Conventional imaging and 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography for predicting the clinical outcome of previously treated non-hodgkin's lymphoma patients

doi:10.1016/S1536-1632(03)00086-6

Molecular Imaging & Biology

Volume 5, Issue 4, July–August 2003, Pages 232-239

https://doi.org/10.1016/S1536-1632(03)00086-6 Get rights and content

Abstract

PURPOSE: The aim of this study was to determine the impact of positron emission tomography (PET) with 2-deoxy-2-[¹⁸F]fluoro-D-glucose (FDG) and combined conventional imaging on clinical stage and their ability to predict the clinical outcome of previously treated lymphoma patients.

PROCEDURES: Seventy-eight patients with Non-Hodgkin's Lymphoma (NHL) were studied with PET within a median interval of 5.3 months after treatment. Conventional imaging performed after treatment and within three months before PET included 3.3±1.3 imaging tests/patient. To determine the independent ability of PET for predicting clinical outcome, PET images were re-read in a blinded fashion. Study endpoints were disease-free survival, or clinical evidence of disease or death.

RESULTS: PET downstaged 18 patients, upstaged nine and revealed the same stage as conventional imaging in 51 patients. Using the clinical outcome as gold standard, the positive and negative predictive values of PET were 95% and 83% versus 72% and 67% for conventional imaging (P<0.05). The prognostic accuracy of PET was superior to that of conventional imaging (90 vs. 71%; P<0.05). Kaplan-Meier analysis for disease-free survival showed a significant difference between PET negative and PET positive results (P<0.0001).

CONCLUSION: Whole-body FDG-PET imaging modified the clinical stage in 35% of lymphoma patients who were reevaluated after treatment. Moreover, FDG-PET predicted patient outcome with a higher predictive accuracy than conventional imaging. This superior prognostic accuracy was achieved with a single FDG-PET study versus multiple conventional imaging procedures/patient.

Introduction

The outcome of patients with Non-Hodgkin's Lymphoma (NHL) has markedly improved over the last decade.¹ Improved management of NHL patients not only depends upon new therapies and more comprehensive understanding of histopathologic patterns, but also on accurate reevaluation of these patients after treatment. Traditionally, this has been accomplished using a variety of noninvasive imaging techniques such as computerized tomography (CT), magnetic resonance imaging, bone scanning, ultrasound, and ⁶⁷Ga-imaging.

Positron emission tomography (PET) with 2-deoxy-2-[¹⁸F]fluoro-D-glucose (FDG) has been used successfully and cost-effectively for diagnosing,² staging,3., 4., 5., 6., 7., 8., 9., 10., 11., 12., 13., 14. and restaging NHL.4., 5., 15., 16., 17., 18., 19., 20. Moreover FDG-PET stages and restages NHL patients with a higher accuracy than conventional imaging modalities.6., 11., 13., 14., 18., 20., 21., 22., 23., 24., 25., 26.

The prognostic value of PET and computed tomography for predicting the outcome of NHL patients has been compared in several studies.16., 20., 22., 25., 26., 27. However, the reevaluation of NHL patients after treatment not only includes CT but several other imaging modalities. The predictive value of PET for patient outcome has not been compared to combined conventional imaging techniques.

The aims of the current study were therefore two-fold. First, the impact of FDG-PET on the clinical stage as determined by routine clinical conventional imaging was assessed. Second, the prognostic value of PET for predicting disease-free survival was compared to that of combined conventional imaging.

Section snippets

Patient population

One hundred and eighty-eight previously treated lymphoma patients were consecutively referred for a clinical PET scan between January 1998 and March 2001. Because of its retrospective nature this study was exempt from requirement to obtain informed consent by the local ethics committee. Seventy-eight of these patients (32 females, 46 males, median age: 57 years, range: 21–84 years) met the following inclusion criteria and were therefore retrospectively enrolled in the study.

Inclusion criteria

The diagnosis of NHL

Conventional imaging tests

Reevaluation by conventional imaging was performed within a median interval of 29 days (range: 0 to 78 days) before PET. It included a total of 259 imaging procedures or 3.3±1.3 tests per patient. The conventional imaging procedures performed are listed in Table 1.

