Pre-transplant positron emission tomography (PET) using fluorine-18-fluoro-deoxyglucose (FDG) predicts outcome in patients treated with high-dose chemotherapy and autologous stem cell transplantation for non-Hodgkin's lymphoma

Abstract

Summary:We investigated the predictive value of sequential FDG PET before and after high-dose chemotherapy (HDT) and autologous stem cell transplantation (ASCT) in 24 patients suffering from non-Hodgkin's lymphoma (NHL). FDG PET was performed at baseline, after three cycles of induction therapy, before and after HDT with ASCT. Response assessment from sequential PET scans using standardized uptake values (SUV) was available in 22 patients at the time of transplantation. Partial metabolic response (PMR) was defined as a Ͻ25% decrease of SUV between successive PET scans. Six of seven patients who did not achieve a PMR after complete induction therapy developed lymphoma progression, while 10 of 15 patients with complete metabolic response (CMR) or PMR remained in continuous remission. Four of seven patients with less than PMR after induction therapy died vs two of 15 patients with CMR/PMR. Median progression-free and overall survival of patients with less than PMR after HDT and ASCT was 9 and 29 months, respectively. In contrast, neither conventional re-staging nor the International Prognostic Index were predictive. These data suggest that sequential quantitative PET imaging does enlarge the concept of chemosensitivity used to select patients with high-risk NHL for HDT and ASCT or to route them to alternative treatments. High-dose chemotherapy (HDT) with autologous stem cell transplantation (ASCT) has been shown to be the best available treatment in patients who have relapsed from nonHodgkin's lymphoma (NHL) after conventional chemotherapy, but who remained chemotherapy-sensitive.1 This has prompted the use of HDT with ASCT as a front-line therapy in patients with high-intermediate or high risk disease according to the International Prognostic Index.2 However, clinical results have been discrepant and additional prognostic factors are needed to predict final outcome of the patients at the time of transplantation.Positron emission tomography (PET) using the glucose analogue fluorine-18-fluorodeoxglucose (FDG) has been demonstrated to improve primary staging of lymphoma and to be more precise than conventional radiological imaging for re-staging after chemotherapy.3-7 Several groups including our own have reported the high predictive value of persisting abnormal FDG uptake for residual or recurrent disease in this context. 7-9Thus FDG-PET does have a potential role in the identification of patients requiring further intensified chemotherapy. Moreover, FDG-PET can be used as a functional and quantitative measure of tumor response to induction chemotherapy 10 and may be able to differentiate between responders and non-responders at an earlier time-point than conventional CT or MRI imaging. Preliminary results in a small patient population studied before onset of treatment and again after one and two chemotherapy cycles support this hypothesis. 11We prospectively enrolled consecutive patients with NHL who were scheduled for HDT including ASCT. Progression-free and overall survival were chosen as end points of the study....

Role of 18FDG-PET/CT in detecting relapse during follow-up of patients with Hodgkin’s lymphoma

“…More recently, some studies indicated that 18 FDG-FDG-PET also provides useful information about disease status before ASCT and even allogeneic stem cell transplantation in relapsed or refractory HL and non-Hodgkin's lymphoma, with a significant correlation between pretransplant PET status and prognosis [20][21][22][23][24][25][26]. CT scan is the most used in restaging lymphoma; however, some authors reported that history and physical examination could be the standard approach to follow-up because in most cases early recurrence is first suspected by the patient himself or by the physician, even with routine screening including CT scans [27,28].…”

Pretransplant positive positron emission tomography/gallium scans predict poor outcome in patients with recurrent/refractory Hodgkin lymphoma

“…21,22 In another study, investigators suggested that FI can identify patients with high-risk lymphoma who might benefit from HDCT/ASCT as front-line therapy, considering that sustained biologic response is an important feature before transplantation. 23 Other studies assessed the value of FI before ASCT; however, many studies PFS indicates progression-free survival; OS, overall survival; 95% CI, 95% confidence interval; M, male; F, female; LD, lymphocyte depleted; LP, lymphocyte predominant; MC, mixed cellularity; NS, nodular sclerosis; CRD1, first complete response duration; END, extranodal disease; ESHAP, etoposide, methylprednisolone, cytarabine, and cisplatin; ASHAP, doxorubicin, methylprednisolone, cytarabine, and cisplatin; CR, complete response; CRu, unconfirmed CR; ASCT, autologous stem cell transplantation; PET, positron emission tomography; Ga, gallium; PR, partial response; FI, functional imaging; pos, positive; neg, negative.…”

Positron emission tomography using F-18 fluorodeoxyglucose pre- and post-autologous stem cell transplant in non-Hodgkin's lymphoma

“…In the analysis by Cremerius et al, 9 16 of 23 patients achieved a CMR, 7 patients did not. Median PFS was 38 versus 14 months, respectively (not statistically significant).…”

“…The first published prospective analysis of patients undergoing FDG PET scans pre-SCT was reported by Cremerius et al 9 In total, 23 of the 24 patients had newly diagnosed lymphoma and were scheduled to receive up front chemotherapy followed by ASCT. In this study, patients underwent FDG PET scanning at baseline, after three cycles of induction therapy, before and after ASCT.…”