Protocol for the Use of PET Scanning in the Management of Patients with Lymphoma

Protocol for the use of PET scanning in the management of patients with lymphoma.

In November 2002 the then Health Technology Board for Scotland (HTBS) published its Health Technology Assessment (HTA) that stated that:-

All patients who require restaging of Hodgkin’s disease should be sent for a FDG-PET scan. Extension to the restaging of all patient with lymphoma should be investigated by further research.

Significant additional new research into the use of PET scan in malignant lymphomas has since been published. Furthermore, the International Working Group for Non-Hodgkin’s lymphoma have recently proposed new response criteria and associated guidelines on the use of PET imaging in lymphomas (Juweid et al, 2007; Cheson et al, 2007). The undernoted protocol has been developed in light of the emerging evidence.

Indications for the use of PET scanning

Hodgkin’s disease (HD) (~ 230 new scans in Scotland each year) .

1.All newly diagnosed patients with Hodgkin’s disease (HD) being considered for curative therapy should have a baseline scan.

2.Early stage HD after 3 courses of treatment within the context of the NCRItrial.

3.Patients with advanced HD (stage IIB, III and IV) who need to be considered for a change to more intensive chemotherapy early in their treatment plan (after 2 cycles of chemotherapy).

4.All HD patients with residual masses post treatment who have not been shown to be PET negative at an interim scan.

5.Patients with relapsed HD undergoing further treatment with curative intent should be considered for baseline and post treatment scanning where this will influence management.

5.1Paediatrics: Patients should be scanned in accordance with CCLG national guidelines. All paediatric patients should be referred to Aberdeen as they currently meet the safety requirements outlined by the UK PET Advisory Group.

Non Hodgkin’s Lymphoma

1.The only indication for PET scanning in low-grade Lymphomas is in stage 1A follicular disease where curative radiotherapy is being considered.

2.Diffuse large B cell lymphoma with residual masses at the end of chemotherapy treatment.

3.Paediatrics: PET scanning may be considered in individual cases where there is a residual mass at the end of chemotherapy treatment.

References:-

Barrington, S.F., Begent, J., Lynch, T., ete al (2008) Guidelines for the use of PET-CT in Children.

Cheson, B.D., Pfister, B. Juweid et al (2007) Revised respnse criteria for malignant lymphoma. J. Clin. Oncol. 25pp. 579-586.

Facey, K., Bradbury, I., Laking, G. and Payne, E. (2007) Overview of the clinical effectiveness of positron emission tomography imaging in selected cancers. Health Technology Assessment. 11 (44)

Gallamani, A., Hutchings, M., Rigacci, L et al (2007 Early Interim Fluoro-2-deoxy-D-Glucose Positron Emission Tomography is prognostically superior to International Prognostic score in advance stage Hodgkin’s lymphoma: A report from a joint Italian-Danish Study. J. Clin. Oncol. 25 pp. 3746-3752.

Hutchings M. Loft A. Hansen M. Pedersen LM. Buhl T. Jurlander J. Buus S. Keiding S. D'Amore F. Boesen AM. BerthelsenAK. Specht L. (2006) FDG-PET after two to three cycles of chemotherapy predicts treatment failure and progression-free survival in Hodgkin lymphoma. Blood. 107(1) pp. 52-59.

Juweid, M.E., Stoobants, S., Hoekstra, O.S. et al (2007) Use of positron emission tomography for response assessment of lymphoma: consensus of the imaging subcommittee of International Harmonisation Project in Lymphoma. J. Clin. Oncol. 25 pp. 571-578.

Phase 3 trial – Using PET scans to help decide treatment options for early stage Hodgkin’s lymphoma – Chief Investigator Professor John Radford – supported by Leukaemia Research Fund.

Prognostic value of FDG-PET scan imaging in lymphoma patients undergoing autologous stem cell transplantation. [Journal Article] Bone Marrow Transplantation. 38(3) pp.211-216. 2006 Aug.

Computed tomography and 18F-FDG positron emission tomography for therapy control of Hodgkin's and non-Hodgkin's lymphoma patients: when do we really need FDG-PET?. [Journal Article] Annals of Oncology. 16(9) pp.15241529. 2005 Sep.

UKCCSG Hodgkin’s Lymphoma Working Group (2006) Interim Guidelines for Management of patient’s with early stage lymphocyte predominant Hodgkin’s lymphoma, version 2. Available at:

UKCCSG Hodgkin’s Lymphoma Working Group (2006) Interim Guidelines for the management of classical Hodgkin’s lymphoma, version 3.

Available at:

Cancer and Genetics

March 2008