-VIM-DHAP) followed by autologous stem cell transplantation (ASCT) were collected and combined with the results of FDG-PET performed before and after 2 cycles of reinduction chemotherapy. PET responses after 2 courses were scored as complete remission (CR), partial remission (PR), or no response (NR). A multivariate analysis was performed to design a predictive model. The number of patients (101 of 117) included those (78 patients with aggressive NHL and 23 patients with HL) that could be analyzed according to protocol. Of these, 80 patients were chemosensitive and 77 received transplants. Both secondary clinical risk score (P<.001) and FDG-PET response (P<.001) were independent predictive factors for the total evaluable group of patients with lymphoma and for patients with NHL alone. The combined use of the clinical risk score and FDG-PET response after 2 chemotherapy courses identified at least 4 categories of patients with a failure-free survival varying between 5% to 100% after transplantation (P<.001). These data indicate that the secondary clinical risk score in conjunction with FDG-PET response provides a more accurate prognostic instrument for the outcome of second-line treatment at least in patients with recurring NHL.
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Affiliation(s)
- Bart W Schot
- Department of Hematology, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, the Netherlands
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32
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Bar-Shalom R. Normal and Abnormal Patterns of 18F-Fluorodeoxyglucose PET/CT in Lymphoma. PET Clin 2006; 1:231-42. [DOI: 10.1016/j.cpet.2006.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Svoboda J, Andreadis C, Elstrom R, Chong EA, Downs LH, Berkowitz A, Luger SM, Porter DL, Nasta S, Tsai D, Loren AW, Siegel DL, Glatstein E, Alavi A, Stadtmauer EA, Schuster SJ. Prognostic value of FDG-PET scan imaging in lymphoma patients undergoing autologous stem cell transplantation. Bone Marrow Transplant 2006; 38:211-6. [PMID: 16770314 DOI: 10.1038/sj.bmt.1705416] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We conducted a retrospective analysis of 50 lymphoma patients (Hodgkin's disease and non-Hodgkin's lymphoma) who had an 18F-fluoro-deoxyglucose positron emission tomography (FDG-PET) scan after at least two cycles of salvage chemotherapy and before autologous stem cell transplantation (ASCT) at our institution. The patients were categorized into FDG-PET negative (N = 32) and positive (N = 18) groups. The median follow-up after ASCT was 19 months (range: 3-59). In the FDG-PET-negative group, the median progression-free survival (PFS) was 19 months (range: 2-59) with 15 (54%) patients without progression at 12 months after ASCT. The median overall survival (OS) for this group was not reached. In the FDG-PET-positive group, the median PFS was 5 months (range: 1-19) with only one (7%) patient without progression at 12 months after ASCT. The median OS was 19 months (range: 1-34). In the FDG-PET-negative group, chemotherapy-resistant patients by CT-based criteria had a comparable outcome to those with chemotherapy-sensitive disease. A positive FDG-PET scan after salvage chemotherapy and prior ASCT indicates an extremely poor chance of durable response after ASCT.
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Affiliation(s)
- J Svoboda
- Bone Marrow and Stem Cell Transplant Program, Abramson Cancer Center of University of Pennsylvania, Philadelphia, PA 19104, USA.
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Wendland MMM, Asch JD, Pulsipher MA, Thomson JW, Shrieve DC, Gaffney DK. The Impact of Involved Field Radiation Therapy for Patients Receiving High-Dose Chemotherapy Followed by Hematopoietic Progenitor Cell Transplant for the Treatment of Relapsed or Refractory Hodgkin Disease. Am J Clin Oncol 2006; 29:189-95. [PMID: 16601441 DOI: 10.1097/01.coc.0000209370.61355.8e] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patients with refractory/relapsed Hodgkin disease (HD) often receive high-dose chemotherapy (HDCT) followed by hematopoietic progenitor cell transplant (HPCT) as salvage therapy. This study sought to determine if involved field radiation therapy (IFRT) in this setting improves patient outcomes. METHODS The records of 65 patients with refractory/relapsed HD who underwent HDCT followed by HPCT between September 1988 and October 2003 were retrospectively reviewed. Forty-four patients did not receive IFRT and 21 received IFRT. RESULTS Thirty-eight patients were alive at the time of analysis with a median follow-up of 3.4 years in the no IFRT group and 1.8 years in the IFRT group (P = 0.38). IFRT patients were more likely to have bulky disease at initial diagnosis (P = 0.05). Progression-free survival (PFS) was similar in the 2 groups (P = 0.83). Twenty-two patients in the no IFRT group and 5 in the IFRT group have died (P = 0.06). Five-year overall survival rates were 55.6% for the no IFRT group and 73.3% for the IFRT group (P = 0.16). There was no significant difference between the treatment groups regarding mortality in the first 100 days after HPCT (P = 0.41), late events (P = 0.26), or failure in sites previously involved with disease (P = 0.76). CONCLUSIONS Although the current study did not demonstrate an improvement in PFS with the addition of IFRT to HDCT and HPCT, there was a trend toward improved overall survival. The potential benefit of IFRT may be underestimated because of the heterogeneity of the treatment groups. The use of IFRT was not associated with an increase in the risk of acute mortality or late events.
