EVALUACIN DE LA RESPUESTA

IMAGINOLGICA EN HEMATOLOGA
PET/CT-CHESON

DIEGO A. AGUIRRE
MD RADILOGO
FUNDACIN SANTA FE DE BOGOT
 OBJETIVOS

Importancia Estandarizacin Criterios

Seguimiento y Respuesta

Criterios de Respuesta

2 | Presentation Title | Presenter Name | Date | Subject | Business Use Only

 Estandarizacin Criterios
Seguimiento y Respuesta
Facilita Interpretacin de informacin
Permiten comparacin entre estudios
Identificacin de terapias mas efectivas
Esencial en Investigaciones Clnicas
En evolucin
1999 IWG criterios anatmicos + Galio
2007 IHG PET + Inmunoqumica
 eral Hospital, Boston, MA;
CA. workshop was held at the NCI on February 25 to 26, 1998,
anuary 25, 1999. with a subsequent meeting on May 16, 1998, to come to
eson, MD, National Cancer Re p or t of on
consensus an aI nstandardized
te r n ati on al set Worof k s guidelines
h op to Stan ford ar d i ze
response
Bethesda, MD 20892; email Re s p on s e C r i te r i a for N on -H od g k i n s Lym p h om as
assessment in adult patients with indolent and aggressive NHL.
Oncology. This
By Bruce D. C heson, report
Sandra J. presents
Horning, Bertrand the recommendations
C oiffier, Margaret A . Shipp, Richard I.from the M.NCI-
Fisher, Joseph C onnors,
T. A ndrew Lister, Julie Vose, A ntonio G rillo-Lopez, A nton Hagenbeek, Fernando C abanillas, Donald Klippensten,
sponsored international
W olfgang Hiddemann, working
Ronald C astellino, group.
N ancy L. Harris, James OThese
. A rmitage,represent,
W illiam C arter, to a
Richard Hoppe, and G eorge P. C anellos

Abstract: Standardized guidelines for response as- emission computed tomography gallium scans are en-

! NUMBER 5 ! FEBRUA
Journal of C linical O ncology, Vol 17, Ncouraged
sessment are needed to ensure comparability among
R Y trials
1 0 in2 non-Hodgkins
007
o 4 (A pril), 1999:
as a valuable pp 1244-1253
adjunct to assessment of pa-
clinical lymphomas (NHL). To tients with large-cell NHL, but such scans require appro-
achieve this, two meetings were convened among United priate ex pertise. Flo w cytometric, cytogenetic, and
States and international lymphoma experts represent- molecular studies are not currently included in response

OF CLINICAL ONCOLOGY
ing medical hematology / oncology, radiology, radiation definitions. Response rates may be the most important
L
co.ascopubs.org and provided by at University of Ca SanSDiego
P EonCMarch
I A 1,L2013
A from
R T I C L E
oncology, and pathology to review currently used re-
sponse definitions and to develop a uniform set of
objective in phase II trials where the activity of a new
agent is important and may provide support for ap-
VOLUME 25 ! NUMBER 5 ! FEBRUARY 10 2007
1999 American Society
132.239.1.231
of Clinical Oncology. All rights reserved.
criteria for assessing response in clinical trials. The proval by regulatory agencies. However, the goals of
criteria that were developed include anatomic defini- most phase III trials are to identify therapies that will

