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Contreras-Trujillo H, Eerdeng J, Akre S, Jiang D, Contreras J, Gala B, Vergel-Rodriguez MC, Lee Y, Jorapur A, Andreasian A, Harton L, Bramlett CS, Nogalska A, Xiao G, Lee JW, Chan LN, Müschen M, Merchant AA, Lu R. Deciphering intratumoral heterogeneity using integrated clonal tracking and single-cell transcriptome analyses. Nat Commun 2021; 12:6522. [PMID: 34764253 PMCID: PMC8586369 DOI: 10.1038/s41467-021-26771-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 10/20/2021] [Indexed: 02/08/2023] Open
Abstract
Cellular heterogeneity is a major cause of treatment resistance in cancer. Despite recent advances in single-cell genomic and transcriptomic sequencing, it remains difficult to relate measured molecular profiles to the cellular activities underlying cancer. Here, we present an integrated experimental system that connects single cell gene expression to heterogeneous cancer cell growth, metastasis, and treatment response. Our system integrates single cell transcriptome profiling with DNA barcode based clonal tracking in patient-derived xenograft models. We show that leukemia cells exhibiting unique gene expression respond to different chemotherapies in distinct but consistent manners across multiple mice. In addition, we uncover a form of leukemia expansion that is spatially confined to the bone marrow of single anatomical sites and driven by cells with distinct gene expression. Our integrated experimental system can interrogate the molecular and cellular basis of the intratumoral heterogeneity underlying disease progression and treatment resistance. DNA barcoding is a promising technology for the simultaneous analysis of genetic and phenotypic heterogeneity. Here, the authors combine DNA barcoding and single-cell RNA-seq to study heterogeneity, progression and response to therapy in B-cell acute lymphoblastic leukaemia patient-derived xenografts.
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Affiliation(s)
- Humberto Contreras-Trujillo
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Jiya Eerdeng
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Samir Akre
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Du Jiang
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Jorge Contreras
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Basia Gala
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Mary C Vergel-Rodriguez
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Yeachan Lee
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Aparna Jorapur
- Division of Hematology, USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Areen Andreasian
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Lisa Harton
- Division of Hematology, USC Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Charles S Bramlett
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Anna Nogalska
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Gang Xiao
- Center of Molecular and Cellular Oncology, Yale Cancer Center, Yale University, New Haven, CT, 06511, USA
| | - Jae-Woong Lee
- Center of Molecular and Cellular Oncology, Yale Cancer Center, Yale University, New Haven, CT, 06511, USA
| | - Lai N Chan
- Center of Molecular and Cellular Oncology, Yale Cancer Center, Yale University, New Haven, CT, 06511, USA
| | - Markus Müschen
- Center of Molecular and Cellular Oncology, Yale Cancer Center, Yale University, New Haven, CT, 06511, USA.,Department of Immunobiology, Yale University, New Haven, CT, 06511, USA
| | - Akil A Merchant
- Division of Hematology and Cellular Therapy, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Rong Lu
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA.
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2
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Moshref Razavi H. Bone Marrow Involvement by Aggressive B Cell Lymphoma Undetected by Aspirate Immunophenotyping. J Hematol 2021; 10:14-17. [PMID: 33643504 PMCID: PMC7891908 DOI: 10.14740/jh766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022] Open
Abstract
Staging for newly diagnosed lymphoma is an essential diagnostic step aimed at not only estimating prognosis but also refining the ensuing therapeutic pathway. Bone marrow is routinely sampled for this reason. Morphological assessment of the bone marrow aspirate and biopsy remains the gold standard approach. Nonetheless, ancillary testing such as aspirate immunophenotyping is also used with the aim to increase sensitivity and add diagnostic utility, e.g., to provide proof of clonality. Both of these techniques are fraught with shortcomings and concordance is often not perfect. Cases of infiltrative lymphoma identified by morphology, and not detected by flow cytometry highlights the dangers of over reliance on aspirate immunophenotyping. Under sampling, disintegration, fibrosis and hemodilution are but some causes of a false negative flow result. Therefore, neither technique is sufficient in isolation. In this submission, a case of such a discrepancy is presented as an introduction for review of literature that highlights this phenomenon.
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Affiliation(s)
- Habib Moshref Razavi
- Fraser Health Authority, The Royal Columbian Hospital, 330 East Columbia Street New Westminster, BC, V3L 3W7, Canada.
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Göçer M, Kurtoğlu E. Comparison of Bone Marrow Involvement with Bone Marrow Biopsy and PET-CT and Evaluation of Any Effects on Survival in Patients Diagnosed with Hodgkin and Non-Hodgkin Lymphoma. Indian J Hematol Blood Transfus 2021; 37:52-59. [PMID: 33707835 PMCID: PMC7900321 DOI: 10.1007/s12288-020-01284-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 04/23/2020] [Indexed: 01/04/2023] Open
Abstract
We aimed to demonstrate whether PET-CT can replace bone marrow biopsy in detecting bone marrow involvement in subtypes of lymphoma. In addition, we aimed to also reveal whether there is a difference between the mean survival of patients with bone marrow involvement via PET-CT or biopsy. A total of 276 newly diagnosed lymphoma patients who underwent bone marrow biopsy and PET-CT prior to the treatment were scanned retrospectively. Bone marrow biopsy was used as the standard method to investigate the presence of bone marrow involvement in PET-CT. The relationship between bone marrow involvement and mean survival was compared using both methods. Out of the 276 patients, bone marrow involvement was detected with PET-CT and with biopsy, respectively in 56 patients (20.2%) and in 78 patients (28.2%). In terms of PET-CT's accuracy with respect to revealing bone marrow involvement, the highest rates were achieved respectively in diffuse large B cell lymphoma (DLBCL) (87.4%) and Hodgkin lymphoma (HL) (77.7%). In both the PET-CT and bone marrow biopsy methods, Overall Survival (OS) was found to be significantly shorter in patients with involvement than in patients without involvement (P: 0.001). PET-CT may replace bone marrow (BM) biopsy in detecting the bone marrow involvement in aggressive lymphoma subtypes such as DLBCL and HL. The presence of BM involvement at the time of diagnosis in both PET-CT and BM biopsy is associated with poor prognosis, and OS is short in this group.
