Page 101 - Haematologica August 2018

Non-Hodgkin Lymphoma
End-of-treatment and serial PET imaging in primary mediastinal B-cell lymphoma following dose-adjusted EPOCH-R: a paradigm shift
in clinical decision making
Christopher Melani,1 Ranjana Advani,2 Mark Roschewski,1 Kelsey M. Walters,2 Clara C. Chen,3 Lucia Baratto,4 Mark A. Ahlman,3 Milos D. Miljkovic,1
Seth M. Steinberg,5 Jessica Lam,2 Margaret Shovlin,1 Kieron Dunleavy,6 Stefania Pittaluga,7 Elaine S. Jaffe7 and Wyndham H. Wilson1
1Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD; 2Stanford Cancer Institute, Stanford University, CA; 3Nuclear Medicine Division, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD; 4Nuclear Medicine and Molecular Imaging Division, Stanford University, CA; 5Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD; 6George Washington University Cancer Center, DC and 7Laboratory of Pathology, Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
ABSTRACT
Dose-adjusted-EPOCH-R obviates the need for radiotherapy in most patients with primary mediastinal B-cell lymphoma. End- of-treatment PET, however, does not accurately identify patients at risk of treatment failure, thereby confounding clinical decision mak- ing. To define the role of PET in primary mediastinal B-cell lymphoma following dose-adjusted-EPOCH-R, we extended enrollment and follow up on our published phase II trial and independent series. Ninety-three patients received dose-adjusted-EPOCH-R without radiotherapy. End- of-treatment PET was performed in 80 patients, of whom 57 received 144 serial scans. One nuclear medicine physician from each institution blindly reviewed all scans from their respective institution. End-of-treat- ment PET was negative (Deauville 1-3) in 55 (69%) patients with one treatment failure (8-year event-free and overall survival of 96.0% and 97.7%). Among 25 (31%) patients with a positive (Deauville 4-5) end-of- treatment PET, there were 5 (20%) treatment failures (8-year event-free and overall survival of 71.1% and 84.3%). Linear regression analysis of serial scans showed a significant decrease in SUVmax in positive end-of- treatment PET non-progressors compared to an increase in treatment failures. Among 6 treatment failures, the median end-of-treatment SUVmax was 15.4 (range, 1.9-21.3), and 4 achieved long-term remission with salvage therapy. Virtually all patients with a negative end-of-treat- ment PET following dose-adjusted-EPOCH-R achieved durable remis- sions and should not receive radiotherapy. Among patients with a posi- tive end-of-treatment PET, only 5/25 (20%) had treatment-failure. Serial PET imaging distinguished end-of-treatment PET positive patients with- out treatment failure, thereby reducing unnecessary radiotherapy by 80%, and should be considered in all patients with an initial positive PET following dose-adjusted-EPOCH-R (clinicaltrials.gov identifier 00001337).
Introduction
Primary mediastinal B-cell lymphoma (PMBCL) is a subtype of diffuse large B-cell lymphoma that is clinically and biologically related to nodular sclerosis Hodgkin lymphoma (nsHL).1,2 As such, it primarily presents as a bulky mediastinal mass in adolescents and young adults and is more common in females.3-8 R-CHOP is com-
Ferrata Storti Foundation
Haematologica 2018 Volume 103(8):1337-1344
CM and RA contributed equally to this work.
Correspondence:
wilsonw@mail.nih.gov
Received: March 5, 2018. Accepted: May 10, 2018. Pre-published: May 10, 2018.
doi:10.3324/haematol.2018.192492
Check the online version for the most updated information on this article, online supplements, and information on authorship & disclosures: www.haematologica.org/content/103/8/1337
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