Childhood Hodgkin Lymphoma Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Diagnosis and Staging
Table 2. Criteria Used for the Classification of Risk Groups in Childhood Hodgkin Lymphoma Clinical Trialsa continued...
End of chemotherapy response assessment
Restaging is carried out upon the completion of all planned initial chemotherapy and may be used to determine the need for consolidative radiation therapy. Key concepts to consider include the following:
Defining complete response.
Although complete response can be defined as absence of disease by clinical examination and/or imaging studies, complete response in Hodgkin lymphoma trials is often defined by a greater than 70% to 80% reduction of disease and a change from initial positivity to negativity on functional imaging. This definition is necessary in Hodgkin lymphoma because fibrotic residual disease is common, particularly in the mediastinum. In some studies, such patients are designated as having an unconfirmed complete response.
The definition of complete response varies by protocol/cooperative group. GPOH studies use very stringent criteria of at least 95% reduction in tumor volume or less than 2 mL residual volume on CT. Consideration of this difference in complete response criteria compared with that used in North American protocols is an important consideration for the omission of radiation therapy, which is stipulated in GPOH trials among favorable-risk patients achieving these strict complete-response criteria.
Timing of PET scanning after completing therapy.
Timing of PET scanning after completing therapy is an important issue. For patients treated with chemotherapy alone, PET scanning should be performed a minimum of 3 weeks after the completion of therapy, while patients whose last treatment modality was radiation therapy should not undergo PET scanning until 8 to 12 weeks postradiation.
Use of anatomic and functional imaging to assess response.
Response assessment using anatomic and functional imaging appears to be superior to that of anatomic imaging alone.
A review of the revised International Workshop Criteria comparing Hodgkin lymphoma response evaluation by CT imaging alone or CT together with PET imaging demonstrated that the combination of CT and PET imaging was more accurate than CT imaging alone.[27,28] While the International Harmonization for assessment of FDG-PET response has been attempted in adults, it has yet to be evaluated in pediatric populations.[29,30]
A Children's Oncology Group study evaluated surveillance CT and detection of relapse in intermediate-stage and advanced-stage Hodgkin lymphoma. The majority of relapses occurred within the first year after therapy or were detected based on symptoms, laboratory, or physical findings. The method of detection of late relapse, whether by imaging or clinical change, did not affect overall survival. Routine use of CT at the intervals used in this study did not improve outcome.
Caution should be used in making the diagnosis of relapsed or refractory disease based solely on anatomic and functional imaging because false-positive results are not uncommon.[32,33,34,35,36] Consequently, pathologic confirmation of refractory/recurrent disease is recommended before modification of therapeutic plans.
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