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The Role of F18-fluorodeoxyglucose Positron Emission Tomography in the Management of Relapsed or Refractory Hodgkin’s Lymphoma

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Published Online: Jun 25th 2012 Oncology & Hematology Review (US), 2012;8(2):111-5 DOI: https://doi.org/10.17925/OHR.2012.08.2.111
Authors: Amanda F Cashen
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Abstract
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Abstract:
Overview

Positron emission tomography (PET) is widely used in the diagnosis and response assessment after first-line treatment of Hodgkin’s lymphoma (HL). For the approximately 30 % of patients who relapse or have refractory disease, PET can provide valuable prognostic information during second-line therapy, at the time of autologous stem cell transplant (ASCT). Retrospective studies performed over the past decade have consistently found a significant association between a positive PET scan after salvage chemotherapy for HL and progression-free and overall survival after ASCT. In fact, the predictive value of pre-transplant PET appears higher than that of more traditional clinical risk factors. Unfortunately, there is little data to recommend the best treatment course for patients who have a positive pre-ASCT PET, and few studies have addressed the role of PET in other relapsed/refractory HL settings.

Keywords

Hodgkin’s lymphoma, positron emission tomography, autologous stem cell transplant, allogeneic stem cell transplant, prognosis

Article:

F18-fluorodeoxyglucose positron emission tomography (FDG-PET), commonly combined with computed tomography (CT), is widely used in the initial evaluation and response assessment of patients with Hodgkin’s lymphoma (HL). Its sensitivity for nodal and extranodal sites of disease can add to the staging information obtained with CT alone,1 and PET is valuable in the response assessment at the end of front-line therapy because it can distinguish active disease from fibrosis in residual masses. In fact, the goal of front-line therapy is now a PET-negative complete remission (CR).2 Interim PET scan, performed during the initial course of therapy, may also have prognostic significance,3 and treatment adapted to interim PET results is under investigation in ongoing clinical trials.

The role of PET in the response assessment and management of relapsed and refractory HL is less well established than in the front-line setting. Up to 30 % of patients with HL will fail to respond to, or will relapse after, initial therapy, and approximately 50 % of these patients can achieve durable disease-free survival with salvage chemotherapy and autologous stem cell transplant (ASCT). Retrospective studies have consistently demonstrated the prognostic significance of a PET scan performed prior to ASCT, although it is unclear how those PET results should guide the choice of salvage therapy or the transplant approach. This article will focus on the role of PET in the management of patients with relapsed or refractory HL who are candidates for ASCT. It will also address the limited evidence for the use of PET in relapsed HL patients who are not undergoing ASCT.

Positron Emission Tomography in Patients Undergoing Autologous Stem Cell Transplant
Prognostic Significance of Pre-transplant Positron Emission Tomography
Over the past two decades, several groups have identified clinical factors that predict the outcome of salvage therapy in patients with relapsed or refractory HL.4–9 They identified adverse factors that include time to relapse less than one year, advanced stage or extranodal disease at relapse, and various components of the International Prognostic Score,10 such as hypoalbuminemia, anemia, older age, and lymphopenia. Because the various proposed prognostic scores are based on factors present at the time of relapse, without incorporating subsequent information about response to salvage therapy, they have the potential to influence the choice of salvage chemotherapy. However, in practice, most patients with relapsed or refractory HL are candidates for ASCT and are treated with standard aggressive combination chemotherapy, regardless of their relapse prognostic score. Instead of clinical factors at relapse, the response to the salvage chemotherapy has emerged as the most important predictor of progression-free survival (PFS) and overall survival (OS) in relapsed HL, and that response is most accurately determined by PET.

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Disclosure

The author has no conflicts of interest to declare.

Correspondence

Amanda F Cashen, MD, Washington University School of Medicine, 660 South Euclid Ave, Box 8007, St Louis MO 63110, US. E: acashen@dom.wustl.edu