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Affiliation(s)
- Mesut Göçer
- Division of Hematology, Department of Internal Medicine, Antalya Training and Research Hospital, 07100 Antalya, Turkey
| | - Erdal Kurtoğlu
- Division of Hematology, Department of Internal Medicine, Antalya Training and Research Hospital, 07100 Antalya, Turkey
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4
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Merzianu M, Groman A, Hutson A, Cotta C, Brynes RK, Orazi A, Reddy V, Teruya-Feldstein J, Amre R, Balasubramanian M, Brandao G, Cherian S, Courville E, Czuchlewski D, Fan G, Grier D, Hoehn D, Inamdar KV, Juskevicius R, Kaur P, Lazarchick J, Lewis MR, Miles RR, Myers JB, Nasr MR, Qureishi HN, Olteanu H, Robu VG, Salaru G, Vajpayee N, Vos J, Zhang L, Zhang S, Aye L, Brega E, Coad JE, Grantham J, Ivelja S, McKenna R, Sultan K, Wilding G, Hutchison R, Peterson L, Cheney RT. Trends in Bone Marrow Sampling and Core Biopsy Specimen Adequacy in the United States and Canada: A Multicenter Study. Am J Clin Pathol 2018; 150:393-405. [PMID: 30052721 PMCID: PMC6166687 DOI: 10.1093/ajcp/aqy066] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess bone marrow (BM) sampling in academic medical centers. METHODS Data from 6,374 BM samples obtained in 32 centers in 2001 and 2011, including core length (CL), were analyzed. RESULTS BM included a biopsy (BMB; 93%) specimen, aspirate (BMA; 92%) specimen, or both (83%). The median (SD) CL was 12 (8.5) mm, and evaluable marrow was 9 (7.6) mm. Tissue contraction due to processing was 15%. BMB specimens were longer in adults younger than 60 years, men, and bilateral, staging, and baseline samples. Only 4% of BMB and 2% of BMB/BMA samples were deemed inadequate for diagnosis. BM for plasma cell dyscrasias, nonphysician operators, and ancillary studies usage increased, while bilateral sampling decreased over the decade. BM-related quality assurance programs are infrequent. CONCLUSIONS CL is shorter than recommended and varies with patient age and sex, clinical circumstances, and center experience. While pathologists render diagnoses on most cases irrespective of CL, BMB yield improvement is desirable.
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Affiliation(s)
- Mihai Merzianu
- Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Adrienne Groman
- Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Alan Hutson
- Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Claudiu Cotta
- Laboratory Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Attilio Orazi
- Pathology, Weill Cornell Medical College, New York, NY
| | | | | | - Ramila Amre
- Pathology, McGill University Health Centre , Royal Victoria Hospital, Montreal, Canada
| | | | - Guilherme Brandao
- Pathology, McGill University Jewish General Hospital, Montreal, Canada
| | | | | | | | - Guang Fan
- Pathology, Oregon Health and Science University, Portland
| | - David Grier
- Pathology, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Daniela Hoehn
- Pathology and Cell Biology, Columbia University Medical Center, New York, NY
| | | | - Ridas Juskevicius
- Pathology, East Carolina University Brody School of Medicine, Greenville, NC
| | - Prabhjot Kaur
- Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - John Lazarchick
- Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston
| | - Michael R Lewis
- Pathology and Laboratory Medicine, University of Vermont, Burlington
| | | | - Jerome B Myers
- Pathology, Penrose Saint Francis Health Services, Colorado Springs, CO
| | | | - Hina N Qureishi
- Pathology and Microbiology, University of Nebraska Medical Center, Omaha
| | | | | | - Gratian Salaru
- Clinical Pathology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Neerja Vajpayee
- Pathology, State University of New York Upstate Medical University, Syracuse
| | - Jeffrey Vos
- Pathology, West Virginia University, Morgantown
| | - Ling Zhang
- Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Shanxiang Zhang
- Pathology and Laboratory Medicine, Indiana University, Indianapolis
| | - Le Aye
- Pathology, Keck School of Medicine of USC, Los Angeles
| | - Elisa Brega
- Pathology, McGill University Jewish General Hospital, Montreal, Canada
| | | | | | - Sinisa Ivelja
- Pathology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Robert McKenna
- Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | | | - Gregory Wilding
- Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Robert Hutchison
- Pathology, State University of New York Upstate Medical University, Syracuse
| | | | - Richard T Cheney
- Pathology and Anatomical Sciences, University at Buffalo–The State University of New York
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5
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Luoni M, Declich P, Fava S, Marinoni P, Montalbetti L, Sangalli G, Sciuccati P, Tocci A, Tosi A. Bone Marrow Biopsy for the Staging of Non-Hodgkin's Lymphoma: Bilateral or Unilateral Trephine Biopsy? TUMORI JOURNAL 2018; 81:410-3. [PMID: 8804465 DOI: 10.1177/030089169508100604] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Aim The occurrence of unilateral involvement in bilateral bone marrow trephine biopsies in non-Hodgkin's lymphomas (NHL) at disease onset (10-20% of cases) has been reported since the early 70s. Therefore, although these studies were based on small series, the use of bilateral bone marrow biopsies has become the rule. However, the clinical value of this procedure has never been clearly established. The aim of the present study was to ascertain the true value of bilateral bone marrow biopsy in the staging of NHL. Study Design We examined 368 cases of NHL (A-H according to the Working Formulation) (WF), without leukemic involvement of the peripheral blood, in order to evaluate: 1) the incidence of unilateral bone marrow involvement; 2) the percentage of patients who, as a result of unilateral bone marrow involvement, changed from stages I-II to stage IV; 3) assessment of response to therapy for patients with both bilateral or unilateral bone marrow involvement. Results In the A-C NHL groups of WF there was a unilateral bone marrow involvement of 8.8%. Overall, bone marrow involvement induced a change from clinical stages I-II to stage IV in 5.6% of cases, a figure which would correspond to a false negative rate of 2.8%, if unilateral bone marrow biopsy was performed. In the D-F and G, H groups of WF, unilateral involvement was 10.1% and 8.5% respectively; the change in stage from I-II to IV by unilateral bone marrow involvement respectively amounted to 1.4% and 2.8%, which correspond to respective false negative rates of 0.7% and 1.4%. Conclusions On the basis of these results and of the present therapeutic strategies, we propose: bilateral bone marrow biopsy for clinical stages I-II of all NHL; no bone marrow biopsy at disease onset for clinical stages III and IV of A to H histologic subtypes of the WF; unilateral bone marrow biopsy (A-C subtypes of the WF) or bilateral (D-H of the WF), after the regression of extramedullary localizations.
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Affiliation(s)
- M Luoni
- Hematology Day Hospital, Italy
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6
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Federico M, Magin RL, Swartz HM, Wright RM, Silingardi V. Detection of Bone Marrow Involvement in Patients with Cancer. TUMORI JOURNAL 2018; 75:90-6. [PMID: 2741229 DOI: 10.1177/030089168907500202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Current methods for the study of bone marrow to evaluate possible primary or metastatic cancers are reviewed. Bone marrow biopsy, radionuclide scan, computed tomography and magnetic resonance imaging (MRI) are analyzed with regard to their clinical usefulness at the time of diagnosis and during the course of the disease. Bone marrow biopsy is still the examination of choice not only in hematologic malignancies but also for tumors that metastasize into the marrow. Radionuclide scans are indicated for screening for skeletal metastases, except for those from thyroid carcinoma and multiple myeloma. Computed tomography is useful for cortical bone evaluation. MRI shows a high sensitivity in finding occult sites of disease in the marrow but its use has been restricted by high cost and limited availability. However, the future of MRI in bone marrow evaluation seems assured. MRI is already the method of choice for diagnosis of multiple myeloma, when radiography is negative, and for quantitative evaluation of lymphoma when a crucial therapeutic decision (i.e. bone marrow transplantation) must be made. Finally, methods are being developed that will enhance the sensitivity and specificity of MRI studies of bone marrow.