Impact of PET on clinical stage

Conventional imaging reports were negative for disease in 27 patients (35%; 16 negative findings, 11 equivocal findings), and positive in 51 patients (65%; 41 positive; 10 suspicious). PET was negative in 36 patients (46%), while 42

Discussion

The current study demonstrates that FDG-PET alters the clinical stage assigned to 35% of NHL patients who were reevaluated after treatment. Importantly, the information provided by FDG-PET was more accurate than that obtained through conventional imaging as evidenced by its significantly higher predictive accuracy.

The current study differs from previous PET investigations in lymphoma patients. First, only patients with NHL were included and conventional imaging was not limited to CT, but

Conclusion

Whole-body FDG-PET imaging modified the clinical stage in 35% of lymphoma patients after treatment. Moreover, FDG-PET predicted patient outcome with a higher predictive accuracy than conventional imaging. The superior prognostic accuracy was achieved with a single PET study versus 3.3±1.3 conventional imaging procedures/patient.

References (39)

M Lapela et al.
Increased glucose metabolism in untreated non-Hodgkin's lymphoma: a study with positron emission tomography and fluorine-18-fluorodeoxyglucose
Blood
(1995)
G Jerusalem et al.
Whole-body positron emission tomography using 18F-fluorodeoxyglucose for posttreatment evaluation in Hodgkin's disease and non-Hodgkin's lymphoma has higher diagnostic and prognostic value than classical computed tomography scan imaging
Blood
(1999)
P.L Zinzani et al.
The role of positron emission tomography (PET) in the management of lymphoma patients
Ann. Oncol.
(1999)
A.G Stansfeld et al.
Updated Kiel classification for lymphomas
Lancet
(1988)
D.G Maloney
Non-Hodgkin's lymphoma
Curr. Opin. Hematol
(1995)
T Klose et al.
Primary staging of lymphomas: cost-effectiveness of FDG-PET versus computed tomography
Eur. J. Nucl. Med.
(2000)
R Martinez-Lazaro et al.
Diagnostic performance of whole-body FDG-PET and CT imaging in malignant lymphomas
J. Nucl Med.
(2000)
M Bangerter et al.
Positron emission tomography with 18-fluorodeoxyglucose in the staging and follow-up of lymphoma in the chest
Acta Oncol.
(1999)
I Buchmann et al.
Positron emission tomography for detection and staging of malignant lymphoma
Recent Results Cancer Res.
(2000)
C.K Hoh et al.
Whole-body FDG-PET imaging for staging of Hodgkin's disease and lymphoma
J. Nucl. Med.
(1997)

G Jerusalem et al.

Whole-body 18F-FDG PET for the evaluation of patients with Hodgkin's disease and non-Hodgkin's lymphoma

Nucl. Med. Commun.

(1999)

C Mainolfi et al.

Positron-emission tomography with fluorine-18-deoxyglucose in the staging and control of patients with lymphoma. Comparison with clinico- radiologic assessment

Radiol. Med. (Torino)

(1998)

F Moog et al.

Lymphoma: role of whole-body 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) PET in nodal staging

Radiology

(1997)

F Moog et al.

Extranodal malignant lymphoma: detection with FDG PET versus CT

Radiology

(1998)

F Moog et al.

18-F-fluorodeoxyglucose-positron emission tomography as a new approach to detect lymphomatous bone marrow

J. Clin. Oncol.

(1998)

F Moog et al.

FDG PET can replace bone scintigraphy in primary staging of malignant lymphoma

J. Nucl. Med.

(1999)

J.S Newman et al.

Imaging of lymphoma with PET with 2-[F-18]-fluoro-2-deoxy-D-glucose: correlation with CT

Radiology

(1994)

G.P Canellos

Residual mass in lymphoma may not be residual disease

J. Clin. Oncol.

(1988)

U Cremerius et al.