JOURNAL OF CLINICAL ONCOLOGY

tions of response, with normal lymph node size after
treatment of 1.5 cm in the longest transverse diameter
prolong the progression-free survival, if not the overall
S P E C I A L A R T I C L
survival, of the treated patients. We hope that these
E
by computer-assisted tomography scan. A designation guidelines will serve to improve communication among
of complete response / unconfirmed w as adopted to in- investigators and comparability among clinical trials
clude patients with a greater than 75% reduction in until clinically relevant laboratory and imaging studies
tumor size after therapy but with a residual mass, to are identified and become more widely available.
include patientsespecially those with large-cell NHL J Clin Oncol 17:1244-1253. ! 1999 by American
who may not have residual disease. Single-photon Society of Clinical Oncology.
Revised Response Criteria for Malignant Lymphoma
Revised Response Criteria for Malignant Lymphoma leukemia,1,2 acute myelogenous leukemia,3 and Hodgkins
S
Bruce D. Cheson, Beate Pfistner,
TANDARDIZED RESPONSE criteria are essential for
Malik E. Juweid, Randy D. Gascoyne, Lena Specht, Sandra J. Horning,
the conduct of clinical research. They facilitate interpre- disease (HD),4 and criteria are now standardized for solid
Bruce D. Cheson, Beate Pfistner, Malik E. Juweid, Randy D. Gascoyne, Lena Specht, Sandra J. Horning,
Bertrand Coiffier, Richard I. Fisher, Anton Hagenbeek, Emanuele Zucca, Steven T. Rosen, Sigrid Stroobants,
tation of data, comparisons of the results among various 5 In 1987, Dixon et al6 emphasized the need for
Bertrand Coiffier, Richard I. Fisher, Antontumors.
Hagenbeek, Emanuele Zucca, Steven T. Rosen, Sigrid Stroobants,
ology/ From the Division of Hematology/
clinical trials, andT.identification of new agents with promis-
T. Andrew Lister,
Oncology, Georgetown University
Richard T.Andrew Hoppe, Martin
Lister, RichardDreyling, Kensei
T. Hoppe, Martin uniform
Tobinai,
reporting
Dreyling, Julie
of end
Kensei M.inVose,
points Julie
Tobinai, clinical
Joseph M.M.Connors,
trials Joseph
M. Vose, of patients Connors,
ersity ing activity, and provide a framework on which to evaluate
Massimo Federico, and Volker Diehl with non-Hodgkins lymphomas (NHL); of particular impor-
University of
Massimo
Hospital, Federico,
Washington, DC; University and
new biologic of Volker Diehl insights into the diseases tance were the complete remission rate, survival, time to
and immunologic
Cologne, Cologne; Department of
being studied. The availability of uniform guidelines ensures A treatment
ent of Nuclear Medicine, University of Iowa, B S failure,
T Rand time A to C relapse
T of complete respond-
y of Iowa, A B S T ers.
a reliable analysis of comparable patient groups among
Iowa City, IA; Department of Pathology,
studies and acquisition of similar data. Response criteria
R Their A recommendations
C T7 were met with controversy that
British Columbia Cancer Agency and Purpose remained unresolved. Therefore, although the need for
f Pathology, have been developed
the University of British Columbia,
for patients with chronic lymphocytic
Standardized response criteria are needed to interpret and compare
common reporting was obvious, the clinical
precise trials and
definitions of for approval
ency and Purpose
Vancouver, British Columbia, Canada; of new therapeutic agents by regulatory agencies. several major end points were neither provided nor uni-
umbia, Standardized
Department of Oncology andresponse
Hematol- criteria are needed to interpret and compare
formly adopted. A consequence is clinical trials
that there are and
currently no for approval
From the NationalMethods
4 | Presentation
ogy, Rigshospitalet, Title | Presenter Name
Copenhagen | Date | Subject | Business Use Only
standardized response criteria for patients with NHL.
of new therapeutic agents by regulatory agencies.
Cancer Institute, Bethesda, MD; Stanford Univer-
, Canada; The International Working Group
France; response criteria (Cheson
University Hospital, Denmark;sity,Division
Palo Alto, CA; Centre Hospitalier Lyon-Sud, Lyon, Recognizing this need, severaletUnited
al, J States
Clin Oncol
lymphoma 17:1244, 1999)
d Hematol- of Oncology and Department of Radia- Cancer
Dana-Farber were widely
Institute, adopted,
Boston, MA; but required
Loyola University, May- reassessment because of identified
investigators from National Cancer Institute (NCI)spon- limitations and the
Methods increased
wood, IL; British Columbia
tion Oncology, Stanford University, use of
Cancer Agency, Vancouver,18
[ F]fluorodeoxyglucose-positron
British Colum- emission tomography (PET), immunohisto-
 Medicin Enfermedad Ejes

