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Workup - staging, surveillance (overview)

Last update: 08/19/2014


Initial Evaluation and Response Assessment | Surveillance

Is there a consensus on how to diagnose, stage, and assess response to treatment across different types of lymphoma?  How should the patient be monitored after treatment that induces a complete response?

Initial Evaluation, Staging, and Response Assessment

* J Clin Oncol. 2014 Aug 11: The Lugano Classification
Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma http://bit.ly/1kMHsRp
Excisional biopsy is preferred for diagnosis, although core-needle biopsy may suffice when not feasible.
Clinical evaluation includes careful history, relevant laboratory tests, and recording of disease-related symptoms.
PET-CT is the standard for FDG-avid lymphomas, whereas CT is indicated for nonavid histologies.A modified Ann Arbor staging system is recommended; however, patients are treated according to prognostic and risk factors. Suffixes A and B are only required for HL.
The designation X for bulky disease is no longer necessary; instead, a recording of the largest tumor diameter is required.
If a PET-CT is performed, a BMB is no longer indicated for HL;

a BMB is only needed for DLBCL if the PET is negative and identifying a discordant histology is important for patient management.

The data in all other lymphoma histologies are insufficient to change the standard practice, and a 2.5-cm unilateral BMB is recommended, along with immunohistochemistry and flow cytometry.

Surveillance (routine, regularly scheduled) Imaging

in patients who achieve complete remission after initial therapy for lymphoma

* asco.org: Surveillance Imaging for Lymphoma: Pros and Cons
Lynch, Zelenetz, Armitage, Carson http://bit.ly/1uB0OfI

Although there is no overwhelming evidence discouraging the practice of surveillance imaging, there is also insufficient data supporting it. Review of the studies in Table 1 demonstrates the low number of asymptomatic relapses detected by surveillance imaging in patients with aggressive NHL and HL, the low positive-predictive value of abnormalities detected by imaging, and no demonstration of a survival benefit.

Although it is possible that some patients may benefıt from surveillance imaging, at this time the uncertainty surrounding the estimates of risks and benefıts does not allow for reasonable estimation of the risk-benefıt ratio. When the absence of demonstrable benefits is considered in conjunction with the possible harm, a cautious approach to surveillance imaging is warranted.

* From JNCCN: Role of Routine Imaging in Lymphoma
Nina D. Wagner-Johnston, MD; Nancy L. Bartlett, MD
http://www.medscape.org/viewarticle/741882  (free registration and login required)

10 part discussion, copying here the conclusion:

Available data do not convincingly show a therapeutic advantage for routine imaging in patients with lymphoma. Surveillance CT and PET/CT yield a low rate of detection of recurrence, and suspected relapses are frequently not confirmed, leading to needless downstream testing and patient anxiety because of false-positive results.

When considering cost-effectiveness and increased risk secondary to radiation exposure, current imaging guidelines must be questioned. The small number of events detected from the mostly retrospective series precludes an overall assessment of whether early detection of relapse may impact outcome. Analyzing large databases may address these concerns. Ultimately, randomized studies are needed to answer questions regarding the role of routine imaging in lymphoma. A national surveillance study comparing routine imaging versus routine care without imaging, similar to those conducted in breast cancer, is justified and would be an excellent expenditure of resources.

See also  About Long Term Risks of CT Imaging

First, it's important to note that cautions about risks of a secondary cancer from CT is generally aimed at the general public and in particular younger people who may receive CT imaging without a clear cut medical necessity to do so. ...  CT imaging - long term risks

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