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Affiliation(s)
- M Federico
- Divisione di Oncologia, Università di Modena, Italy
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7
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Pasoglou V, Michoux N, Larbi A, Van Nieuwenhove S, Lecouvet F. Whole Body MRI and oncology: recent major advances. Br J Radiol 2018; 91:20170664. [PMID: 29334236 DOI: 10.1259/bjr.20170664] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
MRI is a very attractive approach for tumour detection and oncological staging with its absence of ionizing radiation, high soft tissue contrast and spatial resolution. Less than 10 years ago the use of Whole Body MRI (WB-MRI) protocols was uncommon due to many limitations, such as the forbidding acquisition times and limited availability. This decade has marked substantial progress in WB-MRI protocols. This very promising technique is rapidly arising from the research world and is becoming a commonly used examination for tumour detection due to recent technological developments and validation of WB-MRI by multiple studies and consensus papers. As a result, WB-MRI is progressively proposed by radiologists as an efficient examination for an expanding range of indications. As the spectrum of its uses becomes wider, radiologists will soon be confronted with the challenges of this technique and be urged to be trained in order to accurately read and report these examinations. The aim of this review is to summarize the validated indications of WB-MRI and present an overview of its most recent advances. This paper will briefly discuss how this examination is performed and which are the recommended sequences along with the future perspectives in the field.
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Affiliation(s)
- Vassiliki Pasoglou
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Nicolas Michoux
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Ahmed Larbi
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium.,2 Department of Radiology, Nimes University Hospital , Nimes , France
| | - Sandy Van Nieuwenhove
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Frédéric Lecouvet
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium
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8
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Pasoglou V, Michoux N, Larbi A, Van Nieuwenhove S, Lecouvet F. Whole Body MRI and oncology: recent major advances. Br J Radiol 2018. [PMID: 29334236 DOI: 10.1259/bjr.20170664%0a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
MRI is a very attractive approach for tumour detection and oncological staging with its absence of ionizing radiation, high soft tissue contrast and spatial resolution. Less than 10 years ago the use of Whole Body MRI (WB-MRI) protocols was uncommon due to many limitations, such as the forbidding acquisition times and limited availability. This decade has marked substantial progress in WB-MRI protocols. This very promising technique is rapidly arising from the research world and is becoming a commonly used examination for tumour detection due to recent technological developments and validation of WB-MRI by multiple studies and consensus papers. As a result, WB-MRI is progressively proposed by radiologists as an efficient examination for an expanding range of indications. As the spectrum of its uses becomes wider, radiologists will soon be confronted with the challenges of this technique and be urged to be trained in order to accurately read and report these examinations. The aim of this review is to summarize the validated indications of WB-MRI and present an overview of its most recent advances. This paper will briefly discuss how this examination is performed and which are the recommended sequences along with the future perspectives in the field.
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Affiliation(s)
- Vassiliki Pasoglou
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Nicolas Michoux
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Ahmed Larbi
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium.,2 Department of Radiology, Nimes University Hospital , Nimes , France
| | - Sandy Van Nieuwenhove
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Frédéric Lecouvet
- 1 Department of Radiology, Centre du Cancer et Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain , Brussels , Belgium
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Aide N, Talbot M, Fruchart C, Damaj G, Lasnon C. Diagnostic and prognostic value of baseline FDG PET/CT skeletal textural features in diffuse large B cell lymphoma. Eur J Nucl Med Mol Imaging 2017; 45:699-711. [PMID: 29214417 PMCID: PMC5978926 DOI: 10.1007/s00259-017-3899-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/23/2017] [Indexed: 12/20/2022]
Abstract
Purpose Our purpose was to evaluate the diagnostic and prognostic value of skeletal textural features (TFs) on baseline FDG PET in diffuse large B cell lymphoma (DLBCL) patients. Methods Eighty-two patients with DLBCL who underwent a bone marrow biopsy (BMB) and a PET scan between December 2008 and December 2015 were included. Two readers blinded to the BMB results visually assessed PET images for bone marrow involvement (BMI) in consensus, and a third observer drew a volume of interest (VOI) encompassing the axial skeleton and the pelvis, which was used to assess skeletal TFs. ROC analysis was used to determine the best TF able to diagnose BMI among four first-order, six second-order and 11 third-order metrics, which was then compared for diagnosis and prognosis in disease-free patients (BMB−/PET-) versus patients considered to have BMI (BMB+/PET-, BMB−/PET+, and BMB+/PET+). Results Twenty-two out of 82 patients (26.8%) had BMI: 13 BMB−/PET+, eight BMB+/PET+ and one BMB+/PET-. Among the nine BMB+ patients, one had discordant BMI identified by both visual and TF PET assessment. ROC analysis showed that SkewnessH, a first-order metric, was the best parameter for identifying BMI with sensitivity and specificity of 81.8% and 81.7%, respectively. SkewnessH demonstrated better discriminative power over BMB and PET visual analysis for patient stratification: hazard ratios (HR), 3.78 (P = 0.02) versus 2.81 (P = 0.06) for overall survival (OS) and HR, 3.17 (P = 0.03) versus 1.26 (P = 0.70) for progression-free survival (PFS). In multivariate analysis accounting for IPI score, bulky status, haemoglobin and SkewnessH, the only independent predictor of OS was the IPI score, while the only independent predictor of PFS was SkewnessH. Conclusion The better discriminative power of skeletal heterogeneity for risk stratification compared to BMB and PET visual analysis in the overall population, and more specifically in BMB−/PET- patients, suggests that it can be useful to identify diagnostically overlooked BMI.
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Affiliation(s)
- Nicolas Aide
- Nuclear Medicine Department, Caen University Hospital, Caen, France.,Normandie University, Caen, France.,INSERM 1086 ANTICIPE, Normandie University, Caen, France
| | | | | | - Gandhi Damaj
- Haematology Institute, Caen University Hospital, Caen, France
| | - Charline Lasnon
- INSERM 1086 ANTICIPE, Normandie University, Caen, France. .,Nuclear Medicine Department, François Baclesse Cancer Centre, Caen, France.
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10
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Soydal C, Koksoy EB, Yasar A, Turgal E, Erdogan BD, Akbulut H, Kucuk NO. Prognostic Importance of Bone Marrow Uptake on Baseline 18F-FDG Positron Emission Tomography in Diffuse Large B Cell Lymphoma. Cancer Biother Radiopharm 2017; 31:361-365. [PMID: 27996313 DOI: 10.1089/cbr.2016.2132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIM To define the role of 18F-flourodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) in the detection of bone marrow (BM) involvement in patients with diffuse large B cell lymphoma (DLBCL). MATERIALS AND METHODS Fifty-four (mean age: 55.5 ± 18.3 years, 20 female and 34 male) DLBCL patients who underwent pretreatment 18F-FDG PET/CT were included to the study. Focal or diffuse BM 18F-FDG uptake that is higher than mediastinal blood pool uptake was accepted as positive. After staging of disease by CT and 18F-FDG PET/CT, all the patients received R-CHOP treatment after diagnostic blinded bone marrow biopsy (BMB). Presence of positive BM uptake in 18F-FDG PET/CT and histopathological examination results of BMBs were analyzed by Chi-square test. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of 18F-FDG PET/CT in the detection of BM involvement were calculated. Prognostic importance of the presence of BM 18F-FDG uptake was analyzed by Kaplan-Meier analysis. RESULTS BM 18F-FDG uptake was detected in 8 patients. Histopathological examination of BMB revealed BM involvement in 6 out of 8 patients. BMB was negative in all patients who have no 18F-FDG uptake in the evaluation of PET/CT images. Sensitivity, specificity, accuracy, PPV, and NPV of 18F-FDG PET/CT in the detection of BM involvement were calculated as 100%, 96%, 96%, 75%, and 100%, respectively. In the Kaplan-Meier analysis, we found that presence of pretreatment 18F-FDG uptake in BM has a prognostic importance. Whereas mean time to progression (TTP) in patients with BM uptake was 32.25 ± 10.9 months and mean TTP in those without was 51.69 ± 3.6 months (p = 0.013). CONCLUSIONS BM uptake in pretreatment 18F-FDG PET/CT is an important prognostic factor in DLBCL patients. Moreover, in consideration of high NPV, 18F-FDG PET/CT could eliminate unnecessary BMB in FDG-negative patients.