Imgenes Transversales MDCT 5mms

Eje Mayor Eje Menor
5
Tamao Ganglios
Individuos normales Ganglios < 10 mm en el eje corto
Ganglio > 15mm en el dimetro transverso mayor son
considerados anormales
Ganglios entre 10-15mms
Anormales si eje menor > 10mms

Linfoma compromiso parcial o completo ganglionar

Post- tratamiento los ganglios diminuyen de tamao pero
no desaparecen
En linfoma post- tratamiento hasta 15 mm medido en el
eje mayor
Seleccin de ganglios

Deben ser claramente medibles en al menos dos

de sus dimensiones perpendiculares

Medir en regiones diferentes del cuerpo

Incluir ganglios mediastinales y retroperitoneales

cuando estn comprometidos
8
PET-CT En linfoma

ESTADIAJE! EVALUACION! EVALUACION!

INICIAL! DURANTE EL DESPUES DEL
TRATAMIENTO! TRATAMIENTO!
PET-CT
Herramienta para estadificacin, re-estadificacin y
evaluacin respuesta de linfomas

Capacidad de diferenciar entre tumor viable, necrosis o

fibrosis luego de terapia

Aumenta la capacidad de diferenciar la supervivencia libre

de progresin entre remisin completa y respuesta
parcial.
lymphoma subtype, and the relevant end points of the clinical trial background in a location incompatible with normal anatomy or
(Table 1). physiology, without a specific standardized uptake value cutoff.29
1. PET is strongly recommended before treatment for patients Other causes of false-positive scans should be ruled out. Exceptions
with routinely FDG-avid, potentially curable lymphomas (eg, diffuse include mild and diffusely increased FDG uptake at the site of

Avidez de Linfoma por FDG

large B-cell lymphoma [DLBCL], Hodgkins lymphoma) to better
delineate the extent of disease; however, currently it is not mandated
because of limitations imposed by cost and availability. For incurable,
moderate- or large-sized masses with an intensity that is lower than
or equal to the mediastinal blood pool, hepatic or splenic nodules
1.5 cm with FDG uptake lower than the surrounding liver/spleen

Table 1. Recommended Timing of PET (PET/CT) Scans in Lymphoma Clinical Trials

Post-
Response Treatment
Histology Pretreatment Mid-Treatment Assessment Surveillance

Routinely FDG avid

DLBCL Yes! Clinical trial Yes No
HL Yes! Clinical trial Yes No
Follicular NHL No Clinical trial No No
MCL No Clinical trial No No
Variably FDG avid
Other aggressive NHLs No Clinical trial No No
Other indolent NHLs No Clinical trial No No

Abbreviations: PET, positron emission tomography; CT, computed tomography; FDG, [18F]fluorodeoxyglucose; DLBCL, diffuse large B-cell lymphoma; HL,
Hodgkins lymphoma; NHL, non-Hodgkins lymphoma; MCL, mantle-cell lymphoma; ORR, overall response rate; CR, complete remission.
!
Recommended but not required pretreatment.
Recommended only if ORR/CR is a primary study end point.
Recommended only if PET is positive pretreatment.

580 JOURNAL OF CLINICAL ONCOLOGY

Information downloaded from jco.ascopubs.org and provided by at University of Ca San Diego on January 20, 2011 from
Copyright 2007 American Society
132.239.1.231
of Clinical Oncology. All rights reserved.

