Bruce D. Cheson, MD; Gilles Salles, MD, PhD


June 13, 2013

In This Article

Fewer PETs and Back to Basics for Surveillance

Dr. Cheson: The other topic that was discussed at the lymphoma session was the use of PET scans for surveillance in diffuse large B-cell lymphoma and Hodgkin lymphoma. The drugs are going to be very expensive, but another area where we spend a lot of money is on imaging studies. PET scans are going to be used for staging, and they are used for response, but they are also used to follow patients. You don't examine the patient anymore; you just do a PET scan every so often. What studies were presented, and what was your take on them?

Dr. Salles: There were 2 important studies. The first was carried out by colleagues at the Mayo Clinic[6] in patients with diffuse large B-cell lymphoma, and they looked at the way in which the patients relapsed and were identified. They found that in more than 90% of the cases, the relapses were identified by clinical symptoms or clinical examination by the physician and not by imaging.

Dr. Cheson: It was 98%.

Dr. Salles: Yes, that clearly demonstrates that we don't need systematic CT or PET/CT surveillance scans for years in these patients. Most patients in which the disease will recur will come back to the clinics or will be identified during regular visits. Obviously, this was a retrospective study, and it needs to be evaluated. They have a validation survey, and it would be interesting to look at the data in more detail, especially during the first year after the completion of therapy.

But clearly, the study indicates that in the long run, we don't need to follow patient with regular CT or PET/CT. A similar report[7]was given by several institutions in the United States on Hodgkin disease, so both are curable diseases -- large B-cell lymphoma and Hodgkin disease -- indicating that the number of relapses that were picked up with surveillance imaging was 1% or 2%. Most of the relapses were very limited in this series and were picked up by symptoms and the patients coming back with symptoms.

As Dr. Leo Gordon mentioned, we have to bring back clinical history and clinical examination in the way that we manage the lymphoma patients with this curable disease. It's easy, it costs much less, and it doesn't expose the patients to potential harm of repeated x-ray exposures.

Dr. Cheson: They mentioned a cost. It was approximately $593,000 to pick up 1 relapse using PET/CT scans that was probably salvageable by transplant or something else. The cost/benefit ratio at a time of shrinking resources just doesn't seem to be there. In Hodgkin lymphoma and in large cell lymphoma -- the curable diseases -- after I get a scan 6-8 weeks after treatment, I don't do any more scans. Earlier, you said you may do 1 per year, but what about the other diseases? We don't know what to do in follicular and mantle cell lymphoma.


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