What's New: Imaging in Lymphoma

Bruce D. Cheson, MD


November 14, 2014

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This is Bruce Cheson from Georgetown University Hospital Lombardi Comprehensive Cancer Center, speaking for Medscape Hematology. I was sitting around the office with nothing to do, reading a new journal, and lo and behold, I came upon two papers in the September 20, 2014, issue of the Journal of Clinical Oncology. Sally Barrington is the first author of " Role of Imaging in the Staging and Response Assessment of Lymphoma: Consensus of the ICML Working Group."[1] The other article is first authored by me, along with Rich Fisher, Sally Barrington, Franco Cavalli, Larry Schwartz, Manny Zucca, and Andrew Lister, and is titled "Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification."[2]

The journey of these papers started before 1999. Until 1999, there were no standardized response criteria, and staging was done only for Hodgkin lymphoma because it helped the radiation therapists point their beams at the appropriate site. In 1999, we first published the National Cancer Institute's working group guidelines for response and standardized the terminology.[3] This had to be updated in 2007[4] because we began to use PET scans, which helped distinguish scar tissue from viable tumor. These guidelines became known as the International Working Group criteria, and they served us well and were used by all of the cooperative groups, cancer centers, and regulatory agencies.

In 2011, we got together at the International Conference on Malignant Lymphoma (ICML) in Lugano, Switzerland, with representatives of all the major cooperative groups and cancer centers around the world where lymphoma is treated. We identified the problems and the issues that needed to be resolved. We organized subcommittees, and proposals were drafted and presented 2 years later at the next ICML meeting. Modifications of these proposals resulted in these two articles.

What is new? As of 2007, PET scans have been part of response assessment, but now that everyone is doing PET scans prior to therapy, we included them as standard for staging of FDG-avid lymphomas, which comprises all lymphomas except chronic lymphocytic leukemia, small lymphocytic leukemia, marginal zone, lymphoplasmacytic lymphoma, Waldenström's macroglobulinemia, mycosis fungoides, and Sézary syndrome. We modified the Ann Arbor criteria to make them more contemporary. We designated a length of 13 cm as the cut-off for splenomegaly and described how to evaluate the spleen in a more organized manner. We said that it is not enough to use the Ann Arbor criteria to define the geographic extent of the disease—that we should be treating the patients on the basis of risk and prognostic factors. In clinical trials, we no longer need routine chest x-rays for Hodgkin's lymphoma. PET-CT scans are better. We no longer need a bone marrow biopsy for Hodgkin's lymphoma or for most patients with diffuse large B-cell lymphoma. The terms A and B for constitutional symptoms are only prognostic in Hodgkin's lymphoma and therefore don't need to be used in non-Hodgkin's, although we need to record those symptoms.

For response, PET-CT is the gold standard for FDG-avid histologies, but now instead of visual assessment, we use the Deauville five-point scale, which has changed from mediastinal blood pool as the comparator to hepatic blood pool, and has been reproduced and validated repeatedly. A complete response can include a residual mass as long as it is not FDG-avid, and for progressive disease, you only need one node within certain parameters of how big it has to get and what percent it has to increase in size.

We hope that these will serve us well, at least for the foreseeable future, recognizing that changes will be necessary. We still don't have a definition for bulky disease, and several studies suggest that quantitative measures of response with PET may be better than something like the Deauville score, looking at total tumor glycolysis, or looking at the delta SUV alone or in combination with changes in size. There is still work to be done, and eventually another paper will be written.

If you are designing clinical trials in lymphoma, either as an investigator or a pharmaceutical company, this issue of the Journal of Clinical Oncology should serve you well. Cite these papers repeatedly to increase the impact factor of the journal. This is Bruce Cheson for Medscape Hematology.


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