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Affiliation(s)
- Merideth M M Wendland
- Department of Radiation Oncology, Huntsman Cancer Hospital and the University of Utah, Salt Lake City, UT, USA
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35
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Sánchez Salmón A, Barandela Salgado J, Ruibal Morell A. PET in abdominal pathology: advantages and limitations. ACTA ACUST UNITED AC 2006; 31:174-81. [PMID: 16447090 DOI: 10.1007/s00261-005-0384-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
New oncologic procedures are currently more focused on the biological features of tumors. The ideal objective is the administration of personalized effective treatments for each patient that affects not just the location and spread of disease but also special metabolic characteristics of tumoral cells. Radiologic diagnostic methods are extremely important in the management of the patient for staging, restaging, and evaluation of treatment response, and clinicians are avid for some additional functional and metabolic information. Further, they need more dynamic methods for follow-up. Nuclear Medicine and positron emission tomography (PET) in many cases can meet this requirement, although it is not perfect, at least at the present time. Currently 2-((18)F)fluoro-2-desoxi-D: -glucose positron emission tomography is being widely used for oncologic purposes. Its information can be very useful in abdominal diseases and must be taken into account with the results of radiologic imaging. Thus, many changes in the choice of treatment are seen. However, it is very important to know that sometimes there is a lack of specificity that has to be considered.
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Affiliation(s)
- A Sánchez Salmón
- Nuclear Medicine Service, Complejo Hospitalario de Santiago de Compostela, A Choupana s/n, Santiago de Compostela, 15706 La Coruña, Spain.
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Meignan M, Haioun C, Itti E, Rahmouni A, Reyes F. Value of [18F]Fluorodeoxyglucose–Positron Emission Tomography in Managing Adults with Aggressive Non-Hodgkin's Lymphoma. ACTA ACUST UNITED AC 2006; 6:306-13. [PMID: 16507208 DOI: 10.3816/clm.2006.n.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An increased glucose metabolic rate is observed with various degrees of intensity in different subtypes of aggressive lymphomas. [(18)F]Fluorodeoxyglucose (FDG)-positron emission tomography (PET; FDG-PET) allows functional imaging of this phenomenon through 3-dimensional tomographic slices, which are now easily fused with computed tomography (CT) images. [(18)F]Fluorodeoxyglucose-PET staging appears superior to conventional staging modalities for detecting nodal and extranodal lymphoma. When performed after first-line chemotherapy, FDG-PET is more efficient than CT and conventional diagnostic methods to predict the disease outcome. Some studies have reported that the relapse rate is 100% in patients with positive PET findings after treatment and 17% in patients with negative PET findings. This imaging modality can also assess early response after 1-2 cycles of chemotherapy, thus identifying responders from patients whose cancer will fail to respond to first-line therapy or will relapse shortly after having exhibited a partial or complete remission. [(18)F]Fluorodeoxyglucose-PET also seems useful for an accurate selection of patients who will benefit from highly intensive treatment.
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Affiliation(s)
- Michel Meignan
- Department of Nuclear Medicine, Hopital Henri Mondor, Creteil, France.
