To Scan or Not to Scan? The Value of Radiologic Surveillance in Early-Stage Hodgkin Lymphoma

Abstract

181 ISSN 2045-1393 10.2217/IJH.13.21 © 2013 Future Medicine Ltd Int. J. Hematol. Oncol. (2013) 2(3), 181–183 Hodgkin lymphoma (HL) is widely regarded as one of the major success stories in oncology, and rightly so. Over the last century, it has been transformed from a virtual death sentence, to one of the most curable malignancies, with overall survival rates of ≥90% at 5 years in early-stage disease [1]. Although treatment failures persist, increasing awareness of the long-term side effects of chemoradiotherapy has shifted our focus from blind cure to the prudent application of treatment, designed to optimize outcomes and minimize toxicity based on risk-stratification and, increasingly, tumor biology. The successful impact of therapeutic radiation in those early days has been well-documented. Moreover, combined chemoradiation is still the treatment of choice in the USA and Europe for favorable disease, although chemotherapy alone is now another option [2–4]. In addition, the imaging modalities of computed tomography (CT) and PET have increased in use as accessibility and affordability has improved. Even though the use of CT and PET for diagnostic work-up has become standard, their role in prognostication, as well as interim evaluation, remains to be fully defined. While formal guidelines exist for the use of CT in surveillance, particularly in the USA [2], there are legitimate concerns about its sensitivity/specificity for identifying relapse and the emergence of false negatives, in addition to the potential long-term effects of latent DNA damage secondary to radiation exposure. Interim or early post-therapy imaging can be justified to manage refractory disease or early relapse with salvage therapy, but practically and prognostically, patients with early stage, nonbulky, favorable HL who have achieved a complete PET-negative response to standard treatment appear to derive little benefit from extended CT surveillance. Arguably, a patient’s outcome can already be predicted by the evidence base supporting initial risk stratification, and imaging during and post-therapy. So, why carry out surveillance? What are we trying to achieve? First and foremost, we are trying to identify relapse. However, relapse rates in early-stage, nonbulky HL