Very low utility of surveillance imaging in early-stage classic Hodgkin lymphoma treated with a combination of doxorubicin, bleomycin, vinblastine, and dacarbazine and radiation therapy

Abstract

Background: This study evaluated the need for surveillance imaging in early-stage classic Hodgkin lymphoma (cHL) after planned combined-modality therapy (CMT).

Methods: Primary early-stage cHL patients who underwent CMT were included. Positron emission tomography (PET)/computed tomography (CT), CT, or both were performed at the initial staging, during or after chemotherapy, and for at least 2 years during follow-up. Imaging studies and medical records were reviewed to determine if and when relapse had occurred. Radiation doses and costs were also calculated from follow-up imaging.

Results: The study included 78 patients with a median follow-up of 46 months; 85% of the patients had stage II disease (32% with bulky disease). Four of 77 interim PET scans were positive; none of these patients relapsed during follow-up, which ranged from 24 to 80 months. After a total of 466 follow-up imaging studies (91% with CT and 9% with PET/CT), no cHL relapse was detected. Eleven abnormal findings were noted on surveillance imaging: 9 were false-positives, and 2 were second primary malignancies. The average cumulative dose per patient from follow-up imaging was 107 mSv, which translated into an estimated lifetime excess cancer risk of 0.5%; the estimated total costs were $296,817 according to Medicare reimbursements.

Conclusions: Surveillance imaging with either CT or PET/CT can be omitted safely for early-stage cHL treated with a combination of doxorubicin, bleomycin, vinblastine, and dacarbazine and radiation therapy because the risk of relapse is extremely low. This observation also applies to patients with bulky disease. The elimination of surveillance imaging will also reduce healthcare expenses and cumulative radiation doses in these predominantly young patients.

Keywords: Hodgkin lymphoma; combined-modality therapy; early stage; positron emission tomography (PET) scan; surveillance imaging.

Figure 1

Identification of eligible patients. ABVD indicates doxorubicin, bleomycin, vinblastine, and dacarbazine; HL, Hodgkin lymphoma; RT, radiation therapy.

Figure 2

Details of PET/CT and follow-up imaging. CAP indicates chest, abdomen, and pelvis; CMT, combined-modality therapy; CT, computed tomography; EOT, end of treatment; FDG, fludeoxyglucose; FP, false-positive; HL, Hodgkin lymphoma; MR, magnetic resonance; PET, positron emission tomography; pt, patient.