11
Recomendaciones PET-CT
1. Antes del tratamiento en linfomas potencialmente
curables (FDG-avid: difuso de clulas B grandes,
Hodgkin)
1. Evaluar extensin

2. Predictor de Respuesta a Terapia Despus de 1 a 4

ciclos de QuimioTx

3. Evaluar Respuesta a Terapia

1. Respuesta completa en FDG-avid
2. Otros linfomas: PET (+) y evaluar respuesta

4. No recomendado como metodo de seguimiento luego de

re-estadificacin
 LinfomanoHodgkinrecadasmul4plesquimioterapia
Evaluacintempranarespuestaquimioterapia3ciclos

Evaluacin de respuesta durante la terapia

Tiempo Realizacin PET-CT
Cambios inflamatorios post terapia
Post quimioterapia 2-3 semanas
Post radioterapia 2-3 meses

Realizar PET-CT preferiblemente 6 a 8 semanas

post finalizacin de terapia

De realizarlo antes, al menos despus de 3

semanas post terapia
Problemas con PET

Tcnica de la realizacin e interpretacin

Variabilidad entre los lectores y los equipos
Falsos positivos
Infecciones e inflamacin (adenitis, sarcoidosis,
TBC, neumona, etc.)

Captacin fisiolgica (grasa parda, sistema

urinario, timo, msculo, glndulas salivales, etc.)

Hiperplasia tmica benigna

Hiperreactividad de la mdula sea y bazo
debido a factores estimulantes de colonias,
sepsis, anemia, etc.
Dificultades Dicultades

Mediastino

Analisis Ganglios Mediastinales

 Dificultades Dicultades

Variantes

Hipertrofia lipomatosa del septum interatrial

Falsos negativos
Resolucin Anatmica.
Alrededor de 6-7mms depende de la localizacin y caractersticas metablicas del
tumor

Variabilidad en la avidez por FDG de los diferentes tipos histolgicos

de linfomas

Cuando una lesin hipermetablica est en contacto con un tejido

con captacin fisiolgica como el cerebro o el corazn, presentando
un efecto volumen parcial

Hiperglucemia. La glucosa endgena compite con el anlogo (FDG).

Necesaria glicemia normal o al menos menor a 200 mg/dl.
Cmo se mide la enfermedad

Respuesta Completa
Respuesta Parcial
Enfermedad Estable
Recaida o Progresin de Enfermedad

20
 Cmo se mide la enfermedad
Cheson et al

Table 2. Response Definitions for Clinical Trials

Response Definition Nodal Masses Spleen, Liver Bone Marrow

CR Disappearance of all evidence
of disease
PR Regression of measuable
disease and no new sites
SD Failure to attain CR/PR or PD
Relapsed disease Any new lesion or increase
or PD by ! 50% of previously
involved sites from nadir
(a) FDG-avid or PET positive prior to therapy; mass Not palpable, nodules Infiltrate cleared on repeat
of any size permitted if PET negative disappeared biopsy; if indeterminate
(b) Variably FDG-avid or PET negative; regression to by morphology,
normal size on CT immunohistochemistry
should be negative
! 50% decrease in SPD of up to 6 largest dominant ! 50% decrease in Irrelevant if positive prior
masses; no increase in size of other nodes SPD of nodules (for to therapy; cell type
(a) FDG-avid or PET positive prior to therapy; one or single nodule in should be specified
more PET positive at previously involved site greatest transverse
(b) Variably FDG-avid or PET negative; regression on diameter); no
CT increase in size of
liver or spleen
(a) FDG-avid or PET positive prior to therapy; PET
positive at prior sites of disease and no new sites
on CT or PET
(b) Variably FDG-avid or PET negative; no change in
size of previous lesions on CT
Appearance of a new lesion(s) ! 1.5 cm in any axis, ! 50% increase from New or recurrent
! 50% increase in SPD of more than one node, nadir in the SPD of involvement
or ! 50% increase in longest diameter of a any previous
previously identifed node ! 1 cm in short axis lesions
Lesions PET positive if FDG-avid lymphoma or PET
positive prior to therapy

Abbreviations: CR, complete remission; FDG, [18F]fluorodeoxyglucose; PET, positron emission tomography; CT, computed tomography; PR, partial remission; SPD,
sum of the product of the diameters; SD, stable disease; PD, progressive disease.