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Affiliation(s)
- Cigdem Soydal
- 1 Department of Nuclear Medicine, Ankara University Medical Faculty , Ankara, Turkey
| | - Elif Berna Koksoy
- 2 Department of Medical Oncology, Ankara University Medical Faculty , Ankara, Turkey
| | - Arzu Yasar
- 2 Department of Medical Oncology, Ankara University Medical Faculty , Ankara, Turkey
| | - Ebru Turgal
- 3 Department of Biostatistics, Medical Faculty, Hitit University , Corum, Turkey
| | | | - Hakan Akbulut
- 2 Department of Medical Oncology, Ankara University Medical Faculty , Ankara, Turkey
| | - Nuriye Ozlem Kucuk
- 1 Department of Nuclear Medicine, Ankara University Medical Faculty , Ankara, Turkey
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Asenbaum U, Nolz R, Karanikas G, Furtner J, Woitek R, Staudenherz A, Senn D, Raderer M, Weber M, Simonitsch-Klupp I, Mayerhoefer ME. Evaluation of [18F]-FDG-Based Hybrid Imaging Combinations for Assessment of Bone Marrow Involvement in Lymphoma at Initial Staging. PLoS One 2016; 11:e0164118. [PMID: 27723817 PMCID: PMC5056699 DOI: 10.1371/journal.pone.0164118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/20/2016] [Indexed: 01/03/2023] Open
Abstract
The purpose of our study was to determine the value of different hybrid imaging combinations for the detection of focal and diffuse bone marrow infiltration in lymphoma. Patients with histologically proven lymphoma, who underwent both [18F]-FDG-PET/CT and whole-body MRI (including T1- and diffusion-weighted [DWI] sequences) within seven days, and a subsequent bone marrow biopsy, were retrospectively included. Three hybrid imaging combinations were evaluated: (1) [18F]-FDG-PET/CT; (2) [18F]-FDG-PET/T1; and (3) [18F]-FDG-PET/DWI. The presence of focal or diffuse bone marrow infiltration was assessed by two rater teams. Sensitivity, specificity, and accuracy for the detection of overall, focal, and diffuse bone marrow involvement were compared between the three hybrid imaging combinations. Overall, lymphomatous bone marrow involvement was found in 16/60 patients (focal, 8; diffuse, 8). Overall sensitivity, specificity, and accuracy were 81.3%, 95.5%, and 91.7% for [18F]-FDG-PET/CT; 81.3%, 97.7%, and 93.3% for [18F]-FDG-PET/T1; and 81.3%, 95.5%, and 91.7% for [18F]-FDG-PET/DWI. No statistically significant differences between the three imaging combinations were observed, based on overall bone marrow involvement, focal involvement, or diffuse involvement. The sensitivity of all three imaging combinations for detecting diffuse bone marrow involvement was only moderate (62.5% for all three combinations). Although the combination of [18F]-FDG-PET and T1-weighted MRI generally showed the best diagnostic performance for the detection of bone marrow involvement in lymphoma, it was not significantly superior to the two other hybrid imaging combinations. Since the sensitivity of all imaging combinations for the detection of diffuse bone marrow involvement was only moderate, bone marrow biopsy cannot be replaced by imaging as yet.
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Affiliation(s)
- Ulrika Asenbaum
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
- * E-mail:
| | - Richard Nolz
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Georgios Karanikas
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Julia Furtner
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Ramona Woitek
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Anton Staudenherz
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Daniela Senn
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Markus Raderer
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Ingrid Simonitsch-Klupp
- Department of Internal Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Marius E. Mayerhoefer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
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Albano D, Patti C, Lagalla R, Midiri M, Galia M. Whole-body MRI, FDG-PET/CT, and bone marrow biopsy, for the assessment of bone marrow involvement in patients with newly diagnosed lymphoma. J Magn Reson Imaging 2016; 45:1082-1089. [PMID: 27603267 DOI: 10.1002/jmri.25439] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/08/2016] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To compare whole-body MRI (WB-MRI) with diffusion-weighted imaging (DWI), FDG-PET/CT, and bone marrow biopsy (BMB), for the evaluation of bone marrow involvement (BMI) in patients with newly diagnosed lymphoma. MATERIALS AND METHODS This retrospective study was approved by our Institutional Review Board. Two independent radiologists and one nuclear medicine specialist reviewed all WB-MRI and FDG-PET/CT scans prospectively performed on 104 patients with newly diagnosed lymphoma (53 males; 47 Hodgkin; mean age: 44 years; range, 15-86 years) between 2013 and 2015. The delay between imaging scans and BMBs was up to 10 days. The diagnostic accuracy of WB-MRI (1.5 Tesla MR scanner, with T1w, T2w-STIR, and DWI sequences) was evaluated using BMB and FDG-PET/CT as the reference standard. We applied Cohen's kappa coefficient to assess the inter-observer agreement in WB-MRI interpretation and to compare WB-MRI, FDG-PET/CT and BMB. The Student's t test was done to compare pelvic marrow ADC values of patients with positive and negative BMB. A P-value of < 0.01 was considered significant. RESULTS Inter-observer agreement was excellent (k = 0.937). Agreement between WB-MRI and FDG-PET/CT was excellent, with a k = 0.935. Agreement between WB-MRI and BMB was moderate (k = 0.489), and fair between FDG-PET/CT and BMB (k = 0.370). WB-MRI and FDG-PET/CT were falsely negative in four indolent non-Hodgkin lymphomas with BMI < 30% of marrow cellularity. Conversely, WB-MRI and FDG-PET/CT detected all cases with a BMI>30% of marrow cellularity. Mean ADC values in patients with positive and negative BMB were not significantly different (P = 0.049). CONCLUSION WB-MRI and FDG-PET/CT are valuable tools for the assessment of BMI. LEVEL OF EVIDENCE 3 J. Magn. Reson. Imaging 2017;45:1082-1089.
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Affiliation(s)
- Domenico Albano
- Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy
| | - Caterina Patti
- Department of Hematology I, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Roberto Lagalla
- Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy
| | - Massimo Midiri
- Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy
| | - Massimo Galia
- Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy
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Adams HJA, Nievelstein RAJ, Kwee TC. Opportunities and limitations of bone marrow biopsy and bone marrow FDG-PET in lymphoma. Blood Rev 2015; 29:417-25. [PMID: 26113144 DOI: 10.1016/j.blre.2015.06.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/10/2015] [Accepted: 06/12/2015] [Indexed: 12/17/2022]
Abstract
Bone marrow involvement in lymphoma may have prognostic and therapeutic consequences. Bone marrow biopsy (BMB) is the established method for the evaluation of the bone marrow. (18)F-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) plays an important role in lymphoma staging, but its value in the assessment of the bone marrow and whether it can replace BMB is still a topic of debate and investigation. The purpose of this scientific communication is to provide an evidence-based overview about the opportunities and limitations of BMB and FDG-PET in the evaluation of the bone marrow in patients with lymphoma. This article first reviews the basic properties, opportunities and limitations of BMB and bone marrow FDG-PET, and then focuses on the clinical utility of BMB and bone marrow FDG-PET in three major lymphoma subtypes including Hodgkin lymphoma, diffuse large B-cell lymphoma, and follicular lymphoma.