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Kelloff GJ, Hoffman JM, Johnson B, Scher HI, Siegel BA, Cheng EY, Cheson BD, O'shaughnessy J, Guyton KZ, Mankoff DA, Shankar L, Larson SM, Sigman CC, Schilsky RL, Sullivan DC. Progress and promise of FDG-PET imaging for cancer patient management and oncologic drug development. Clin Cancer Res 2005; 11:2785-808. [PMID: 15837727 DOI: 10.1158/1078-0432.ccr-04-2626] [Citation(s) in RCA: 463] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
2-[(18)F]Fluoro-2-deoxyglucose positron emission tomography (FDG-PET) assesses a fundamental property of neoplasia, the Warburg effect. This molecular imaging technique offers a complementary approach to anatomic imaging that is more sensitive and specific in certain cancers. FDG-PET has been widely applied in oncology primarily as a staging and restaging tool that can guide patient care. However, because it accurately detects recurrent or residual disease, FDG-PET also has significant potential for assessing therapy response. In this regard, it can improve patient management by identifying responders early, before tumor size is reduced; nonresponders could discontinue futile therapy. Moreover, a reduction in the FDG-PET signal within days or weeks of initiating therapy (e.g., in lymphoma, non-small cell lung, and esophageal cancer) significantly correlates with prolonged survival and other clinical end points now used in drug approvals. These findings suggest that FDG-PET could facilitate drug development as an early surrogate of clinical benefit. This article reviews the scientific basis of FDG-PET and its development and application as a valuable oncology imaging tool. Its potential to facilitate drug development in seven oncologic settings (lung, lymphoma, breast, prostate, sarcoma, colorectal, and ovary) is addressed. Recommendations include initial validation against approved therapies, retrospective analyses to define the magnitude of change indicative of response, further prospective validation as a surrogate of clinical benefit, and application as a phase II/III trial end point to accelerate evaluation and approval of novel regimens and therapies.
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Affiliation(s)
- Gary J Kelloff
- Cancer Imaging Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland 20892, USA.
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Abstract
Positron emission tomography (PET) using (18)F-fluorodeoxyglucose ((18)F-FDG) is the best noninvasive imaging technique for to assess response in patients suffering from lymphoma. Early response evaluation ("interim PET") after one, a few cycles, or at midtreatment can predict response, progression-free survival, and overall survival. We calculated from data of 7 studies an overall sensitivity to predict treatment failure of 79%, a specificity of 92%, a positive predictive value (PPV) of 90%, a negative predictive value (NPV) of 81%, and an accuracy of 85%. Although it is not yet indicated to change patient management based on residual (18)F-FDG uptake on interim scan in chemotherapy-sensitive patients, prospective studies evaluating the role of an interim PET in patient management clearly are warranted. (18)F-FDG PET also has an important prognostic role in relapsing patients after reinduction chemotherapy before high-dose chemotherapy (HCT) followed by autologous stem cell transplantation (ASCT). However, all chemotherapy-sensitive patients remain candidates for HCT followed by ASCT, even if (18)F-FDG PET showed residual (18)F-FDG uptake. We calculated from data of 3 studies an overestimated risk of relapse in 16% of all PET-positive patients. Some patients with residual (18)F-FDG uptake will have a good outcome after HCT followed by ASCT. (18)F-FDG PET is the imaging technique of choice for end-of-treatment evaluation. However, (18)F-FDG is not specific for tumoral tissue. Active inflammatory lesions and infectious processes can be falsely interpreted as malignant residual cells. However, a negative (18)F-FDG PET cannot exclude minimal residual disease. Consequently, it is always indicated to correlate PET findings with clinical data, other imaging modalities, and/or a biopsy. We calculated, from data of 17 studies in end-of-treatment evaluation, a sensitivity of 76%, a specificity of 94%, a PPV of 82%, a NPV 92%, and an accuracy of 89%.
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Affiliation(s)
- Guy Jerusalem
- Division of Medical Oncology, Department of Medicine, University of Liège, CHU Sart Tillman B35, B-4000 Liège 1, Belgium.
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Fulignati C, Pantaleo P, Cipriani G, Turrini M, Nicastro R, Mazzanti R, Neri B. An uncommon clinical presentation of retroperitoneal non-Hodgkin lymphoma successfully treated with chemotherapy: A case report. World J Gastroenterol 2005; 11:3151-5. [PMID: 15918208 PMCID: PMC4305858 DOI: 10.3748/wjg.v11.i20.3151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We report the case of a patient affected by an extra-nodal non-Hodgkin lymphoma presenting as a unique, large retroperitoneal mass with an unusual clinical presentation mimicking gastric peptic or neoplastic disease. The patient was successfully treated with a first generation therapy, CHOP modified regimen (cyclophosphamide 600 mg/m2 intravenously on d 1, epirubicin 55 mg/m2 intravenously on d 1, vincristine 1.2 mg/m2 intravenously on d 1, prednisone 60 mg/m2 on d 1-5), and a complete response was achieved. The (18)F-fluorodeoxyglucose positron emission tomography was used to assess the therapy outcome. A brief review of literature is provided.