21
4. If the bone marrow was involved by lymphoma before treat- who have persistent morphologic bone marrow involvement will be
ment, the infiltrate must have cleared on repeat bone marrow biopsy. considered partial responders.
Respuesta completa

1. Desaparicin completa de toda evidencia

clnica de enfermedad detectable y de los
sntomas relacionados con la enfermedad
presentes antes del tratamiento.
 Respuesta completa
2A. Linfomas vidos al FDG:

Pacientes con PET pre-tratamiento (+) se permiten masas

de cualquier tamao si PET es negativo.

PET PET
INICIAL CONTROL

Mesotelioma
Peritoneal
23
Respuesta completa

2B. Linfomas con avidez variable o desconocida al FDG:

Pacientes sin PET pre-tratamiento o pacientes con PET

pre-tratamiento (-), todos los ndulos linfticos y masas
nodales debern haber regresado a su tamao normal por
CT.

24
Respuesta Completa CT

25
Respuesta completa

3. Si hay hepatomegalia o esplenomegalia

antes del tratamiento debe regresar a su tamao
y no debe ser palpable clnicamente (hgado,
riones).

4. La mdula sea, si es positiva en el estudio

de base, debe ser histolgicamente negativa
(inmunohistoqumica, citometra de flujo).
Respuesta completa

27
Respuesta completa no confirmada

Categora eliminada.

Corresponda al periodo entre respuesta

completa a respuesta parcial.
Respuesta parcial

Disminucin 50% en SPD de los 6 ndulos

dominantes o masas nodales.

No aumento de otros ganglios, hgado ni bazo.

Ndulos hepticos y esplnicos deben disminuir

50% en la SPD.

Afectacin de otros rganos es generalmente

valorable y no debe haber enfermedad medible.
Disminucion
82%
Respuesta
Parcial
Compromiso Nodular Heptico
Difcil Valoracin en seguimiento

31
Respuesta parcial

No evidencia de nuevos sitios de enfermedad

Linfomas avidos para FDG: Persistencia de

compromiso

Linfomas con avidez variable o no conocida a

FDG: se utilizan criterios aplicables a CT.
CT INICIAL
PET INICIAL
CT SEGUIMIENTO
PET SEGUIMIENTO
Enfermedad estable
No cumple los criterios para respuesta completa o
respuesta parcial, ni tampoco los criterios para
enfermedad en progresin.

Linfomas vidos FDG: PET positivo, sin nuevas reas de

captacin.

Linfomas avidez variable o desconocida FDG: No

cambios en el tamao de lesiones en el CT
postratamiento.

No debe haber ningn cambio en el tamao de los

ndulos ni en la captacin de los mismos.
CT INICIAL
PET INICIAL
CT CONTROL
PET CONTROL
Progresin de la enfermedad
Recaida (luego de respuesta completa)
Aparicin de cualquier nueva lesin 1.5 cm en cualquiera
de los ejes, durante o al final de la terapia, aunque otras
lesiones de tamao.

El de la captacin de FDG en rea no afectada, solo se

considera enfermedad recurrente o en progresin
despus de confirmar con otras modalidades.

Aumento >50% en el SPD de cualquier ganglio

previamente identificado, o en tamao de otras lesiones
(hepticas / esplnica)
Progresin de la enfermedad
Recaida (luego de respuesta completa)
Aumento> 50% en dimetro mayor de un ndulo
previamente identificado de mas de 1 cm en eje
corto.

Enfermedad extraganglionar medible se debe

evaluar similar a la enfermedad nodal.