Clinical value of FDG PET for therapy monitoring of malignant lymphoma- -results of a retrospective study in 72 patients

Nuklearmedizin

(1999)

Cited by (13)

Imaging in staging of malignant lymphoma: A systematic review
2008, Blood
Citation Excerpt :
Sensitivities and specificities for restaging HD ranged between 85% (lesion-based)54 and 100% (patient-based),38,41,44,50,51 and between 57.1% (patient-based)41 and 100% (patient-based),43 respectively. Five studies (separately or exclusively) investigated patients with NHL.46,47,50,51,54 One study did not describe the histologic subtype(s) of NHL investigated,50 2 studies investigated patients with both high-grade and low-grade NHL,46,54 and 2 studies investigated patients with aggressive NHL47,51 (Table 12).
Computed tomography (CT) is currently the most commonly used means for staging malignant lymphoma. ¹⁸F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET), FDG-PET/CT fusion, and whole-body magnetic resonance imaging (WB-MRI) are potential alternatives. The purpose of this study was to systematically review published data on the diagnostic performance of CT, FDG-PET, FDG-PET/CT fusion, and WB-MRI in staging of malignant lymphoma. In addition, technical aspects, procedures, advantages, and drawbacks of each imaging modality are outlined. Three CT studies, 17 FDG-PET studies, and 4 FDG-PET/CT fusion studies were included in this systematic review. The studies were of moderate methodological quality and used different scoring systems to stage malignant lymphoma. CT remains the standard imaging modality for initial staging of malignant lymphoma, while FDG-PET has an essential role in restaging after treatment. Early results suggest that FDG-PET/CT fusion outperforms both CT alone and FDG-PET alone. Data on the diagnostic performance of WB-MRI are lacking. Future well-designed studies, expressing their results according to the Ann Arbor staging system, are needed to determine which imaging modality is most accurate and cost-effective in staging malignant lymphoma.
Impact of involved field radiotherapy in partial response after doxorubicin-based chemotherapy for advanced aggressive non-Hodgkin's lymphoma
2006, International Journal of Radiation Oncology Biology Physics
Citation Excerpt :
Evidently, the definition of PR—although not changed during the years with respect to measurements—has won in quality by modern imaging techniques. New tools such as PET scans have been introduced to distinguish between remnants of necrotic tissue or viable residual NHL and can therefore differentiate between unconfirmed CR and PR (23, 24). The excellent performance of PET imaging justifies the recent proposal by Cheson et al. to skip the definition of unconfirmed CR in the near future (25).
Purpose: Whether salvage therapy in patients with advanced aggressive non-Hodgkin’s lymphoma (NHL) in partial remission (PR) should consist of radiotherapy or autologous stem-cell transplantation (ASCT) is debatable. We evaluated the impact of radiotherapy on outcome in PR patients treated in four successive European Organization for Research and Treatment of Cancer trials for aggressive NHL.
Patients and Methods: Records of 974 patients (1980–1999) were reviewed regarding initial response, final outcome, and type and timing of salvage treatment. After 8 cycles of doxorubicin-based chemotherapy, 227 NHL patients were in PR and treated: 114 received involved field radiotherapy, 16 ASCT, 93 second-line chemotherapy, and 4 were operated. Overall survival (OS) and progression-free survival (PFS) after radiotherapy were estimated (Kaplan-Meier method) and compared with other treatments (log–rank). Impact on survival was evaluated by multivariate analysis (Cox proportional hazards model).
Results: The median PFS in PR patients was 4.2 years and 48% remained progression-free at 5 years. Half of the PR patients converted to a complete remission. After conversion, survival was comparable to patients directly in complete remission. Radiotherapy resulted in better OS and PFS compared with other treatments, especially in patients with low to intermediate International Prognostic Index score, bulky disease, or nodal disease only. Correction by multivariate analysis for prognostic factors such as stage, bulky disease, and number of extranodal locations showed that radiotherapy was clearly the most significant factor affecting both OS and PFS.
Conclusion: This retrospective analysis demonstrates that radiotherapy can be effective for patients in PR after fully dosed chemotherapy; assessment in a randomized trial (radiotherapy vs. ASCT) is justified.
The value of <sup>18</sup>F-fluoro-2-deoxy-D-glucose positron emission tomography (<sup>18</sup>F-FDG PET) in diagnosis of neoplastic diseases
2005, Medicina Clinica
La tomografía por emisión de positrones (PET) tiene la habilidad de detectar el cáncer a través de mecanismos basados en procesos moleculares y bioquímicos dentro de los tejidos tumorales. El radiotrazador más utilizado en oncología es un análogo de la glucosa marcado con flúor, ¹⁸F-fluoro-2-desoxi-D-glucosa (¹⁸F-FDG). Al igual que la glucosa, la ¹⁸F-FDG pasa al interior de las células mediante proteínas transportadoras y rápidamente se convierte en ¹⁸F-glucosa-6-fosfato. Mediante PET-FDG se diagnostica, estadifica y reestadifica la mayoría de los cánceres, con exactitudes diagnósticas entre el 80 y el 90%. Mediante la PET se puede conocer la respuesta al tratamiento tempranamente y con mayor precisión que con los métodos anatómicos de imagen, con información pronóstica superior a la de los métodos convencionales, para la mayoría de los cánceres. El objetivo de este artículo de revisión es mostrar las indicaciones clínicas más prometedoras de la PET-FDG en oncología.
Positron emission tomography (PET) has the ability to detect cancer based on molecular and biochemical processes within the tumor tissues. The most widely used radiotracer in oncology at this time is the glucose analogue ¹⁸F-fluoro-2-deoxy-D-glucose (¹⁸F-FDG). Like glucose, ¹⁸F-FDG is transported into cells by a glucose transporter protein and rapidly converted into ¹⁸F-FDG-6-phosphate. PET imaging with ¹⁸F-FDG is able to diagnose, stage, and restage many cancers with accuracies ranging from 80% to 90%. Responses to therapy can be identified earlier and with greater accuracy than is possible with anatomic imaging modalities. The prognostic information available through ¹⁸F-FDG PET is superior to that of conventional imaging for many cancers. The aim of this review article is to show the most promising clinical indications for the use of PET in oncology.
Fluorodeoxyglucose-Positron Emission Tomography in Relapsed/Refractory Hodgkin Lymphoma: A Practical Approach
2024, Chemotherapy
Imaging Techniques in Drug Development and Clinical Practice
2011, Drug Delivery in Oncology: From Basic Research to Cancer Therapy
Molecular imaging techniques in body imaging
2007, Radiology