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Affiliation(s)
- Chiara Fulignati
- Department of Internal Medicine, Centre of Experimental and Clinical Oncology, University of Florence, School of Medicine, Viale Morgagni, 85, I-50134 Firenze, Italy
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Hart DP, Avivi I, Thomson KJ, Peggs KS, Morris EC, Goldstone AH, Linch DC, Ell PJ, Bomanji JB, Mackinnon S. Use of 18F-FDG positron emission tomography following allogeneic transplantation to guide adoptive immunotherapy with donor lymphocyte infusions. Br J Haematol 2005; 128:824-9. [PMID: 15755287 DOI: 10.1111/j.1365-2141.2005.05388.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Fluorine-18 fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) provides valuable prognostic information in the management of lymphoma patients. However, the utility of (18)F-FDG PET following allografting is unclear. We analysed the use of (18)F-FDG PET after allogeneic reduced-intensity transplantation (RIT) performed in our institution. Between June 1998 and January 2002, 55 patients underwent RIT for either Hodgkin or non-Hodgkin lymphoma. At least one (18)F-FDG PET scan was performed during the post-transplant period (median five studies) in 15 (27.2%) of these 55 patients. PET scans were performed after re-staging computed tomography (CT) and were categorised depending on (18)F-FDG uptake. The first PET scan was informative in 11 of 15 patients (73%) and influenced the administration of donor lymphocyte infusions (DLI) in nine: leading to earlier DLI administration in two patients, earlier dose escalation in one, withholding of DLI administration in five and dose reduction in one. In addition, subsequent monitoring with (18)F-FDG PET scans documented a graft-versus-lymphoma effect in five patients (median post-DLI follow-up 33 months, range 13-36 months). These preliminary data suggest that (18)F-FDG PET has a role in guiding DLI administration and monitoring the immunotherapeutic effect in patients after allogeneic transplantation. This retrospective pilot study forms the basis for a prospective study to clarify the utility of (18)F-FDG PET/CT in these patients.
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Affiliation(s)
- D P Hart
- Department of Haematology, University College London Hospital, London, UK
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Ruiz Hernández G, Romero de Avila Y Avalos C, Carreras Delgado JL. [The value of 18F-fluoro-2-deoxy-D-glucose positron emission tomography (18F-FDG PET) in diagnosis of neoplastic diseases]. Med Clin (Barc) 2005; 124:229-36. [PMID: 15737307 DOI: 10.1157/13071769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Positron emission tomography (PET) has the ability to detect cancer based on molecular and biochemical processes within the tumor tissues. The most widely used radiotracer in oncology at this time is the glucose analogue 18F-fluoro-2-deoxy-D-glucose (18F-FDG). Like glucose, 18F-FDG is transported into cells by a glucose transporter protein and rapidly converted into 18F-FDG-6-phosphate. PET imaging with 18F-FDG is able to diagnose, stage, and restage many cancers with accuracies ranging from 80% to 90%. Responses to therapy can be identified earlier and with greater accuracy than is possible with anatomic imaging modalities. The prognostic information available through 18F-FDG PET is superior to that of conventional imaging for many cancers. The aim of this review article is to show the most promising clinical indications for the use of PET in oncology.
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Kanter P, Zeidman A, Streifler J, Marmelstein V, Even-Sapir E, Metser U, Stein GY, Cohen AM. PET-CT imaging of combined brachial and lumbosacral neurolymphomatosis. Eur J Haematol 2005; 74:66-9. [PMID: 15613109 DOI: 10.1111/j.1600-0609.2004.00369.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Neurolymphomatosis is a rare manifestation of progressive non-Hodgkin's lymphoma. A 44-yr-old man with diffuse large B-cell lymphoma presented with unilateral progressive peripheral sensorimotor neuropathy after the 7th cycle of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) therapy. No pathology in the nervous system was evident by computerized tomography (CT), magnetic resonance imaging (MRI) of the head, spinal axis and plexuses and by repeated analysis of cerebrospinal fluid. However, the hybrid modality of positron emission tomography (PET) of fluorinated deoxyglucose (FDG) combined with CT scan (PET-CT) showed unilateral involvement of both the brachial and lumbosacral nervous plexuses. A complete recovery of neurological manifestations and normalization of PET-CT followed intensive chemotherapy with autologous stem cell transplantation. The diagnosis and localization of neurolymphomatosis may be supported by PET-CT imaging.
