Surveillance imaging of Hodgkin lymphoma patients in first remission

Abstract

BACKGROUND:The majority of patients with Hodgkin lymphoma (HL) achieve disease remission after primary therapy. To the best of the authors' knowledge, no consensus exists for postremission surveillance imaging. METHODS: Retrospectively analyzed were 192 adult patients with classic HL in first remission. Events were defined as recurrent HL or secondary malignancies. Primary outcome was positive predictive value (PPV) of surveillance positron emission tomography/computed tomography (PET/CT) and CT scans in event detection. Secondary outcomes were costs and radiation exposures of surveillance scans. RESULTS: Sixteen events (12 recurrent HL cases and 4 secondary malignancies) were detected during a median follow-up of 31 months. The PPV of surveillance PET/CT was 22.9% compared with 28.6% for CT (P ¼ .73). Factors that were found to significantly improve the PPV of scans in detecting recurrent HL included PET and CT concordance, involvement of a prior disease site, or the occurrence of a radiographic abnormality within 12 months. There were too few events to determine whether event detection by PET/CT versus CT or the presence of symptoms at the time of event detection affected overall outcomes. The cost to detect a single event was approximately $100,000. Radiation exposure to detect a single event was 146.6 millisieverts per patient for each of 9 patients. CONCLUSIONS: For patients with HL in first disease remission, surveillance radiography appears to be expensive, with limited clinical impact. Surveillance CT is generally adequate. Cancer 2010;116:3835-42.

Positron Emission Tomographic Scans in Lymphoma: Convention and Controversy

“…52 Particularly in aggressive lymphomas and those patients with extranodal involvement, most relapses are diagnosed clinically. Only in selected patients with Hodgkin lymphoma were relapses more commonly detected by routine imaging.…”

Positron emission tomography/computed tomography surveillance in patients with lymphoma: a fox hunt?

“…7 Even with its relatively high sensitivity, the risks and benefits of routine surveillance PET/CT imaging remain controversial, mainly, because of its cost, radiation burden and the high rate of false-positive results (30-80%) 3,[8][9][10][11][12] with potential consequences of overtreatment. In this issue of the Journal, El-Galaly et al report the value of surveillance PET/CT in a retrospective cohort of 161 HL patients who achieved a complete or partial remission after first-line treatment.…”

“…While PET/CT has not been closely investigated in a surveillance setting, it has become clear that its accuracy is superior to that of CT imaging. According to results from a meta-analysis, FDG-PET predicts disease relapse with a sensitivity and specificity of 50-100% and 67-100%, respectively, for HL and 33-77% and 82-100%, respectively, for NHL, irrespective of the association of a residual mass on CT. 7 Even with its relatively high sensitivity, the risks and benefits of routine surveillance PET/CT imaging remain controversial, mainly, because of its cost, radiation burden and the high rate of false-positive results (30-80%) 3,[8][9][10][11][12] with potential consequences of overtreatment. In this issue of the Journal, El-Galaly et al report the value of surveillance PET/CT in a retrospective cohort of 161 HL patients who achieved a complete or partial remission after first-line treatment.…”

“…The cost associated with indiscriminate routine imaging for HL or DLBCL patients proves prohibitive with today's restrictions in allocations of healthcare resources. 5,9,15,23 The cost of detecting a single event in HL patients was approximately $100,000. 9 The cost of detecting one asymptomatic relapse in patients with aggressive NHL by surveillance imaging, over a 5-year period, was between $42,750 and $85,500.…”

“…5,9,15,23 The cost of detecting a single event in HL patients was approximately $100,000. 9 The cost of detecting one asymptomatic relapse in patients with aggressive NHL by surveillance imaging, over a 5-year period, was between $42,750 and $85,500. 15 It should be emphasized that the missing link is the unequivocally proven issue of whether or not an early detection of relapse translates into a survival benefit.…”