ABVD alone and a PET scan complete remission negates the need for radiologic surveillance in early‐stage, nonbulky Hodgkin lymphoma

Abstract

BACKGROUND: Patients with early‐stage, nonbulky classic Hodgkin lymphoma (cHL) undergo intensive posttreatment radiologic surveillance despite having a low risk of disease recurrence. The current study attempted to evaluate the risk of disease recurrence and the value of radiologic surveillance in patients treated with the combination of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) alone who achieved a complete remission (CR) as noted on posttreatment positron emission tomography (PET). METHODS: Forty‐seven patients who underwent therapy with interim and/or posttreatment PET scans were evaluated for disease recurrence during ≥ 24 months of follow‐up. Their presenting characteristics and imaging results were assessed and interpreted in relation to clinical outcome. RESULTS: All 47 patients were eligible for analysis. The majority of patients were female (35 patients) with a median age of 28 years (range, 17 years‐65 years.). The nodular sclerosing subtype was the predominant histology (41 patients). A total of 34 patients were staged with IIA disease, 6 with IA disease, 6 with IIB disease, and 1 with IIEA disease (lung) (according to Cotswolds modification of the Ann Arbor staging system). All patients completed 6 cycles of planned ABVD therapy and achieved a CR. Two had a positive PET scan (1 interim scan and 1 posttreatment scan); both were biopsy‐proven sarcoidosis. Two patients developed disease recurrence at 7 months and 24 months, respectively, after negative interim and posttreatment imaging. One case of recurrence was identified through surveillance imaging and the other was identified simultaneously by the patient and surveillance scan. A total of 45 patients experienced a durable CR; 21 had additional unscheduled imaging/workup during surveillance to investigate symptoms or imaging signs of concern. CONCLUSIONS: Because of a low risk of disease recurrence, posttreatment radiologic surveillance appears to be unnecessary in patients with early‐stage, nonbulky (CD20 negative) cHL who achieve a PET‐detected CR with the ABVD combination alone. This will reduce cumulative radiation exposure and health care costs in a predominantly young patient population. Cancer 2013. © 2012 American Cancer Society.

Imaging for Staging and Response Assessment in Lymphoma

“…Surveillance FDG PET/CT scans, those performed after patients have achieved remission, have been shown to have high false-positive rates (80) and are not generally recommended. Surveillance CT imaging is still widely performed but may not be necessary in all patients (81). The Lugano criteria provide a consensus statement on follow-up imaging advising against routine surveillance FDG PET/CT scans in asymptomatic patients and recommending imaging with CT for follow-up as indicated by clinical signs or symptoms or as required by a clinical trial.…”

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

“…Imaging studies included PET/CT and dedicated CT scans performed either at our institution or outside facilities that followed standard protocols as described previously. 27 PET/CT scans were obtained from the base of the skull to the upper thighs (low-dose CT performed with 120 kV and 80 mA; 12-15 mCi of [ 18 F]FDG). Dedicated CT imaging included the chest, abdomen, and pelvis in most cases and neck imaging as required after the administration of oral and intravenous contrast material.…”

“…[18][19][20][21][22][23][24] The increasing use of medical imaging has also led to concerns about the potential long-term biologic effects of ionizing radiation, particularly in young patients with early-stage cHL who have a high probability of long-term survival. 1,25,26 On the basis of our prior work, 27 we investigated the utility of any surveillance imaging in patients with early-stage cHL treated with CMT who achieved a complete metabolic response according to either interim or postchemotherapy PET/CT.…”

Role of FDG-PET/CT in staging and first-line treatment of Hodgkin and aggressive B-cell lymphomas

“…Following adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD), a negative PET/CT is associated with a 5-year relapse free survival (RFS) of ~ 95 % in stage I/II HL [29][30][31][32] (typically with subsequent radiotherapy) [29,30,32] and ~ 80 % in stage III/IV disease, where only few patients are irradiated [29]. Under more aggressive chemotherapy with BEACOPP-escalated, advanced stage patients with a residual mass > 2.5 cm and a negative PET/CT enjoy a 5-year RFS of approximately 90 % without radiotherapy [33].…”