Staging and Evaluation of the Patient with Lymphoma

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Patients who have non-Hodgkin's lymphoma or Hodgkin lymphoma most often present for medical attention because of signs or symptoms referable to enlarged lymph nodes or other disease-related symptoms (such as fevers, night sweats or fatigue). Less often, enlarged lymph nodes or splenomegaly may be incidental findings during evaluation for other medical issues. Determination of the extent of disease and accurate assessment of responses are necessary for appropriate management. Newer technologies have improved the ability to evaluate patients and to conduct clinical trials, leading to more effective therapies. This article addresses the advances in staging and evaluation of patients who have lymphoma, specifically examining the use of positron emission tomography.

Section snippets

Pretreatment evaluation

Patients with non-Hodgkin's lymphoma (NHL) or Hodgkin's lymphoma (HL) most often present for medical attention because of signs or symptoms referable to enlarged lymph nodes or other disease-related symptoms, such as fevers, night sweats, or fatigue. They less often present with secondary effects of lymphoma on critical organs, such as bone marrow, lung, liver, spleen, or kidneys. Because of the nonspecific nature of these findings, months may elapse before the diagnosis of lymphoma is

Response assessment

In the absence of effective therapies, assessment of response is almost irrelevant. However, as an increasing number of effective treatments become available, standardized measures of evaluation become critical.

Prior to 1999, the lack of standardized measures led to variability among clinical trials groups and cancer centers in how response to therapy was evaluated and, thus, impeded comparisons of study results. Response was sometimes assessed prospectively, other times retrospectively, with

Recommendations for the use of PET in clinical trials

The clinical use of FDG-PET has far exceeded the validation of this technology in clinical trials. Juweid and colleagues22 were the first to integrate PET into the IWG criteria in NHL. PET not only increased the number of complete remissions in patients with diffuse large B-cell NHL, but it eliminated CRus, and provided a better separation of the progression-free survival curves between CR and partial remission (PR) patients. This information, along with the increasing availability of FDG-PET,

Follow-up evaluation

The most important components of monitoring patients following treatment are a careful history and physical examination along with complete blood count and serum chemistries, including LDH and other relevant blood tests. Recently, the National Comprehensive Cancer Network published recommendations for follow-up of patients with Hodgkin's and non-Hodgkin's lymphoma:55, 56 for patients with Hodgkin's lymphoma in an initial complete remission, follow-up should include an interim history and

Issues with PET(/CT)

A number of important limitations of PET remained to be resolved. Differences in equipment, technique, and variability in interpretation among readers impairs comparisons among studies. Newer technology, such as PET/CT, makes comparisons with older data difficult. Histologic subtypes also differ in FDG-avidity.13, 63, 64, 65, 66 Moreover, there are many common causes of false-positive and false-negative PET scans.22, 28, 51, 67 In addition, the usefulness of PET in clinical trials requires

References (67)

  • M. Hutchings et al.

    FDG-PET after two cycles of chemotherapy predicts treatment failure and progression-free survival in Hodgkin lymphoma

    Blood

    (2006)
  • P. Seam et al.

    The role of FDG-PET scans in patients with lymphoma

    Blood

    (2007)
  • R. Carr et al.

    Detection of lymphoma in bone marrow by whole-body positron emission tomography

    Blood

    (1998)
  • T.C. Kwee et al.

    Imaging in staging of malignant lymphoma: a systematic review

    Blood

    (2008)
  • P.L. Zinzani et al.

    Early positron emission tomography (PET) restaging: a predictive final response in Hodgkin's disease patients

    Ann Oncol

    (2006)
  • M. Liedtke et al.

    Surveillance imaging during remission identifies a group of patients with more favorable aggressive NHL at time of relapse: a retrospective analysis of a uniformly-treated patient population

    Ann Oncol

    (2006)
  • G. Jerusalem et al.

    Early detection of relapse by whole-body positron emission tomography in the follow-up of patients with Hodgkin's disease

    Ann Oncol

    (2003)
  • M. Hoffmann et al.

    Positron emission tomography with fluorine-18-2-fluoro-2-deoxy-D-glucose (F18-FDG) does not visualize extranodal B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT)-type

    Ann Oncol

    (1999)
  • R. Elstrom et al.

    Utility of FDG-PET scanning in lymphoma by WHO classification

    Blood

    (2003)
  • M. Hoffmann et al.

    18F-fluoro-deoxy-glucose positron emission tomography in lymphoma of mucosa-associated lymphoid tissue: histology makes the difference

    Ann Oncol

    (2006)
  • B.D. Cheson

    Hodgkin's disease, alcohol and vena caval obstruction

    JAMA

    (1978)
  • B.D. Cheson et al.

    Report of an International Workshop to standardize response criteria for non-Hodgkin's lymphomas

    J Clin Oncol

    (1999)
  • B.D. Cheson et al.

    Revised response criteria for malignant lymphoma

    J Clin Oncol

    (2007)
  • A. Surbone et al.

    Residual abdominal masses in aggressive non-Hodgkin's lymphoma after combination chemotherapy: significance and management

    J Clin Oncol

    (1988)
  • J.A. Radford et al.

    The significance of residual mediastinal abnormality on the chest radiograph following treatment for Hodgkin's disease

    J Clin Oncol

    (1988)
  • K. Spaepen et al.

    Prognostic value of positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose ([18F]FDG) after first-line chemotherapy in non-Hodgkin's lymphoma: is [18F]FDG-PET a valid alternative to conventional diagnostic methods?

    J Clin Oncol

    (2001)
  • G. Jerusalem et al.

    Whole-body positron emission tomography using 18F-fluorodeoxyglucose compared to standard procedures for staging patients with Hodgkin's disease

    Haematologica

    (2001)
  • G. Jerusalem et al.

    Whole-body 18F-FDG PET for the evaluation of patients with Hodgkin's disease and non-Hodgkin's lymphoma

    Nucl Med Commun

    (1999)
  • P.L. Zinzani et al.

    The role of positron emission tomography (PET) in the management of lymphoma patients

    Ann Oncol

    (1999)
  • R. Naumann et al.

    Prognostic value of popsitron emission tomography in the evalaution of post-treatment residual mass in patients with Hodgkin's disease and non-Hodgkin's lymphoma

    Br J Haematol

    (2001)
  • L. Kostakoglu et al.

    Comparison of fluorine-18 fluorodeoxyglucose positron emission tomography and Ga-67 scintigraphy in evaluation of lymphoma

    Cancer

    (2002)
  • R. Naumann et al.

    Substantial impact of FDG PET imaging on the therapy decision in patients with early-stage Hodgkin's lymphoma

    Br J Cancer

    (2004)
  • M. Juweid et al.

    Response assessment of aggressive non-Hodgkin's lymphoma by integrated International Workshop criteria (IWC) and 18F-fluorodeoxyglucose positron emission tomography (PET)

    J Clin Oncol

    (2005)
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