Enfermedad no medible se registra como

presente o ausente (Ej. Derrame pleural).
CT INICIAL
CT SEGUIMIENTO
45
 RESUMEN: CRITERIOS DE RESPUESTA
Categoria Definicion Ganglios Bazo - Higado Mdula sea

Respuesta Desaparicin FDG avid / PET (+) PET No Palpable Normal en nueva
Evidencia Negativo Desapacin de biopsia Inmuno-
Completa Enfermedad FDG variable o PET (-) Tamao lesiones histoqumica
normal en CT negativa

Respuesta Regresin 50% disminucin SPD lesiones Disminucin Irrelevante

enfermedad indice (6) sin aumento de 50% SPD
Parcial Medible no nuevo lesiones ndulos
compromiso FDG avid / PET (+) persistencia No megalias
PET +
PET Negativo regresin CT

Enfermedad Ausencia de RC-RP FDG avid / PET (+) PET positivo

sin nuevo compromiso
Estable PET (-) no cambios en tamao

Recada - Lesiones nuevas O Aparicin nuevas lesiones Aumento 50% Compromiso

Aumento 50% 15mms SPD lesiones nuevo o
Progresin enfermedad Aumento 50% SPD 1 o mas recurrente
ganglios
Aumento 50% diametro mayor
de ganglio menor de 10mms eje
menor
Nuevas lesiones en PET
Referencias
1. Drew A. Torigian, Steve S. Huang, Mohamed Houseni and Abass Alavi: Functional Imaging of Cancer with Emphasis on Molecular
Techniques. CA Cancer J Clin 2007;57;206-224

2. Hoffman JM, Gambhir S: Molecular Imaging: The Vision and Opportunity for Radiology in the Future. Radiology: 244: 2007

3. Rmer W, Hanauske AR, Ziegler S, et al: Positron emission tomography in non Hodgkins lymphoma: Assessment of chemotherapy
with fluorodeoxyglucose. Blood 91:4464-4471, 1998

4. Hutchings M, Loft A, Hansen M, et al: FDGPET after two cycles of chemotherapy predicts treatment failure and progression-free
survival in Hodgkin lymphoma. Blood 107:52-59, 2007

5. PET scans in staging of lymphoma current status Friedberg J. W., Chengazi V. The oncologist 2003; 8: 438-447

6. Schoder H, Noy A, Gonen M, et al. Intensity of 18fluorodeoxyglucose uptake in positron emission tomography distinguishes between
indolent and aggressive non-Hodgkins lymphoma. J Clin Oncol. 2005;23:46434651.

7. Cheson BD, Horning SJ, Coiffier B et al. Report of an International Workshop to standardize response criteria for non-Hodgkins
lymphoma. J Clin Oncol 1999;17:1244-1253.

8. Juweid ME, Stroobants S, Hoekstra OS et al. Use of positron emission tomography for response assessment of lymhoma: consensus
recommendations of the Imagining Subcommittee of the International Harmonization Project in Lymphoma: J Clin Oncol 2007; 25:
571-578

9. Delbeke D, Coleman RE, Guiberteau MJ, et al: Procedure guidelines for tumor imaging with FDGPET/ CT 1.0. J Nucl Med 47:885-894,
2006

10. Guermazi A, Juweid ME, PET poised to alter de current paradigm for response assessment of non Hodgkins Lynphoma. The British
Journal of Radiology 79 (2006), 365-367
11. Olsen K, Sohi J, Abraham T, Juweid M: Initial validation of standardized qualitative (visual) criteria for FDG-PET assessment of
residual masses followinglymphoma therapy. Radiological Society of North America 92nd Scientific Assembly and Annual Meeting
Program, 2006, pp 323 (abstr. 55:E23-02)

12. Kostakoglu L. Comparison of FDG PET and Ga-67 in lymphoma. Cancer 2002; 94:879-888

47
Conclusiones

Inmunohistoqumica para evaluacin de la mdula sea

en el diagnstico y reclasificacin luego de la terapia.

La sensibilidad puede con el uso de pneles de Ac

especficos.

