Overview of early response assessment in lymphoma with FDG-PET

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.

Figure 1

In this patient with clinical and CT stage II NHL involving the left supraclavicular and superior mediastinal nodal stations, high FDG uptake in axillary and para-aortic nodes of normal size, and in a non-enlarged spleen, rendered the patient stage IIIS by PET criteria. These findings have potential management and prognostic implications. Due to lack of baseline radiological abnormality, CT is obviously of limited utility in monitoring response at these sites.

Figure 2

PET/CT offers the ability to assess both the metabolic and structural characteristics of a tumoral mass and can also metabolically guide biopsy of heterogeneous masses to increase the likelihood of diagnostic pathological results. In this patient with a partial radiological response, PET demonstrated a sustained complete metabolic response.

Figure 3

Despite evidence that a complete metabolic response (normalization of baseline abnormalities) indicates a substantially better prognosis than lack thereof, it should not be assumed that this represents cure as demonstrated by this case where an interim CMR was clearly followed by local relapse in the mediastinum. Of note, interim CT showed only a partial response whereas the recurrent disease detected by post-treatment PET was not apparent on CT at that time with the patient being classified as having had a complete response.