Impact of imaging modality on clinical outcome in Hodgkin lymphoma in a resource constraint setting

Abstract

Summary Treatment of Hodgkin lymphoma (HL) has evolved with risk‐stratified therapy based on PET‐CT scan at multiple timepoints. In a resource constraint setting even a single PET‐CT scan ($400) is inaccessible to many patients, who are re‐assessed with only clinical examination, abdominal ultrasonogram and/or x‐ray (C/U/X) ($10). To compare clinical outcomes in patients with HL who have had suboptimal imaging after completion of chemotherapy for HL, with those who had a CT or PET‐CT, 283 patients were treated for HL from 2011 to 2015, and 268 patients completed six cycles of ABVD therapy with response assessment modality by CT/PET in 185 patients and by C/U/X in 83. There was no difference in the number of patients with advanced (64·1% vs. 61·1%; P = 0·650) or bulk disease (8·1% vs. 7·2%). A significantly higher number of patients in the CT/PET group received IFRT (25·4% vs. 7·7%; P = 0·0005). The three‐year overall survival and progression‐free survival of all treated patients (n = 283) was 83·5 ± 2·3% and 76·7 ± 2·6% respectively [median follow‐up 36 months (range 2–93)]. At three years, the overall relapse‐free survival (RFS) was 80·1 ± 2·5%, with RFS of 77 ± 3·2% vs. 85 ± 4·0% in the CT/PET group and C/U/X groups respectively (P = 0·349). There was no difference in RFS between the two groups either in early‐stage disease (88·1 ± 4·6% vs. 91·8 ± 5·6%; P = 0·671) or late‐stage disease (73·9 ± 4·8% vs. 81·3 ± 6·0%; P = 0·747). The only significant factor adversely affecting RFS was advanced disease (P = 0·004). Factors not affecting RFS were age (P = 0·763), sex (P = 0·925), bulk disease (P = 0·889) and imaging modality (P = 0·352). There was no difference in relapse rates between patients who had suboptimal imaging compared to those who had a PET/CT. It is possible to use these basic imaging modalities when resources are a constraint, with acceptable outcomes.

Real-World Outcomes of Hodgkin Lymphoma: A Multi-Centric Registry From India

“…Secondly, the propensity to implement empiric treatment for tuberculosis, many times implied on fine needle aspiration, contributed to delays in diagnosis causing stage migration before eventual diagnosis was confirmed by biopsy (20)(21)(22)(23). Mixed cellularity contrary to nodular sclerosis was the most common histological subtype (60.60%) in this study with similar reports from India and other limited-resource countries (4,(24)(25)(26)(27). The higher frequency of mixed cellularity could be more related to higher incidence of EBV infection (25,28).…”

How I treat advanced Hodgkin lymphoma — a global view

“…On this basis, I endorse my US, UK and Indian (where the patient has the resources to pay for a single interim PET after 2 cycles), colleagues' adoption of the RATHL approach if commencing treatment with ABVD for this man. Notwithstanding this recommendation, clinicians in resource constrained settings where even a single PET‐CT is not possible will be reassured by the comparable relapse free survival rate in patients receiving ABVD with suboptimal imaging analysis, as recently reported in this journal 57 …”

“…Notwithstanding this recommendation, clinicians in resource constrained settings where even a single PET-CT is not possible will be reassured by the comparable relapse free survival rate in patients receiving ABVD with suboptimal imaging analysis, as recently reported in this journal. 57 Alternatively, while there is no clear OS difference, the cumulative data supports a PFS advantage if commencing treatment with escalated BEACOPP. The German Hodgkin Study Group (GHSG) HD18 study 34 provides an excellent PET-adapted approach, potentially limiting the escalated BEACOPP exposure to only 4 cycles in the 52% of patients who achieve PET-2 negativity.…”

Validation of deauville score for response evaluation in hodgkin's lymphoma

“…A recent retrospective study from our center did not show a difference in relapse rates between patients who were examined with suboptimal imaging techniques and clinical examination as compared to those who had a PET/CT and reiterates the use of basic imaging modalities as assessment tools when resources are a constraint. [ 28 ] However, it is difficult to distinguish posttreatment fibrosis from active residual disease using basic imaging modalities thus resulting in increasing number of false-negative reports. Although PET/CT has much strength and is widely recognized as a standard assessment modality in HL, it is important to acknowledge that there are limitations to its use, which become apparent during routine clinical practice.…”