Para deteccin de enfermedad oculta en la mdula sea.

Problemas tcnicos impiden su uso general en el
momento.
Avidez por FDG en linfomas
Segn el tipo histolgico presentan variaciones.

ALTA: Linfomas Hodgkin, linfomas de clulas difusas tipo B, LNH

folicular, Linfoma del manto.

VARIABLE: MALT, LNH linfoctico de clulas pequeas, LH

predominio linfoctico, LNH burkitt, Linfoblstico y de clulas T.
Consideraciones especiales

Precaucin en interpretacin de biopsias.

Despus de terapia para enfermedad residual.
Rituximab puede conducir a falsos (-) por econocimiento o
bloqueo de eptopos.
Consideraciones especiales

La enfermedad clonal residual puede existir sin evidencia

morfolgica de linfoma.

Uso de estos mtodos diagnsticos deben ser

incorporados.

Para determinar su pertinencia y utilidad para dirigir la

terapia.
 Respuesta completa
PET INICIAL PET CONTROL
Introduccin

1999 IWG public: Pautas para la evaluacin de la

respuesta en Linfoma no Hodgkin
Alta variacin inter e intraobservador.
Varios puntos fueron puntos de interpretaciones errneas.

2007 Pautas revisadas evaluacion respuesta

Incluye PET CT
Indicaciones PET en linfoma

a) Complemento de la estadificacin inicial

b) En forma temprana a los 2 a 4 ciclos de quimioterapia.

c) Para su re-estadificacin al completar el tratamiento

d) Como seguimiento post Respuesta Completa

e) Como criterio de elegibilidad previo al autotrasplante

f) Como monitoreo temprano de la terapia

 (59). Nevertheless, studies have found measurement of SUV apeutic regimen has demonstrated a role in identifying
gallium generator, but its short half-life of only 68 min makes
seen in 7 patients, with combined
to be consistent: One study that repeated imaging within 10 d
showed the 95% normal range for differences in SUV to be
it less useful for producing good PET images. 66Ga has a
patients who will experience relapse and may require
longer half-life (9.5 h) but is difficult to produce in most
taging disease in 2 patients and
only 60.9, implying that a change in SUV will be con-
sidered significant if the difference is more than 0.9 (60).
cyclotrons. Its longer half-life, however, means that com-
further treatment, but attention to the timing of the scan
mercial manufacturing and distribution would be feasible.
ients. PET/CT has been particularly
PET/CT. The widespread use of combined PET/CT Other 18F-labeled tracers are also under investigation.
in relation to chemotherapy and growth factors is crucial.
Algoritmo PET LH y LNH
systems offers the potential for more accurate staging with 18F-39-deoxy-39-fluorothymidine (FLT) is a marker of cel-

se-positive PET findings, especially

18F-FDG PET. In particular, PET/CT allows accurate spa-

tial localization of abnormal radioactivity uptake. Although

lular proliferation that is currently being investigated as an
Many studies have used subjective grading systems to
alternative to 18F-FDG PET. Although the bone marrow
e tissue (28,29). Although uptake in
software for merging PET and CT images obtained on
different scanners exists, such merging does not always
uptake of 18F-FLT may reduce its sensitivity, initial studies
have demonstrated promise in imaging NHL (68,69). These
often symmetric, particularly in the
result in accurately fused images (61). Moreover, combined
PET/CT offers the advantage of maintaining the same
studies, of only a few patients, have shown comparable re-
sults between 18F-FLT and 18F-FDG PET. One perceived
oper localization is especially im-
patient positioning on the same bed for both scans. One
study compared the reading of side-by-side PET and CT
advantage of 18F-FLT PET is that it does not accumulate
in areas of inflammation (which can be common in this
s the upper abdomen, where asym-
images with the reading of combined PET/CT images and
followed the patients for more than 12 mo (62). That study
particular patient population after radiation or infection)
and may thus reduce the false-positive rate.
mistaken for malignancy (30).
of only 27 patients demonstrated a sensitivity of 78% for
CONCLUSION
CT alone, 86% for 18F-FDG PET alone, 93% for side-by-
s, in most cases, not optimized forandAlthough
side CT and 18F-FDG PET, and 93% for combined PET/CT.
CT remains the gold standard for the staging
This result demonstrates the inherent problem facing com-
follow-up of malignant lymphomas, F-FDG PET has 18

