What are the key issues in the NCCN Guidelines related to imaging patients with HL?

FAQ published on August 12, 2015
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Richard Hoppe, MD
Henry S. Kaplan-Harry Lebeson Professor of Cancer Biology
Stanford School of Medicine
Stanford, California
What are the key issues in the NCCN Guidelines related to imaging patients with HL?
Welcome to Managing Hodgkin Lymphoma. My name is Richard Hoppe, and I am a professor of radiation oncology at the Stanford Cancer Center. I specialize in the management of patients with lymphoma, and I chair the NCCN Hodgkin Lymphoma Guidelines Committee. I am frequently asked, “What are the key issues in the NCCN Guidelines related to imaging patients with Hodgkin lymphoma?” Well, imaging is an important component to patient management in Hodgkin lymphoma, and this is well-recognized in the NCCN Guidelines. PET-CT scanning is an essential component for initial staging. This has been noted in the guidelines for several years and is now endorsed as part of the Lugano Staging Classification System. In addition, a CT scan of diagnostic quality may be helpful if the treatment intent is likely to include radiation therapy, or if the patient is on a clinical trial where careful assessment of nodal size is important. The guidelines also incorporate interim PET-CT evaluation, that is a PET-CT following a portion of the chemotherapy, for example following 2 cycles of ABVD. This is used to predict prognosis and in some cases to define subsequent therapy. The guidelines incorporate the Deauville Scale for evaluating response. The Deauville criteria evaluate the PET SUV (standardized uptake value) in areas previously involved compared to the SUV in the mediastinal blood pool or liver. In this scoring system, a score of 1 or 2 is negative, and a score of 4 or 5 is positive. A score of 3 falls into a gray zone. It may be considered a positive score if the treatment decision to de-escalate therapy in stage I or II disease might result, or it might be considered a negative score if a decision to escalate therapy in stage III to IV disease may result. The key questions here related to the Deauville criteria are, “Does your nuclear medicine physician know it? Does your nuclear medicine physician use it? Does your nuclear medicine physician incorporate it into the report?” Unfortunately, the answers are often no. The nuclear medicine community requires some education on the Deauville Scale and its importance in the managing of patients with Hodgkin lymphoma or the non-Hodgkin lymphomas. With respect to overall response assessment, an end-of-treatment PET-CT is essential. Finally, regarding surveillance imaging, the general recommendation is less is better. Relapse in Hodgkin lymphoma is usually suspected by clinical symptoms and findings as opposed to surveillance imaging. Two or three CT scans during the course of follow-up over a period of 2 or 3 years may be okay, but in no case, is a surveillance PET-CT scan indicated. The risk of a false positive examination is just too great. Of course, if there is suspicion of relapse, then imaging is an essential component of further evaluation, but in that case, it would not be considered to be surveillance imaging. Thank you for viewing this activity. For additional resources, please view the other educational activities on ManagingHodgkinLymphoma.com.
Last modified: August 3, 2015
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