The role of bone marrow biopsy and FDG‐PET/CT in identifying bone marrow infiltration in the initial diagnosis of high grade non‐Hodgkin B‐cell lymphoma and Hodgkin lymphoma. accuracy in a multicenter series of 372 patients

Abstract

Bone marrow infiltration (BMI), categorized as an extra-nodal site, affects stage and is associated with poor prognosis in newly diagnosed lymphoma patients. We have evaluated the accuracy of PET/CT and bone marrow biopsy (BMB) to assess BMI in 372 lymphoma patients [140 Hodgkin Lymphoma (HL) and 232 High Grade B-cell non-Hodgkin Lymphoma (HG B-NHL), among them 155 Diffuse Large B-Cell Lymphoma (DLCL)]. For HL cases, and taking into account PET/CT, sensitivity, negative predictive value (NPV) and accuracy were 96.7, 99.3, and 99.3% while those of BMB were 32.3, 83.8, and 85%, respectively. For HG B-NHL and considering PET/CT, sensitivity, NPV, and accuracy were 52.7, 81.7, and 84.1%, while those of BMB were 77.6, 90.2, and 90.7%, respectively. In the HG B-NHL group, 25 patients would have been under-staged without BMB. These results lead us to recommend PET/CT and the avoidance of BMB to assess BMI in HL. In the case of HG B-NHL, bone marrow status should be assessed firstly by means of PET/CT; only in either focal or diffuse PET/CT with low borderline SUV max values or in negative cases, should BMB be carried out afterwards. In the HG B-NHL setting and at the present moment, both techniques are complementary.

Bone marrow biopsy superiority over PET/CT in predicting progression‐free survival in a homogeneously‐treated cohort of diffuse large B‐cell lymphoma

“…Diagnostic performance has been considered an argument to abrogate the routine use of BMB in this setting due to a claimed superiority of PET/CT. However, we and others have shown before that the performance of PET/CT in terms of sensitivity and accuracy was not as high as stated in other series [10,12,13]. To this regard, it has been proposed that this could rely in histologically unproven cases that could have been inappropriately considered true positives [12,19,21].…”

Reply to H.J adams et al: “Is FDG‐PET/CT a sensitive and specific method for the detection of extranodal involvement in diffuse large B‐cell lymphoma?”

“…In a retrospective cohort study by Adams' own group, focally increased FDG uptake in the bone marrow was not prognostic for PFS or OS. However, because of the small number of patients the analysis is likely underpowered and 34/78(44%) of patients had PET/CT-detected bone marrow involvement, which is higher than usually reported [1,10,[13][14][15][16]. Our study supports an independent prognostic value of PET/CT-ascertained bone marrow involvement, but we do not "claim" prognostic irrelevance of BMB, as accused by Adams et al The fact that positive BMB was only prognostic in univariate analysis rather reflects the interplay with other important prognostic factors.…”

“…This evokes the third objection by Adams et al We are aware that some previous studies, including large series and our own data, have shown suboptimal sensitivities of PET/CT to detect bone marrow involvement by BMB [13,16,18]. The Lugano classification recommends BMB in patients without evidence of bone marrow involvement by PET/CT and only if finding of a discordant histology is relevant for patient management [19].…”

How useful is bone marrow study as an initial investigative tool without lymph node biopsy in malignant lymphoma?: Eleven years of experience at a single institution

“…Marrow involvement in the advanced‐stage disease like DLBCL is usually sufficiently depicted by PET‐CT, and BM biopsy provides little additional staging information. However, BM biopsy is indicated when a PET/CT scan is negative . In another study, it was suggested BM biopsy could provide information in addition to BM involvement, such as information on the hematologic status of patients .…”