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Affiliation(s)
- Pazit Kanter
- Department of Internal medicine B, Rabin Medical Center, Golda- Hasharon Campus, Petah-Tikva, Israel
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Kumar R, Maillard I, Schuster SJ, Alavi A. Utility of fluorodeoxyglucose-PET imaging in the management of patients with Hodgkin's and non-Hodgkin's lymphomas. Radiol Clin North Am 2004; 42:1083-100. [PMID: 15488559 DOI: 10.1016/j.rcl.2004.08.008] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
FDG-PET imaging has a number of advantages in the management of patients with lymphoma. PET shows a functional metabolic status and gives quantitative information. In addition, PET provides whole-body images that give a comprehensive assessment of disease extent during the staging and followup. Based on the present literature, FDG-PET is at least equivalent to CT for the initial staging of lymphomas. The impact of new technologies of combined PET/CT and fast-scanning CT with contrast has yet to be evaluated in the management of lymphoma patients, however. At this point, FDG-PET and CT must be considered as giving complementary staging information. FDG-PET also has high diagnostic accuracy for restaging lymphoma after initial treatment. FDG-PET has shown high accuracy in the early prediction of response to chemotherapy and in the evaluation of residual masses after chemotherapy or radiation therapy. Therefore, PET is likely to play a major role in tailoring the intensity of the treatment to the individual patient. A pretreatment FDG-PET study is essential for accurate assessment of residual masses and early monitoring of response to the treatment. In addition, a baseline PET scan will help detect relapse or residual disease, because relapse occurs most often in the region of previous disease.
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Affiliation(s)
- Rakesh Kumar
- Division of Nuclear Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 110 Donner Building, Philadelphia, PA 19104, USA
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Meyer RM, Ambinder RF, Stroobants S. Hodgkin's lymphoma: evolving concepts with implications for practice. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2004; 2004:184-202. [PMID: 15561683 DOI: 10.1182/asheducation-2004.1.184] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Hodgkin's lymphoma is a unique neoplasm of B lymphocytes. Recent data provide new understandings of the pathogenesis and options for staging and therapy of the disease. Three specific topics are addressed in this chapter. In Section I, Dr. Richard Ambinder reviews implications of the relationship of Epstein-Barr virus (EBV) and Hodgkin's lymphoma. This relation includes varying geographic epidemiologic associations, including varying associations with the clinical syndrome of infectious mononucleosis. There are plausible mechanisms, including processes initiated by viral proteins, by which EBV might lead to tumorigenesis. These mechanisms include promotion of genetic instability and alteration of normal processes of apoptosis. In addition to an epidemiologic association and potential role in pathogenesis, viral antigens may pose theoretical targets for anti-cancer therapies, including vaccination. In Section II, Dr. Sigrid Stroobants describes the potential role of positron emission tomographic (PET) scanning. By assessing differences in the metabolic activities of cancer cells, PET scanning may be superior to computerized tomographic scanning, which is limited to showing structural anatomical abnormalities. In patients with Hodgkin's and non-Hodgkin's lymphoma, PET scanning has been tested as an initial staging tool, to assess the rate of therapeutic response from a prognostic perspective, and to differentiate residual tumor from fibrotic masses in patients who have completed therapy. Particularly in assessing the nature of a residual mass seen with other post-therapeutic imaging modalities, PET scanning may provide unique information; very high negative predictive values have been reported. However, before this technology can be recommended for incorporation into standard management, properly conducted prospective trials are required to better evaluate the clinical utility of PET with respect to eventual patient outcomes. In Section III, Dr. Ralph Meyer reviews current data regarding the management of patients with limited-stage Hodgkin's lymphoma. Over the past decade, standard treatment has evolved to consist of combined-modality therapy that includes an abbreviated course of chemotherapy and involved-field radiation. As this therapy continues to include radiation therapy, patients will remain at risk of long-term toxicities that include the development of second cancers and cardiovascular events. These "late-effects" now account for more deaths than those attributed to progressive Hodgkin's lymphoma. Comparative data testing the role of chemotherapy alone are now available and demonstrate that omission of radiation therapy results in small but statistically significant reduction in disease control, but no detectable differences in overall survival. Further follow-up will clarify whether chemotherapy alone is the preferred treatment option; at present patients should be informed of the trade-offs involved in choosing between this option and combined modality therapy.
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Affiliation(s)
- Ralph M Meyer
- Juravinski Cancer Centre and McMaster University, Hamilton ONT, Canada
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