Role of routine imaging in detecting recurrent lymphoma: A review of 258 patients with relapsed aggressive non‐Hodgkin and Hodgkin lymphoma

Abstract

After first-line therapy, patients with Hodgkin lymphoma (HL) and aggressive non-HL are followed up closely for early signs of relapse. The current follow-up practice with frequent use of surveillance imaging is highly controversial and warrants a critical evaluation. Therefore, a retrospective multicenter study of relapsed HL and aggressive non-HL (nodal T-cell and diffuse large B-cell lymphomas) was conducted. All included patients had been diagnosed during the period 2002-2011 and relapsed after achieving complete remission on first-line therapy. Characteristics and outcome of imaging-detected relapses were compared with other relapses. A total of 258 patients with recurrent lymphoma were included in the study. Relapse investigations were initiated outside preplanned visits in 52% of the patients. Relapse detection could be attributed to patient-reported symptoms alone or in combination with abnormal blood tests or physical examination in 64% of the patients. Routine imaging prompted relapse investigations in 27% of the patients. The estimated number of routine scans per relapse was 91-255 depending on the lymphoma subtype. Patients with imaging-detected relapse had lower disease burden (P 5 0.045) and reduced risk of death following relapse (hazard ratio 5 0.62, P 5 0.02 in multivariate analysis). Patient-reported symptoms are still the most common factor for detecting lymphoma relapse and the high number of scans per relapse calls for improved criteria for use of surveillance imaging. However, imaging-detected relapse was associated with lower disease burden and a possible survival advantage. The future role of routine surveillance imaging should be defined in a randomized trial.

Imaging of Non-Hodgkin Lymphomas: Diagnosis and Response-Adapted Strategies

“…Finally, the use of routine surveillance imaging in aggressive NHL can only be justified if early relapse detection is associated with improved survival. Some studies have suggested that imagingdetected relapse of aggressive non-Hodgkin lymphoma could be associated with improved outcome, whereas others found no difference in outcome [76,78,81]. However, the retrospective design of these studies does not allow firm conclusions about the causal role of imaging due the presence of important bias (lead time, length time, and guarantee time).…”

“…Low disease stage and ECOG performance status 0-1 at relapse are associated with a better outcome in DLBCL [73]. With less than a quarter of the relapses being imaging detected, routine imaging did not contribute significantly to relapse detection in studies based on imaging modalities less sensitive than PET/CT [74][75][76][77][78]. Furthermore, the number of scans per relapse exceeded 100 per preclinical relapse for both DLBCL and PTCLs in first complete remission, and out of all patients in complete remission entering intensive follow-up protocols, only a very small minority (2-3 %) will experience imaging-detected relapse [78].…”

Baseline and ongoing PET-derived factors predict detrimental effect or potential utility of 18F-FDG PET/CT (FDG-PET/CT) performed for surveillance in asymptomatic lymphoma patients in first remission

“…Actually, the clinical relevance of surveillance FDG-PET/ CT in lymphoma is almost entirely founded on the assumption that an early salvage treatment could improve survival on selected patients, even though evidence supporting this concept was relatively scarce [6]. However, a recent multicenter study has surprisingly highlighted a lower disease burden and a possible survival advantage in case of imaging-detected relapse in selected subgroups of lymphoma patients [12]. In this study, multivariate analysis demonstrated that early treatment of relapsing disease, driven by prompt detection on medical images, granted a 40 % risk reduction for death among patients with diffuse large B cell lymphoma (DLBCL), as well as a trend toward a better outcome in HL patients.…”

Utility of Routine Post-Therapy Surveillance Imaging in Diffuse Large B-Cell Lymphoma

“…[10][11][12] One recent study from El-Galaly et al 21 reported a reduced risk of death in patients with DLBCL detected solely via imaging, however, this association was no longer significant after excluding those who relapsed with an indolent lymphoma histology and those with relapse before first surveillance imaging. Furthermore, scans have potential downsides-patient anxiety, 22 radiation exposure, 23,24 false-positive results leading to more testing, 9,20,25 and cost.…”