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Affiliation(s)
- Hugo J A Adams
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Rutger A J Nievelstein
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas C Kwee
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Adams HJ, Kwee TC, Fijnheer R, Dubois SV, Nievelstein RA, de Klerk JM. Diffusely increased bone marrow FDG uptake in recently untreated lymphoma: incidence and relevance. Eur J Haematol 2015; 95:83-9. [DOI: 10.1111/ejh.12483] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Hugo J.A. Adams
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - Thomas C. Kwee
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - Rob Fijnheer
- Department of Hematology; Meander Medical Center; Amersfoort The Netherlands
| | - Stefan V. Dubois
- Department of Pathology; Meander Medical Center; Amersfoort The Netherlands
| | - Rutger A.J. Nievelstein
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - John M.H. de Klerk
- Department of Nuclear Medicine; Meander Medical Center; Amersfoort The Netherlands
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Abstract
The role of PET and PET/computed tomography (CT) has evolved significantly in the last few decades. 2-Deoxy-2-[18F]-fluoro-d-glucose (FDG)-PET/CT is now an integral part of the management of patients with lymphoma. FDG-PET/CT at the time of initial staging can help in appropriate staging of the patients. Both interim and end-of-therapy PETs have significant prognostic value in patients with Hodgkin lymphoma and aggressive non-Hodgkin lymphoma and more accurately assess for the presence of residual malignancy than anatomic imaging. The impact of interim FDG-PET/CT on risk-adapted strategies is an area of active investigation and the results of ongoing clinical trials will be informative.
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Kim HY, Kim JS, Choi DR, Kim HS, Kwon JH, Jang GD, Kim JH, Jung JY, Song HH, Lee YK, Min SK, Hwang HS, Kim HJ, Zang DY, Kim HJ. The Clinical Utility of FDG PET-CT in Evaluation of Bone Marrow Involvement by Lymphoma. Cancer Res Treat 2014; 47:458-64. [PMID: 25648095 PMCID: PMC4506116 DOI: 10.4143/crt.2014.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 05/12/2014] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Bone marrow biopsy is a standard method for the evaluation of bone marrow infiltration by lymphoma; however, it is an invasive and painful procedure. Fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) is a noninvasive imaging technique with the potential to detect bone marrow involvement by lymphoma. MATERIALS AND METHODS We retrospectively reviewed medical records of lymphoma patients. All patients were examined by FDG PET-CT and iliac crest bone marrow biopsy for initial staging work-up. RESULTS The study population comprised 94 patients (median age, 60 years; 56 males) with Hodgkin's lymphoma (n=8) or non-Hodgkin's lymphoma (n=86). Maximum standardized uptake values on the iliac crest of patients with lymphoma infiltrated bone marrow were significantly higher than those of patients with intact bone marrow (2.2±1.2 g/mL vs. 1.3±0.4 g/mL; p=0.001). The calculated values for FDG PET-CT during evaluation of bone marrow involvement were as follows: sensitivity 50%, specificity 96%, positive predictive value 80%, negative predictive value 85%, and positive likelihood ratio (LR+) 11.7. The value of LR+ was 16.0 in patients with aggressive subtypes of non-Hodgkin's lymphoma (NHL). CONCLUSION FDG PET-CT could not replace bone marrow biopsy due to the low sensitivity of FDG PET-CT for detection of bone marrow infiltration in lymphoma patients. Conversely, FDG PET-CT had high specificity and LR+; therefore, it could be a useful tool for image-guided biopsy for lymphoma staging, especially for aggressive subtypes of NHL. In addition, unilateral bone marrow biopsy could be substituted for bilateral bone marrow biopsy in lymphoma patients with increased FDG uptake on any iliac crest.
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Affiliation(s)
- Ho Young Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Ju-Seok Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Dae Ro Choi
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyeong Su Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Geun-Doo Jang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jung Han Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Joo Young Jung
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hun Ho Song
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Young Kyung Lee
- Department of Laboratory Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Soo Kee Min
- Department of Pathology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hee Sung Hwang
- Department of Nuclear Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hwa Jung Kim
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Young Zang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
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Adams HJ, Kwee TC, Fijnheer R, Dubois SV, Nievelstein RA, de Klerk JM. Bone marrow 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography cannot replace bone marrow biopsy in diffuse large B-cell lymphoma. Am J Hematol 2014; 89:726-31. [PMID: 24711255 DOI: 10.1002/ajh.23730] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 03/14/2014] [Accepted: 04/04/2014] [Indexed: 12/29/2022]
Abstract
This study aimed to investigate whether visual and quantitative (18) F-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (FDG-PET/CT)-based bone marrow assessment can replace blind bone marrow biopsy (BMB) in newly diagnosed diffuse large B-cell lymphoma (DLBCL). This retrospective study included 78 patients with newly diagnosed DLBCL who had undergone both FDG-PET/CT and BMB. FDG-PET/CT images were visually evaluated for bone marrow involvement. Patient-based sensitivity of visual FDG-PET/CT assessment was calculated using BMB as the reference standard. Metabolically active volume, maximum standardized uptake value, 3D partial volume corrected mean standardized uptake value, and 3D partial volume corrected mean metabolic volume product (cMVPmean ) of FDG-avid bone marrow lesions were measured. Cox regression analysis was used to determine the influence of (potential) prognostic factors (BMB status, visual [dichotomous] FDG-PET/CT bone marrow status, metabolically active volume, maximum standardized uptake value, 3D partial volume corrected mean standardized uptake value, 3D partial volume corrected mean metabolic volume product, and International Prognostic Index score) on progression-free survival and overall survival. FDG-PET/CT detected bone marrow involvement in 34 (43.6%) cases and BMB in 16 (20.5%) of 78 cases, of whom 11 were also detected by FDG-PET/CT, resulting in a patient-based sensitivity of 68.8% (95% confidence interval = 44.2%-86.1%) for FDG-PET/CT. In the multivariate Cox proportional hazards model, only BMB status was an independent predictive factor of progression-free survival (P = 0.016) and overall survival (P = 0.004). In conclusion, FDG-PET/CT misses bone marrow involvement that has been detected by BMB in a non-negligible proportion of patients. Furthermore, both visual and quantitative FDG-PET/CT-based bone marrow assessments are prognostically inferior to BMB. Therefore, FDG-PET/CT cannot replace BMB in newly diagnosed DLBCL.
