Has PET/CT an established role in the management of lymphoma? YES! - - PowerPoint PPT Presentation

Has PET/CT an established role in the management of lymphoma? YES!

Martin Hutchings MD PhD Departments of Oncology and Haematology Copenhagen University Hospital, Denmark

Patient-tailored therapy Cure rates vs. late effects Risk of overtreatment vs. risk of relapse

Ideal

Accurate pre-treatment prognostic and predictive markers

Real world

Clinical staging Prognostic indices Response monitoring

Higher sensitivity than CT and other conventional staging methods, but not at the expense of the specificity 10-25% of patients are upstaged as a result of PET/CT, many to a more advanced treatment group Very few patients are downstaged

PET/CT improves the accuracy of lymphoma staging

CT-based planning PET/CT-based planning PET/CT affects the delineation of modern radiotherapy fields in roughly ¼-⅓ of patients

Hutchings et al. Eur J Haematol 2007 Girinsky et al. Radiother Oncol 2007

• Probably, but only if accompanied by relevant and

necessary changes in therapeutic strategy Examples:

• IFRT to INRT
• Respiratory gated PET/CT guided radiotherapy

Is the improved staging accuracy of any benefit to the patients?

Normal PET/CT Respiratory gated PET/CT

Courtesy of Annika Loft

Response to initial treatment is the most powerful prognostic indicator in lymphoma Responders and non-responders can be precisely identified by PET after a few chemotherapy cycles

PET for early treatment monitoring

Spaepen et al. Ann Oncol 2002 Hutchings et al. Blood 2006 Jerusalem et al. Haematologica 2000 Hutchings et al. Ann Oncol 2005 Mikhaeel et al. Ann Oncol 2005 Gallamini et al. Haematologica 2006 Gallamini et al. JCO 2007 Kostakoglu et al. J Nucl Med 2002 Kostakoglu et al Cancer 2006. Haioun et al. Blood 2005

Response to initial treatment is the most powerful prognostic indicator in lymphoma Responders and non-responders can be precisely identified by PET after a few chemotherapy cycles Early interim PET is the best tool for risk-adapted lymphoma therapy

PET has very high NPV and variable PPV for post-treatment evaluation with conventional treatment New response criteria: If PET-negative = CR

Post-treatment evaluation

• 60 pts., all stages
• Treated with Stanford

V or MOPP/ABVD

• Additional

radiotherapy in most patients

Brepoels et al. Leuk Lymphoma 2007;48:1539–47

Hodgkin lymphoma

Time to next treatment (years) Time to next treatment (years) Overall survival (years) Overall survival (years)

Brepoels et al. Leuk Lymphoma 2007;48:1522–30

Aggressive NHL

Has only been investigated in few studies

e.g. Jerusalem et al. Ann Oncol 2003, Zinzani et al. Haematologica 2007

PET identifies some relapsing patients before CT and prior to clinical symptoms Large number of false positive results Benefit for relapsing patients is unclear

PET in the follow-up setting

Nucleoside analogues - target cell proliferation Amino acid tracers - reflecting protein synthesis Tracers directly targeting apoptosis Tracers targeting more disease-specific cell surface molecules

Other tracers than FDG

• Staging:

Yes: 1) Better basis for risk stratified treatment, and 2) more refined definition

• f radiotherapy volumes – less irradiation to normal tissues
• Early treatment monitoring:

–Yes: Early PET/CT may help tailor therapy to the individual patient and thus improve outcomes while still reduce unnecessary over-treatment

• Posttreatment evaluation:

–Yes: PET/CT is the cornerstone of the revised response criteria and seems prognostically stronger than the old ones

• Radiotherapy planning:

–Yes: PET/CT is needed to further refine radiotherapy volumes and help reduce irradiation to normal tissues

• Follow-up:

–No. The value remains to be proven (as does the value of CT)

Does PET/CT have a role in lymphoma?

Common reading criteria for interim PET and for post-treatment PET PET in monitoring radioimmunotherapy and biological agents Enrol our patients into PET-driven clinical trials

Works ahead