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Surveillance imaging unnecessary for most patients with early-stage Hodgkin's lymphoma
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Routine radiologic surveillance with CT or PET/CT can be safely omitted for patients with early-stage Hodgkin’s lymphoma who are treated with a specific chemotherapy and radiation combination, according to a study findings.
Patients who receive doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD) plus radiotherapy have an extremely low risk of relapse, results showed. The elimination of routine imaging would result in reduced radiation exposure and health care expenses, researchers wrote.
Heiko Schöder
Imaging is often used to detect an early relapse; however, imaging asymptomatic patients with Hodgkin’s lymphoma after successful treatment is controversial because most relapses are detected by clinicians based on suspicion or symptoms reported by the patient, according to study background. There also is a concern about long-term biological effects for patients with a high probability of long-term survival who are overexposed to radiation.
“A number of recent studies have questioned the value of ‘surveillance imaging’ or ‘routine follow-up imaging’ in potentially curable lymphoma patients who achieve a complete response after all planned therapy,” Heiko Schöder, MD, deputy chief of molecular imaging and therapy service at Memorial Sloan Kettering Cancer Center, told HemOnc Today. “Nevertheless, routine follow-up imaging is still widely performed, usually with CT scans or FDG PET/CT or a combination of both.
“The probability of finding relapsed, asymptomatic disease on these surveillance scans is generally low. However, current national guidelines vary in their recommendation of imaging tests in the follow-up of lymphoma patients, and practitioners and patients are reluctant to abandon follow-up imaging tests,” Schöder said. “This is largely based on the premise that a negative follow-up scan is reassuring to patients and oncologists, but it ignores the potential false-positive imaging findings as well as the involved costs and unnecessary radiation dose to patients. The latter seems particularly relevant in younger patients.”
Schöder and colleagues conducted a study to investigate the utility of any surveillance imaging in 78 patients (median age, 43 years) with early-stage Hodgkin’s lymphoma who achieved a complete response — based on either their interim or post-chemotherapy radiologic surveillance (CT or PET) — with ABVD plus radiation. A majority of patients (61.5%) were younger than 45 years and had stage II disease (85%).
Patients underwent imaging with PET, CT or both at the initial staging, during or after chemotherapy and for at least 2 years during follow-up.
Seventy-seven patients underwent interim PET/CT scans, 94.8% of whom achieved a complete response. Of the four patients who remained PET-positive, none relapsed during follow-up. Median follow-up was 46 months (range, 24-126 months).
During 466 follow-up scans (91% CT alone, 9% PET/CT), researchers detected no Hodgkin’s lymphoma relapses. Eleven patients had abnormalities detected, nine of which were false positives and two of which were second primary malignancies.
No relapses occurred in the 25 patients (32%) who had bulky disease.
The average cumulative radiation dose per patient during follow-up imaging was 107 mSv, which is equivalent to an estimated lifetime excess cancer risk of 0.5%. The estimated cost of the imaging — based on Medicare reimbursements — was $296,817, although the researchers suggested that real costs were likely to be even higher.
The researchers noted that although there was a short median follow-up, most Hodgkin’s lymphoma relapses occur within 2 years. However, secondary solid malignancies are more common in long-term survivors and often occur with a latency of more than 5 to 10 years, which suggests large, prospective studies with extended follow-up would be needed to determine the best imaging strategy to track for secondary malignancies.
“Routine follow-up imaging tests, therefore, do not appear justified in this group of patients,” Schöder said. “Unnecessary surveillance exposure to diagnostic radiation and its attendant cost are other reasons that argue against routine follow-up imaging.
“Importantly, our results are confined to patients who successfully achieved a complete metabolic response on FDG PET/CT, either during chemotherapy or after completion of combined modality therapy,” Schöder said. “A negative PET scan in this setting has extremely high negative predictive value. [We], therefore, suggest that these patients can be reassured and followed clinically without the need for surveillance imaging.” – by Anthony SanFilippo
For more information:
Heiko Schöder, MD, can be reached at Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065; email: schoderh@mskcc.org.
Perspective
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Bruce D. Cheson, MD
Although it has been 25 years since PET scans were first introduced for lymphoma, it wasn’t until the 2007 International Working Group recommendations that they were incorporated into the routine restaging of patients with Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma because of their ability to distinguish residual fibrotic masses from active tumor and, until 2014 with the new Lugano Classification, as part of routine staging of FDG-avid histologies because of their increased sensitivity compared with CT scans.Other uses, however, remain controversial. Gandikota and colleagues studied patients with early-stage HL and provided additional ammunition against the commonly performed but unsupportable practice of surveillance imaging following initial response assessment. The expectation is that recurrence will be detected early and treated promptly with improved outcome. However, this and other papers in HL, as well as NHL — both limited and advanced disease — demonstrate that additional imaging beyond response assessment contributes increased radiation exposure, anxiety and false-positive results, with resulting additional testing, often including biopsies. Indeed, the available data demonstrate that the likelihood of identifying an asymptomatic recurrence by routine scanning is exceptionally low and is not associated with improved outcome. As a result, the recent Lugano Classification clearly discourages surveillance imaging in HL and diffuse large B-cell lymphoma, with the judicious use of such studies in other histologies.
What are the alternatives? Deep sequencing or other assays of minimal residual disease can identify lower levels of tumor than scans and eventually may provide less expensive — and non-invasive — methods of identifying persistent or recurrent disease. Thus, a blood test may replace nuclear imaging for follow-up of patients with lymphoma. Whether patient outcome will be favorably impacted will still need to be demonstrated by prospective clinical trials.
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