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Affiliation(s)
- Hugo J.A. Adams
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - Thomas C. Kwee
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - Rob Fijnheer
- Department of Hematology; Meander Medical Center; Amersfoort The Netherlands
| | - Stefan V. Dubois
- Department of Pathology; Meander Medical Center; Amersfoort The Netherlands
| | - Rutger A.J. Nievelstein
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - John M.H. de Klerk
- Department of Nuclear Medicine; Meander Medical Center; Amersfoort The Netherlands
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Can Full-Dose Contrast-Enhanced CT Be Omitted From an FDG-PET/CT Staging Examination in Newly Diagnosed FDG-Avid Lymphoma? J Comput Assist Tomogr 2014; 38:620-5. [DOI: 10.1097/rct.0000000000000067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Adams HJA, Kwee TC, de Keizer B, Fijnheer R, de Klerk JMH, Littooij AS, Nievelstein RAJ. Systematic review and meta-analysis on the diagnostic performance of FDG-PET/CT in detecting bone marrow involvement in newly diagnosed Hodgkin lymphoma: is bone marrow biopsy still necessary? Ann Oncol 2013; 25:921-7. [PMID: 24351400 DOI: 10.1093/annonc/mdt533] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study aimed to systematically review and meta-analyze published data on the diagnostic performance of (18)F-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (FDG-PET/CT) in detecting bone marrow involvement in newly diagnosed Hodgkin lymphoma, and to determine whether FDG-PET/CT can replace blind bone marrow biopsy (BMB) in these patients. PATIENTS AND METHODS The PubMed/Medline and Embase databases were systematically searched for relevant studies. Methodological quality of each study was assessed. Sensitivities and specificities of FDG-PET/CT in individual studies were calculated and underwent meta-analysis with a random effects model. A summary receiver operating characteristic curve (sROC) was constructed with the Moses-Shapiro-Littenberg method. The weighted summary proportion of FDG-PET/CT-negative patients with a positive BMB among all cases was calculated under the fixed effects model. RESULTS Nine eligible studies, comprising a total of 955 patients with newly diagnosed Hodgkin lymphoma, were included. Overall, the studies were of moderate methodological quality. The sensitivity and specificity of FDG-PET/CT for the detection of bone marrow involvement ranged from 87.5% to 100% and from 86.7% to 100%, respectively, with pooled estimates of 96.9% [95% confidence interval (CI) 93.0% to 99.0%] and 99.7% (95% CI 98.9% to 100%), respectively. The area under the sROC curve was 0.9860. The weighted summary proportion of FDG-PET/CT-negative patients with a positive BMB among all cases was 1.1% (95% CI 0.6% to 2.0%). CONCLUSION Although the methodological quality of studies that were included in this systematic review and meta-analysis was moderate, the current evidence suggests that FDG-PET/CT may be an appropriate method to replace BMB in newly diagnosed Hodgkin lymphoma.
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Affiliation(s)
- H J A Adams
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Utrecht
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Adams HJA, Kwee TC, de Keizer B, Fijnheer R, de Klerk JMH, Nievelstein RAJ. FDG PET/CT for the detection of bone marrow involvement in diffuse large B-cell lymphoma: systematic review and meta-analysis. Eur J Nucl Med Mol Imaging 2013; 41:565-74. [DOI: 10.1007/s00259-013-2623-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 10/24/2013] [Indexed: 12/31/2022]
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Adams HJ, Kwee TC, Lokhorst HM, Westerweel PE, Fijnheer R, Kersten MJ, Verkooijen HM, Stoker J, Nievelstein RA. Potential prognostic implications of whole-body bone marrow MRI in diffuse large B-cell lymphoma patients with a negative blind bone marrow biopsy. J Magn Reson Imaging 2013; 39:1394-400. [DOI: 10.1002/jmri.24318] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/25/2013] [Indexed: 11/08/2022] Open
Affiliation(s)
- Hugo J.A. Adams
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - Thomas C. Kwee
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - Henk M. Lokhorst
- Department of Hematology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Peter E. Westerweel
- Department of Hematology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Rob Fijnheer
- Department of Hematology; Meander Medical Center; Amersfoort The Netherlands
| | - Marie José Kersten
- Department of Hematology; Academic Medical Center; Amsterdam The Netherlands
| | - Helena M. Verkooijen
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
| | - Jaap Stoker
- Department of Radiology; Academic Medical Center; Amsterdam The Netherlands
| | - Rutger A.J. Nievelstein
- Department of Radiology and Nuclear Medicine; University Medical Center Utrecht; Utrecht The Netherlands
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Arima H, Maruoka H, Nasu K, Tabata S, Kurata M, Matsushita A, Imai Y, Takahashi T, Ishikawa T. Impact of occult bone marrow involvement on the outcome of rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone therapy for diffuse large B-cell lymphoma. Leuk Lymphoma 2013; 54:2645-53. [DOI: 10.3109/10428194.2013.788697] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Adams HJA, Kwee TC, Vermoolen MA, de Keizer B, de Klerk JMH, Adam JA, Fijnheer R, Kersten MJ, Stoker J, Nievelstein RAJ. Whole-body MRI for the detection of bone marrow involvement in lymphoma: prospective study in 116 patients and comparison with FDG-PET. Eur Radiol 2013; 23:2271-8. [PMID: 23591618 DOI: 10.1007/s00330-013-2835-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 02/17/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess and compare the value of whole-body MRI with FDG-PET for detecting bone marrow involvement in lymphoma. METHODS A total of 116 patients with newly diagnosed lymphoma prospectively underwent whole-body MRI and blind bone marrow biopsy (BMB) of the posterior iliac crest. Of 116 patients, 80 also underwent FDG-PET. Patient-based sensitivities of whole-body MRI for detecting bone marrow involvement were calculated using BMB as reference standard and compared with FDG-PET in aggressive and indolent lymphomas separately. RESULTS Sensitivity of whole-body MRI in all lymphomas was 45.5 % [95 % confidence interval (CI): 29.8-62.0 %]. Sensitivity of whole-body MRI in aggressive lymphoma [88.9 % (95 % CI: 54.3-100 %)] was significantly higher (P = 0.0029) than that in indolent lymphoma [23.5 % (95 % CI: 9.1-47.8 %)]. Sensitivity of FDG-PET in aggressive lymphoma [83.3 % (95 % CI: 41.8-98.9 %)] was also significantly higher (P = 0.026) than that in indolent lymphoma [12.5 % (95 % CI: 0-49.2 %)]. There were no significant differences in sensitivity between whole-body MRI and FDG-PET (P = 1.00) CONCLUSION: Sensitivity of whole-body MRI for detecting lymphomatous bone marrow involvement is too low to (partially) replace BMB. Sensitivity of whole-body MRI is significantly higher in aggressive lymphoma than in indolent lymphoma and is equal to FDG-PET in both entities. KEY POINTS • Bone marrow involvement in lymphoma has prognostic and therapeutic implications. • Blind bone marrow biopsy (BMB) is standard for bone marrow assessment. • Neither whole-body MRI nor FDG-PET can yet replace BMB. • Both techniques have higher sensitivity in aggressive than in indolent lymphoma. • Both imaging techniques are complementary to BMB.
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Affiliation(s)
- Hugo J A Adams
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Peungjesada S, Chuang HH, Prasad SR, Choi H, Loyer EM, Bronstein Y. Evaluation of cancer treatment in the abdomen: Trends and advances. World J Radiol 2013; 5:126-42. [PMID: 23671749 PMCID: PMC3650203 DOI: 10.4329/wjr.v5.i3.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 01/24/2013] [Accepted: 01/31/2013] [Indexed: 02/06/2023] Open
Abstract
Response evaluation in Oncology has relied primarily on change in tumor size. Inconsistent results in the prediction of clinical outcome when size based criteria are used and the increasing role of targeted and loco-regional therapies have led to the development of new methods of response evaluation that are unrelated to change in tumor size. The goals of this review are to expose briefly the size based criteria and to present the non-size based approaches that are currently applicable in the clinical setting. Other paths that are still being explored are not discussed in details.