View all citing articles on Scopus

View full text

ArticleConventional imaging and 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography for predicting the clinical outcome of previously treated non-hodgkin's lymphoma patients

Abstract

Introduction

Section snippets

Patient population

Inclusion criteria

Conventional imaging tests

Impact of PET on clinical stage

Discussion

Conclusion

Blood

Blood

Ann. Oncol.

Lancet

Non-Hodgkin's lymphoma

Curr. Opin. Hematol

Primary staging of lymphomas: cost-effectiveness of FDG-PET versus computed tomography

Eur. J. Nucl. Med.

Diagnostic performance of whole-body FDG-PET and CT imaging in malignant lymphomas

J. Nucl Med.

Positron emission tomography with 18-fluorodeoxyglucose in the staging and follow-up of lymphoma in the chest

Acta Oncol.

Positron emission tomography for detection and staging of malignant lymphoma

Recent Results Cancer Res.

Whole-body FDG-PET imaging for staging of Hodgkin's disease and lymphoma

J. Nucl. Med.

Whole-body 18F-FDG PET for the evaluation of patients with Hodgkin's disease and non-Hodgkin's lymphoma

Nucl. Med. Commun.

Positron-emission tomography with fluorine-18-deoxyglucose in the staging and control of patients with lymphoma. Comparison with clinico- radiologic assessment

Radiol. Med. (Torino)

Lymphoma: role of whole-body 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) PET in nodal staging

Radiology

Extranodal malignant lymphoma: detection with FDG PET versus CT

Radiology

18-F-fluorodeoxyglucose-positron emission tomography as a new approach to detect lymphomatous bone marrow

J. Clin. Oncol.

FDG PET can replace bone scintigraphy in primary staging of malignant lymphoma

J. Nucl. Med.

Imaging of lymphoma with PET with 2-[F-18]-fluoro-2-deoxy-D-glucose: correlation with CT

Radiology

Residual mass in lymphoma may not be residual disease

J. Clin. Oncol.

Clinical value of FDG PET for therapy monitoring of malignant lymphoma- -results of a retrospective study in 72 patients

Nuklearmedizin

Article
Conventional imaging and 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission tomography for predicting the clinical outcome of previously treated non-hodgkin's lymphoma patients