or attenuation correction of the PETapredicting

parisons of PET/CT with PET alone, in that a careful review
potential role in accurately staging disease and in
of functional 18F-FDG images is complete only when
response to therapy. This role has the potential
T for attenuation correction (rathertodecision
comparable structural (CT or MR) images are reviewed at
affect both the initial choice of chemotherapy and the
the same time. A larger study, of 73 patients, followed up
to alter management based on the initial response
nsmission source) reduces scanningtoapeutic
the patients clinically and through additional imaging and
therapy (Fig. 4). PET performed early in a chemother-
histology examinations. Discordant results between PET
regimen has demonstrated a role in identifying
results in virtually noiseless atten-patients who will experience relapse and may require
only and PET/CT were seen in 7 patients, with combined
PET/CT correctly upstaging disease in 2 patients and
further treatment, but attention to the timing of the scan
s (63,64). Current practice consistsin relation to chemotherapy and growth factors is crucial.
downstaging it in 5 patients. PET/CT has been particularly
useful in decreasing false-positive PET findings, especially
Many studies have used subjective grading systems to
e, unenhanced CT for PET atten-
uptake in brown adipose tissue (28,29). Although uptake in
brown adipose tissue is often symmetric, particularly in the
on and, when indicated, separate
neck and shoulders, proper localization is especially im-
portant for areas such as the upper abdomen, where asym-
Because this approach increases the
metric uptake may be mistaken for malignancy (30).
The CT component is, in most cases, not optimized for
adiation, much attention has been
structural imaging but for attenuation correction of the PET
images. The use of CT for attenuation correction (rather
iodinated contrast material on CT-
than a 68Ge or 137Cs transmission source) reduces scanning
time by 40% and also results in virtually noiseless atten-
ction. Some studies have shown that
uation correction factors (63,64). Current practice consists
of performing low-dose, unenhanced CT for PET atten-
ed with intravenous contrast material
uation and coregistration and, when indicated, separate
contrast-enhanced CT. Because this approach increases the
facts (65,66), whereas other studies
patients exposure to radiation, much attention has been
placed on the effect of iodinated contrast material on CT-
r additional contrast-enhanced CT is
based attenuation correction. Some studies have shown that
PET/CT can be performed with intravenous contrast material
atients with lymphoma (67).
without introducing artifacts (65,66), whereas other studies
are investigating whether additional contrast-enhanced CT is
and Future Directions. Positron-
even needed at all in patients with lymphoma (67).
Other PET Tracers and Future Directions. Positron-
allium would be a natural choiceFIGUREFIGURE
emitting isotopes of gallium would be a natural choice
4. Summary of 4.management
Summary of management of HD and aggressive
of HD and aggressive
for PET, and several are being investigated for use. 68Ga is
NHL using F-FDG PET. 18
68
e being investigated for use. Ga is NHL using F-FDG PET. 18

1332 THE JOURNAL OF NUCLEAR MEDICINE Vol. 47 No. 8 August 2006

57
Progresin de la enfermedad o
Recaida (luego de respuesta completa)
Se consideran ndulos linfticos patolgicos si su eje
mayor es superior a 1,5 cm. independientemente de su
eje menor.

Si un ndulo linftico tiene un eje mayor entre 1,1 y 1,5

cm., se debe considerar patolgico nicamente si su eje
menor es mayor de 1 cm.

Los ndulos linfticos 1,0 cm. x 1,0 cm. no se

consideran como anormales para criterios de recada o
progresin.