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Influence of imperfect reference standard bias on the diagnostic performance of MRI in the detection of lymphomatous bone marrow involvement. Clin Radiol 2013; 68:750-1. [PMID: 23535313 DOI: 10.1016/j.crad.2013.01.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 01/23/2013] [Indexed: 11/20/2022]
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SUV on dual-phase FDG PET/CT correlates with the Ki-67 proliferation index in patients with newly diagnosed non-Hodgkin lymphoma. Clin Nucl Med 2012; 37:e189-95. [PMID: 22785526 DOI: 10.1097/rlu.0b013e318251e16e] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE PET using 18F-FDG integrated with CT is beneficial for staging patients with non-Hodgkin lymphoma (NHL). The Ki-67 index is used to assess the proliferation potential of tumor cells. The aim of this study was to evaluate the correlation of the Ki-67 index in tissue samples with the SUV at different sites on dual-phase FDG PET/CT of patients with newly diagnosed NHL. MATERIALS AND METHODS From September 2009 to March 2011, patients with newly diagnosed NHL who had received dual-phase FDG PET/CT for staging and biopsy samples that were evaluated for the Ki-67 expression were enrolled. The SUVmax of the biopsy site, the tumorous lesion sites, and 3 different bone marrow sites (right iliac crest, sternum, and L1) were measured. The SUVmean of the liver and spleen were also measured. RESULTS There were a total of 27 patients in this study. Significant correlations were observed between the Ki-67 index and the SUVmax of the right iliac crest in patients with early-stage disease (stage I and II) patients, the SUVmax of the biopsy and whole-body lesion sites in patients with late-stage disease (stage III and IV), and the retention index of SUVmax of the right iliac crest in patients whose bone marrow were involved by lymphoma cells. CONCLUSIONS For patients with newly diagnosed NHL, the significant correlation between the Ki-67 index and the SUV in this study suggests that dual-phase FDG PET/CT may be used as a noninvasive measurement of tumor proliferation.
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Aubry OA, Spangler EA, Schleis SE, Smith AN. Evaluation of bone marrow aspirates from multiple sites for staging of canine lymphoma and mast cell tumours. Vet Comp Oncol 2012; 12:58-66. [DOI: 10.1111/j.1476-5829.2012.00331.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 03/23/2012] [Indexed: 12/23/2022]
Affiliation(s)
- O. A. Aubry
- Department of Clinical Sciences; Auburn University; Auburn AL USA
- Southern California Veterinary Specialty Hospital; Irvine CA USA
| | - E. A. Spangler
- Department of Pathobiology; Auburn University; Auburn AL USA
| | - S. E. Schleis
- Department of Clinical Sciences; Auburn University; Auburn AL USA
| | - A. N. Smith
- Department of Clinical Sciences; Auburn University; Auburn AL USA
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Abstract
The lymphomas, Hodgkin lymphoma and non-Hodgkin lymphoma, are among the most common types of cancer in the United States. Imaging plays an important role in the evaluation of patients with lymphoma, because it aids in treatment planning and in the determination of prognosis. Structural imaging entails the assessment of morphologic features of normal tissues and organs of the body and of malignant lesions within these structures, and plays a major role in the noninvasive assessment of lymphoma. This article reviews cross-sectional structural imaging modalities with an emphasis on computed tomography and magnetic resonance imaging, with some mention of ultrasonography.
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Affiliation(s)
- Thomas C Kwee
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Rutger A J Nievelstein
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Drew A Torigian
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19102, USA
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Wu LM, Chen FY, Jiang XX, Gu HY, Yin Y, Xu JR. 18F-FDG PET, combined FDG-PET/CT and MRI for evaluation of bone marrow infiltration in staging of lymphoma: a systematic review and meta-analysis. Eur J Radiol 2010; 81:303-11. [PMID: 21145680 DOI: 10.1016/j.ejrad.2010.11.020] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 11/10/2010] [Accepted: 11/12/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Evaluation of bone marrow infiltration is an essential step in the staging of lymphoma. The accuracy of (18)F-fluorodeoxyglucose-positron emission tomography ((18)F-FDG PET), combined (18)F-fluorodeoxyglucose-positron emission tomography/computed tomography ((18)F-FDG-PET/CT) and magnetic resonance imaging (MRI) in diagnosing bone marrow involvement of lymphoma has never been systematically assessed, and the present systematic review was aimed at this issue. METHODS MEDLINE, EMBASE, Cochrane library and some other databases, from January 1995 to July 2010, were searched for initial studies. All the studies published in English or Chinese relating to the diagnostic value of (18)F-FDG PET, PET/CT and MRI for patients with bone marrow involvement of lymphoma were collected. We extracted data to calculate sensitivity, specificity, SROC curves and AUC and to test for heterogeneity. The statistic software called "Meta-Disc 1.4" was used for data analysis. RESULT In 32 included studies, PET/CT had the highest pooled sensitivity, 91.6% (95%CI: 85.1, 95.9) and highest pooled specificity, 90.3% (95%CI: 85.9, 93.7). PET/CT also had the highest pooled DOR, 68.89 (95%CI: 15.88, 298.92). The AUC of PET, PET/CT, and MRI were 0.9430, 0.9505 and 0.8764. There was heterogeneity among studies and no evidence of publication bias. CONCLUSION PET/CT was a highly sensitive and specific modality in diagnosing patients with bone marrow involvement in lymphoma. Compared with MRI and PET alone, PET/CT can play important roles in the staging of lymphoma.
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Affiliation(s)
- Lian-Ming Wu
- Department of Radiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
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Measuring the "unmeasurable": assessment of bone marrow response to therapy using FDG-PET in patients with lymphoma. Acad Radiol 2010; 17:1175-85. [PMID: 20634105 DOI: 10.1016/j.acra.2010.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 04/29/2010] [Accepted: 05/01/2010] [Indexed: 11/21/2022]
Abstract
RATIONALE AND OBJECTIVES To determine if anatomically "nonmeasurable" disease in bone marrow (BM) is assessable for response to therapy by [(18)F]-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT). MATERIALS AND METHODS FDG PET/CT images of 27 patients with lymphoma, FDG-avid bone marrow (BM) lesions, and >or=1 FDG-avid, tumor-involved lymph node (LN) at baseline were retrospectively reviewed. FDG uptake in target LNs and BM foci was determined pre- and posttherapy using the standardized uptake value corrected for lean body mass (SUL(mean)). Size of the same target LNs was measured pre- and posttherapy on CT. Percentage decreases of LN size and LN and BM SUL were calculated. Response was classified according to revised International Workshop Criteria (IWC) with and without modification for metabolic evaluation of BM and correlated to overall survival. Statistical analyses were performed using paired t-tests, Pearson correlation coefficients, and z-tests. RESULTS LN size, LN SUL(mean), and BM SUL(mean) were significantly higher pre- versus posttherapy (2337 mm(2) +/- 1810 vs. 309 mm(2) +/- 323; 6.94 +/- 4.96 vs. 1.02 +/- 1.00; and 6.81 +/- 4.58 to 1.84 +/- 1.58, all P < .001, respectively). After therapy, significant correlation was found between percentage declines of LN size and SUL(mean) of LNs (r = 0.84, P < .001) or BM (r = 0.56, P = .002) and SUL(mean) of LN and BM (r = 0.76, P < .001). Including a metabolic assessment of BM correctly altered overall response assessment in 5/27 (19%) patients and better predicted overall survival than revised IWC. CONCLUSION Anatomically "unmeasurable" BM infiltration with lymphoma behaves similarly to LN disease after therapy and is "measurable" by FDG PET/CT. FDG PET/CT is valuable for monitoring tumor response in "measurable" disease and BM, which was previously considered "unmeasurable" by anatomical imaging.
