ESR Essentials: imaging of lymphoma-practice recommendations by the European Society of Oncologic Imaging.

in European radiology by Doris Leithner, Emanuele Neri, Melvin D'Anastasi, Heinz-Peter Schlemmer, Michael Winkelmann, Wolfgang G Kunz, Clemens C Cyran, Dania Cioni, Evis Sala, Marius E Mayerhoefer

TLDR

  • The study provides guidelines for the use of imaging tests in lymphoma staging and treatment response assessment, with [F]FDG PET/CT being the primary modality for most lymphomas.
  • The choice of imaging test and treatment response assessment methods depend on the type of lymphoma.

Abstract

Imaging is used for lymphoma detection, Ann Arbor/Lugano staging, and treatment response assessment. [F]FDG PET/CT should be used for most lymphomas, including Hodgkin lymphoma, aggressive/high-grade Non-Hodgkin lymphomas (NHL) such as diffuse large B-cell lymphoma, and many indolent/low-grade NHLs such as follicular lymphoma. Apart from these routinely FDG-avid lymphomas, some indolent NHLs, such as marginal zone lymphoma, are variably FDG-avid; here, [F]FDG PET/CT is an alternative to contrast-enhanced CT at baseline and may be used for treatment response assessment if the lymphoma was FDG-avid at baseline. Only small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) should exclusively undergo CT at baseline and follow-up unless transformation to high-grade lymphoma is suspected. While [F]FDG PET/CT is sufficient to rule out bone marrow involvement in Hodgkin lymphoma, biopsy may be needed in other lymphomas. The 5-point (Deauville) score for [F]FDG PET that uses the liver and blood pool uptake as references should be used to assess treatment response in all FDG-avid lymphomas; post-treatment FDG uptake ≤ liver uptake is considered complete response. In all other lymphomas, CT should be used to determine changes in lesion size; for complete response, resolution of all extranodal manifestations, and for lymph nodes, long-axis decrease to ≤ 1.5 cm are required. KEY POINTS: [F]FDG-PET/CT and contrast-enhanced CT are used to stage lymphoma depending on type. Imaging is required for staging, and biopsies may be required to rule out bone marrow involvement. For treatment response assessment, the 5-PS (Deauville) score should be used; in a few indolent types, CT is used to determine changes in lesion size.

Overview

  • The study discusses the use of imaging for lymphoma detection, Ann Arbor/Lugano staging, and treatment response assessment.
  • The main focus of the study is to inform the choice of imaging modality for different types of lymphomas.
  • The primary objective is to provide guidelines for the use of [F]FDG PET/CT and contrast-enhanced CT in lymphoma staging and treatment response assessment.

Comparative Analysis & Findings

  • The study highlights the role of [F]FDG PET/CT in detecting most lymphomas, including Hodgkin lymphoma, aggressive/high-grade NHLs, and many indolent/low-grade NHLs.
  • For some indolent NHLs, such as marginal zone lymphoma, [F]FDG PET/CT is an alternative to contrast-enhanced CT at baseline, and may be used for treatment response assessment if the lymphoma was FDG-avid at baseline.
  • Biopsy may be needed to rule out bone marrow involvement in lymphomas other than Hodgkin lymphoma

Implications and Future Directions

  • The study's findings have significant implications for the management of lymphoma patients, particularly in terms of imaging modality choice and treatment response assessment.
  • Future research could focus on further refining the guidelines for imaging modality choice and treatment response assessment for specific types of lymphoma.
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