Received

2012-08-22T00:00:00

References

  1. Rigacci L, Vitolo U, Nassi L, et al., Positron emission tomography in the staging of patients with Hodgkin’s lymphoma. A prospective multicentric study by the Intergruppo Italiano Linfomi, Ann Hematol, 2007;86(12):897–903.
  2. Cheson BD, Pfistner B, Juweid ME, et al., Revised response criteria for malignant lymphoma, J Clin Oncol, 2007; 25(5):579–86.
  3. Gallamini A, Hutchings M, Rigacci L, et al., Early interim 2- [18F]fluoro-2-deoxy-D-glucose positron emission tomography is prognostically superior to international prognostic score in advanced-stage Hodgkin’s lymphoma: a report from a joint Italian-Danish study, J Clin Oncol, 2007;25(24):3746–52.
  4. Josting A, Franklin J, May M, et al., New prognostic score based on treatment outcome of patients with relapsed Hodgkin’s lymphoma registered in the database of the German Hodgkin's lymphoma study group, J Clin Oncol, 2002;20(1):221–30.
  5. Brice P, Bastion Y, Divine M, et al., Analysis of prognostic factors after the first relapse of Hodgkin’s disease in 187 patients, Cancer, 1996;78(6):1293–9.
  6. Bonfante V, Santoro A, Viviani S, et al., Outcome of patients with Hodgkin’s disease failing after primary MOPP-ABVD, J Clin Oncol, 1997;15(2):528–34.
  7. Bierman PJ, Lynch JC, Bociek RG, et al., The International Prognostic Factors Project score for advanced Hodgkin’s disease is useful for predicting outcome of autologous hematopoietic stem cell transplantation, Ann Oncol, 2002;13(9):1370–7.
  8. Sureda A, Constans M, Iriondo A, et al., Prognostic factors affecting long-term outcome after stem cell transplantation in Hodgkin’s lymphoma autografted after a first relapse, Ann Oncol, 2005;16(4):625–33.
  9. Moskowitz CH, Nimer SD, Zelenetz AD, et al., A 2-step comprehensive high-dose chemoradiotherapy second-line program for relapsed and refractory Hodgkin disease: analysis by intent to treat and development of a prognostic model, Blood, 2001;97(3):616–23.
  10. Hasenclever D, Diehl V, Armitage JO, et al., A prognostic score for advanced Hodgkin’s disease. International Prognostic Factors Project on Advanced Hodgkin’s Disease, N Engl J Med, 1998;339(21):1506–14.
  11. Poulou L, 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, 2010;37(1):156–62.
  12. Palmer J, Goggins T, Broadwater G, et al., Early post transplant (F-18) 2-fluoro-2-deoxyglucose positron emission tomography does not predict outcome for patients undergoing auto-SCT in non-Hodgkin and Hodgkin lymphoma, Bone Marrow Transplant, 2011;46(6):847–51.
  13. Jabbour E, Hosing C, Ayers G, et al., Pretransplant positive positron emission tomography/gallium scans predict poor outcome in patients with recurrent/refractory Hodgkin lymphoma, Cancer, 2007;109(12):2481–9.
  14. Moskowitz AJ, Yahalom J, Kewalramani T, et al., Pretransplantation functional imaging predicts outcome following autologous stem cell transplantation for relapsed and refractory Hodgkin lymphoma, Blood, 2010;116(23):4934–7.
  15. Sucak GT, Özkurt ZN, Suyanı E, et al., Early posttransplantation positron emission tomography in patients with Hodgkin lymphoma is an independent prognostic factor with an impact on overall survival, Ann Hematol, 2011;90(11):1329–36.
  16. Devillier R, Coso D, Castagna L, et al., Positron emission tomography response at the time of autologous stem cell transplantation predicts outcome of patients with relapsed and/or refractory Hodgkin’s lymphoma responding to prior salvage therapy, Haematologica, 2012;97(7):1073–9.
  17. Mocikova H, Pytlik R, Markova J, et al., Pre-transplant positron emission tomography in patients with relapsed Hodgkin lymphoma, Leuk Lymphoma, 2011;52(9):1668–74.
  18. Smeltzer JP, Cashen AF, Zhang Q, et al., Prognostic significance of FDG-PET in relapsed or refractory classical Hodgkin lymphoma treated with standard salvage chemotherapy and autologous stem cell transplantation, Biol Blood Marrow Transplant, 2011;17(11):1646–52.
  19. Castagna L, Bramanti S, Balzarotti M, et al., Predictive value of early 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) during salvage chemotherapy in relapsing/refractory Hodgkin lymphoma (HL) treated with high-dose chemotherapy, Br J Haematol, 2009;145(3):369–72.
  20. Juweid ME, Stroobants S, Hoekstra OS, et al., 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(5):571–8.
  21. Cocorocchio E, Peccatori F, Vanazzi A, et al., High-dose chemotherapy in relapsed or refractory Hodgkin lymphoma patients: a reappraisal of prognostic factors, Hematol Oncol, 2012 Mar 30 [Epub ahead of print].
  22. Arai S, Letsinger R, Wong RM, et al., Phase I/II trial of GN-BVC, a gemcitabine and vinorelbine-containing conditioning regimen for autologous hematopoietic cell transplantation in recurrent and refractory hodgkin lymphoma, Biol Blood Marrow Transplant, 2010;16(8):1145–54.
  23. Meignan M, Gallamini A, Itti E, et al., Report on the Third International Workshop on Interim Positron Emission Tomography in Lymphoma held in Menton, France, 26-27 September 2011 and Menton 2011 consensus, Leuk Lymphoma, 2012 Apr 23 [Epub ahead of print].
  24. Horning SJ, Juweid ME, Schöder H, et al., Interim positron emission tomography scans in diffuse large B-cell lymphoma: an independent expert nuclear medicine evaluation of the Eastern Cooperative Oncology Group E3404 study, Blood, 2010;115(4):775–7.
  25. Schot B, Pruim J, van Imhoff G, et al., The role of serial pre-transplantation positron emission tomography in predicting progressive disease in relapsed lymphoma, Haematologica, 2006;91(4):490–5.
  26. Moskowitz CH, Matasar MJ, Zelenetz AD, et al., Normalization of pre-ASCT, FDG-PET imaging with second-line, non-crossresistant, chemotherapy programs improves event-free survival in patients with Hodgkin lymphoma, Blood, 2012;119(7):1665–70.
  27. Morschhauser F, Brice P, Fermé C, et al., Risk-adapted salvage treatment with single or tandem autologous stem-cell transplantation for first relapse/refractory Hodgkin's lymphoma: results of the prospective multicenter H96 trial by the GELA/SFGM study group, J Clin Oncol, 2008;26(36):5980–7.
  28. Lambert JR, Bomanji JB, Peggs KS, et al., Prognostic role of PET scanning before and after reduced-intensity allogeneic stem cell transplantation for lymphoma, Blood, 2010;115(14):2763–8.
  29. Kletter K, Kalhs P, (18)F-deoxyglucose PET: useful in the management of patients with stem cell transplantation for lymphoma?, Expert Rev Hematol, 2010;3(4):405–10.
  30. Dodero A, Crocchiolo R, Patriarca F, et al., Pretransplantation [18-F]fluorodeoxyglucose positron emission tomography scan predicts outcome in patients with recurrent Hodgkin lymphoma or aggressive non-Hodgkin lymphoma undergoing reduced-intensity conditioning followed by allogeneic stem cell transplantation, Cancer, 2010;116(21):5001–11.

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