The predictive role of interim positron emission tomography for Hodgkin lymphoma treatment outcome is confirmed using the interpretation criteria of the Deauville five-point scale

Abstract

© F e r r a t a S t o r t i F o u n d a t i o ncomparable, with different timing of the interim PET during the course of treatment and differing PET methodologies. Most studies used stand-alone PET, which has now been replaced by PET-CT. Reporting methods were not consistent making it difficult to judge how these results should be applied in clinical practice.In 2009 an international meeting attended by hematologists and nuclear medicine specialists was held in Deauville, France, with the intention of defining simple and reproducible criteria for interim-PET reporting in lymphoma.11 A five-point scale (5-PS) developed at Guy's and St. Thomas' Hospital in London was adopted 12 as the "Deauville criteria". An international study was launched to compare previous reports on the accuracy of interim PET in predicting treatment outcome in Hodgkin lymphoma with an international cohort of patients scanned using PET-CT after two cycles of ABVD and to evaluate the reproducibility of the 5-PS among reporters. The criteria for enrollment, the breakdown of patients according to stage (early unfavorable and advanced-stage) and the endpoints were the same as in the JID. Methods Retrieval of patients' dataConsecutive patients affected by Hodgkin lymphoma from participating centers worldwide diagnosed between January 2002 and December 2009 were retrospectively enrolled with the following inclusion criteria: (i) stage IIB to stage IVB or stage IIA Hodgkin lymphoma with adverse prognostic factors (at least three nodal sites involved, sub-diaphragmatic presentation, bulky disease, and erythrocyte sedimentation rate > 40 mm/h); (ii) treatment with four to eight cycles of ABVD with or without involved-field radiotherapy or consolidation radiotherapy; (iii) staging with PET/CT at baseline and after two courses of ABVD (PET-0 and PET-2, respectively); (iv) no change to treatment based on interim-PET results; and (v) a minimum follow-up of 1 year after completion of firstline treatment. Patients escalated to salvage treatment during ABVD chemotherapy were eligible only if the treatment change was based on clinical and/or radiological evidence of disease progression/resistance.The study was approved by the ethical committee of the coordinating center in Cuneo (Italy) and conducted according to the Helsinki declaration. Specific informed written consent was not required as all data were retrospectively collected in an anonymized format, in agreement with specific institutional and national requirements. AG, SC and ER analyzed the data and all co-authors had access to the primary data.Clinical data on 400 patients were collected; however only 335 paired scans (baseline and interim) were available for review. Of these, 75 were then excluded because there were no CT data (n=21), no baseline PET (n=25), no interim PET (n=1), missing CT slices (n=3), missing PET slices (n=10), poor quality PET images (n=6) or miscellaneous reasons (n=9). Complete data from 260 patients were available for analysis from 17 international academic institut...

Advanced Hodgkin’s lymphoma: End-of-treatment FDG-PET should be maintained

“…These results were obtained despite the use of the standardized interpretation criteria based on the 5-point scale [3], and central reviewing of PET findings [13,14]. These relapse rates in interim-PETnegative patients are three times higher than expected from early reports (3-year PFS 95%) [16] and call for maintaining a FDG PET evaluation at the end of the treatment in order to identify those patients who require further therapy. However, because the risk of relapse in interim PET negative patients varied according to initial risk stratification [14], the debate remains open, as regards cost-effectiveness, if end-oftreatment PET should be performed in all patients with advanced HL or only those with stage III-IV disease.…”

“…that is now available; for example, the possibilities of combining chemotherapy and targeted therapy with the anti-CD30 antibody-drug conjugate brentuximab vedotin [18]. Surprisingly, in both trials, the relapse rates in patients with a negative interim-PET were much higher than the rates expected from historical data [16]. In the SWOG S0816 study, which included only advanced stages, the 2-year PFS in interim PET-negative patients was 82% [13].…”

“…These trials were triggered by observational studies showing high prognostic accuracy of interim PET [15]. For example, in one retrospective multicenter study of patients with advancedstage or early unfavorable HL, the 3-year PFS for patients with positive interim-PET after two cycles of ABVD (score ≥ 4 on the Deauville 5-point scale) was 28% and for patients with negative interim-PET 95.0% (P < .0001) [16].…”

The role of FDG-PET in defining prognosis of Hodgkin lymphoma for early-stage disease

“…The reproducibility of Deauville 5PS was also confirmed in an international multicenter study of a retrospective cohort of 260 advanced-stage HL patients imaged after 2 of 6 intended cycles (ie, PET-2) of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine), with no treatment change based on PET-2 results. 29 The sensitivity, specificity, NPV, and PPV for PET-2 were 73%, 94%, 94%, and 73%, respectively. After a mean follow-up of 27 months, the 3-year failure-free survival was 28% for PET-2 ϩ patients and 95% for PET-2 Ϫ patients (P Ͻ .0001).…”

Recent treatment advances in Hodgkin lymphoma: a concise review

“…This is being assessed in both advanced and early stage disease. Results of interim PET/CT appear to correlate well with long-term outcome following treatment with ABVD 28 . In early stage disease, PET/CT-adapted therapy was trialled in the recently completed RAPID UK study 29 , with the aim of establishing non-inferiority of treatment de-escalation based on interim PET/CT performed after three cycles of ABVD.…”