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Routine imaging does not significantly improve OS in relapsed DLBCL
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Method of detection did not significantly impact OS in relapsed cases of diffuse large B-cell lymphoma that occur after autologous hematopoietic cell transplantation, according to a retrospective, multicenter study published in Clinical Lymphoma, Myeloma & Leukemia.
Routine imaging detected a majority of DLBCL relapses; however, it may be of limited use after patients undergo autologous hematopoietic stem cell transplantation (HSCT).
“Currently there is a lack of consensus regarding optimal method and frequency of radiographic imaging surveillance for diffuse large B-cell lymphoma (DLBCL) patients whose disease is in remission,” Narendranath Epperla, MD, hematology and oncology fellow at Medical College of Wisconsin, and colleagues wrote. “[Although] there is a growing literature suggesting a lack of clinical benefit of surveillance imaging for DLBCL in first complete remission, little is known about the potential value of surveillance imaging for patients with relapsed and refractory DLBCL who experience a complete remission after autologous HSCT. In this setting, there is a considerably higher risk for relapse compared to patients in first complete remission.”
The researchers performed a study of 160 patients with DLBCL who achieved complete remission after transplantation and underwent surveillance imaging. All patients had received care at academic tertiary care centers in Milwaukee, Chicago or Houston between January 2000 and December 2013.
Forty-five patients experienced a relapse after 100 days posttransplantation.
Routine imaging detected relapses in 32 (71%) of those patients, and clinical detection found relapses in 13 patients (29%).
Median time from diagnosis to cell transplantation was similar between groups (radiographic detection, 389 days vs. clinical detection, 621 days), as was median follow-up after transplantation (2,464 days vs. 1,593 days).
Median time from transplantation to relapse was 191 days in radiographically detected relapses, compared with 492 days in clinically detected relapses.
Patients with radiographically detected relapses had longer postrelapse survival (359 days vs. 123 days). However, researchers reported that median posttransplantation OS was similar for both groups of relapsed patients (643 days vs. 586 days).
“Given these data … there appears to be limited utility for routine imaging after autologous [HSCT], except in select cases where earlier detection and salvage with allogeneic [HSCT] is an option, in which case surveillance up to two years after autologous [HSCT] may be warranted,” the researchers wrote. “However, a randomized controlled trial comparing clinical surveillance versus radiographic surveillance after autologous hematopoietic cell transplantation with a larger sample size is needed to definitively determine whether surveillance imaging offers a survival benefit over clinical surveillance in this patient subset.” – by Andy Polhamus
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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About one-third of all newly diagnosed patients with B cell non-Hodgkin lymphoma belong to the category of diffuse large B cell lymphoma (DLBCL). R-CHOP remains the standard of care for the majority of patients with DLBCL. Radiological imaging before and at the end of treatment is essential for disease assessment. However, routine radiological surveillance after end of primary therapy for patients in remission has come into question due to health care costs, risk of excessive radiation exposure and unnecessary invasive diagnostic procedures due to false positive results. European Society of Medical Oncology and the National Comprehensive Cancer Network guidelines recommend surveillance CT scans no more than every 6 months for the first 2 years after end of primary therapy. Several studies including 2014 Lugano classification system advises against routine surveillance imaging.
Autologous stem cell transplantation (ASCT) is the standard of care for patients with relapsed chemosensitive DLBCL. Unfortunately, 50% to 60% of patients relapse after ASCT. Even if the evidence is mounting against use of routine radiological surveillance after end of primary therapy for patients in remission, there is paucity of data in the posttransplant setting. Practice varies from institution to institution. Some centers perform a scan only once to document disease response at day 100 post-ASCT, whereas others believe in routine periodic surveillance.
Epperla and colleagues conducted a multicenter retrospective review examining DLBCL patients who received routine surveillance imaging after complete response from autologous hematopoietic cell transplantation (auto-HCT). They found no significant survival benefit for surveillance imaging, but the paper did suggest potential value of routine imaging after auto-HCT in select cases where earlier detection and salvage therapy with allogeneic HCT would be an option because the majority of relapses (71%) were detected by radiologic imaging. The manuscript fails to mention whether early allogeneic transplantation would translate to improved survival in the surveillance cohort. At our institution, we tried to answer a similar question prior to auto-ASCT in classifying relapses in two cohorts — relapse detected by clinical means versus relapse detected by routine scanning — and did not find any difference in survival among the groups after transplantation. In the absence of any prospective data, we can only summarize that the need for routine surveillance and its frequency and duration after ASCT be determined by the treating physician as a case-by-case basis.
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