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Updated Recommendations for Evaluation, Staging, and Response Assessment for Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification

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Key Points

  • FDG PET-CT is formally incorporated into standard staging for FDG-avid lymphomas in the updated recommendations.
  • PET-CT is recommended for assessing response in FDG-avid histologies using the 5-point scale; CT is preferred for low or variable FDG avidity.
  • Surveillance scans after remission are discouraged, particularly for diffuse large B-cell lymphoma and Hodgkin lymphoma.

Updated recommendations (the Lugano Classification) for initial evaluation, staging, and assessment of response in patients with Hodgkin lymphoma and non-Hodgkin lymphoma (NHL) have been presented in the Journal of Clinical Oncology by Cheson et al.

The recommendations are the result of two International Conference on Malignant Lymphoma workshops in Lugano, Switzerland. A workshop at the 11th International Conference, in June 2011, included leading hematologists, oncologists, radiation oncologists, pathologists, radiologists, and nuclear medicine physicians representing major international lymphoma clinical trials groups and cancer centers. In June 2013, clinical and imaging subcommittees presented their conclusions at a workshop at the 12th International Conference, leading to revisions in criteria for staging and in the 2007 International Working Group Guidelines for response assessment. The highlights of the updated recommendations follow:

Staging

  • 18F-fluorodeoxyglucose (FDG) positron-emission tomography (PET)-computed tomography (CT) is formally incorporated into standard staging for FDG-avid lymphomas. PET-CT is the standard for FDG-avid lymphomas, whereas CT is indicated for nonavid histologies.
  • A modification of the Ann Arbor descriptive terminology is recommended for use for the anatomic distribution of disease extent. The A and B suffixes for symptoms will be included only for Hodgkin lymphoma.
  • The designation X for bulky disease is no longer necessary; instead, the largest tumor diameter should be reported.
  • If PET-CT is performed, bone marrow biopsy is no longer indicated for routine staging of Hodgkin lymphoma and most diffuse large B-cell lymphomas. Bone marrow biopsy is needed only for diffuse large B-cell lymphoma if PET is negative and if identifying discordant histology is important for patient management.
  • Regardless of stage, general practice is to treat patients based on limited (stages I and II, nonbulky) or advanced (stage III or IV) disease; stage II bulky disease is considered as limited or advanced based on histology and prognostic factors.

Response Assessment

  • PET-CT is to be used to assess response in FDG-avid histologies using the 5-point scale; CT is preferred for low or variable FDG avidity.
  • A complete metabolic response is considered a complete remission even with a persistent mass.
  • Partial response requires a decrease by > 50% in the sum of the product of the perpendicular diameters of up to six representative nodes or extranodal lesions.
  • Progressive disease on CT criteria requires only an increase in the perpendicular diameters of a single node by ≥ 50%.
  • Surveillance scans after remission are discouraged, particularly for diffuse large B-cell lymphoma and Hodgkin lymphoma; repeat scans may be considered in cases of equivocal findings after treatment. Judicious use of follow-up scans can be considered in indolent lymphomas with residual intra-abdominal or retroperitoneal disease.

The authors concluded: “These recommendations should improve evaluation of patients with lymphoma and enhance the ability to compare outcomes of clinical trials.”

Bruce D. Cheson, MD, of Georgetown University Hospital, Lombardi Comprehensive Cancer Center, is the corresponding author for the Journal of Clinical Oncology article.

For full disclosures of the study authors, visit jco.ascopubs.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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