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Merli M, Arcaini L, Boveri E, Rattotti S, Picone C, Passamonti F, Tenore A, Sozzani L, Lucioni M, Varettoni M, Rizzi S, Morello L, Ferretti V, Pascutto C, Paulli M, Lazzarino M. Assessment of bone marrow involvement in non-Hodgkin’s lymphomas: comparison between histology and flow cytometry. Eur J Haematol 2010; 85:405-15. [DOI: 10.1111/j.1600-0609.2010.01503.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Whole-Body MRI, Including Diffusion-Weighted Imaging, for the Initial Staging of Malignant Lymphoma. Invest Radiol 2009; 44:683-90. [DOI: 10.1097/rli.0b013e3181afbb36] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Huang W, Yang Y, Sun Z, Zeng X. Early radiation-induced bone marrow injury: serial MR imaging during initial 4 weeks after irradiation. Acad Radiol 2009; 16:733-8. [PMID: 19297208 DOI: 10.1016/j.acra.2008.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 12/04/2008] [Accepted: 12/02/2008] [Indexed: 10/21/2022]
Abstract
RATIONALE AND OBJECTIVES Magnetic resonance (MR) imaging has been widely used to detect bone marrow (BM) changes after radiotherapy. However, little information about the dynamic MR appearance of early radiation-induced BM injury is available. This experimental study was designed to determine the MR appearance of irradiated BM during the initial 4 weeks after irradiation. MATERIALS AND METHODS After focal BM irradiation (20 Gy, single dose, x-ray), 12 of 20 rabbits underwent serial MR studies weekly from days 7 to 28; eight rabbits were used for histologic investigation on days 7, 14, 21, and 28 after irradiation. RESULTS Under microscopy, early BM changes after irradiation consisted of sinusoid dilatation and congestion, followed by a progressive decrease in cellularity and later fat degeneration. All irradiated BM showed relative hyperintensity on short-inversion time inversion recovery (STIR) imaging from days 7 to 21 after irradiation and increased enhancement with gadolinium diethylenetriamine pentaacetic acid (DTPA) administration from days 7 to 28 after irradiation. However, on STIR imaging and gadolinium DTPA enhancement, the relative signal intensity of irradiated BM appeared to decline in a time-dependent way. On fast spin-echo (FSE) T1-weighted imaging, relative hyperintensity was detected in irradiated BM from day 21 after irradiation. On fat-suppressed FSE T1-weighted imaging, a slight increase in signal intensity was shown in some irradiated BM (in five of 12 rabbits) on day 7 after irradiation. CONCLUSION STIR imaging was sensitive to early BM congestion and sinusoidal dilatation, spin-echo T1-weighted imaging was effective in detecting later fatty degeneration in irradiated BM, and gadolinium DTPA enhancement may contribute to the evaluation of BM vascular injury in response to irradiation.
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Lee KW, Yi J, Choi IS, Kim JH, Bang SM, Kim DW, Im SA, Kim TY, Yoon SS, Lee JS, Bang YJ, Park S, Kim BK, Cho HI, Heo DS. Risk factors for poor treatment outcome and central nervous system relapse in diffuse large B-cell lymphoma with bone marrow involvement. Ann Hematol 2009; 88:829-38. [DOI: 10.1007/s00277-008-0682-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 12/16/2008] [Indexed: 02/05/2023]
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35
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Role of whole-body [18F] fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) and conventional techniques in the staging of patients with Hodgkin and aggressive non Hodgkin lymphoma. Radiol Med 2008; 113:578-90. [DOI: 10.1007/s11547-008-0264-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 05/29/2007] [Indexed: 12/16/2022]
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36
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Kwee TC, Kwee RM, Verdonck LF, Bierings MB, Nievelstein RAJ. Magnetic resonance imaging for the detection of bone marrow involvement in malignant lymphoma. Br J Haematol 2008; 141:60-8. [DOI: 10.1111/j.1365-2141.2008.07020.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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37
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Hwang S, Panicek DM. Magnetic resonance imaging of bone marrow in oncology, Part 2. Skeletal Radiol 2007; 36:1017-27. [PMID: 17492444 DOI: 10.1007/s00256-007-0308-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Revised: 03/05/2007] [Accepted: 03/07/2007] [Indexed: 02/02/2023]
Abstract
Magnetic resonance imaging plays an integral role in the detection and characterization of marrow lesions, planning for biopsy or surgery, and post-treatment follow-up. To evaluate findings in bone marrow on MR imaging, it is essential to understand the normal composition and distribution of bone marrow and the changes in marrow that occur with age, as well as the basis for the MR signals from marrow and the factors that affect those signals; these points have been reviewed and illustrated in part 1 of this two-part article. Part 2 will emphasize the practical application of MR imaging to facilitate differentiation of normal marrow, tumor, and treatment-related marrow changes in oncology patients, and will review complementary MR techniques under development.
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Affiliation(s)
- Sinchun Hwang
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, New York, NY 10021, USA
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38
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Daldrup-Link HE, Henning T, Link TM. MR imaging of therapy-induced changes of bone marrow. Eur Radiol 2006; 17:743-61. [PMID: 17021706 PMCID: PMC1797072 DOI: 10.1007/s00330-006-0404-1] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Revised: 05/30/2006] [Accepted: 06/23/2006] [Indexed: 11/24/2022]
Abstract
MR imaging of bone marrow infiltration by hematologic malignancies provides non-invasive assays of bone marrow cellularity and vascularity to supplement the information provided by bone marrow biopsies. This article will review the MR imaging findings of bone marrow infiltration by hematologic malignancies with special focus on treatment effects. MR imaging findings of the bone marrow after radiation therapy and chemotherapy will be described. In addition, changes in bone marrow microcirculation and metabolism after anti-angiogenesis treatment will be reviewed. Finally, new specific imaging techniques for the depiction of regulatory events that control blood vessel growth and cell proliferation will be discussed. Future developments are directed to yield comprehensive information about bone marrow structure, function and microenvironment.
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Affiliation(s)
- Heike E Daldrup-Link
- Department of Radiology, University of California San Francisco, 505 Parnassus Ave., San Francisco, CA, 94143-0628, USA.
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Haddy TB, Parker RI, Magrath IT. Bone marrow involvement in young patients with non-Hodgkin's lymphoma: the importance of multiple bone marrow samples for accurate staging. MEDICAL AND PEDIATRIC ONCOLOGY 2006; 17:418-23. [PMID: 2796857 DOI: 10.1002/mpo.2950170512] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Of 95 young patients with non-Hodgkin's lymphoma treated at the National Cancer Institute on Pediatric Branch Protocol 7704, 18 (18.9%) had bone marrow involvement prior to treatment. Their mean age was 20.5 years. Twelve patients had small, non-cleaved lymphoma (ten Burkitt's and two undifferentiated, unspecified), five had lymphoblastic lymphoma, and one had a diffuse large cell lymphoma. All had extensive disease. We obtained bilateral bone marrow biopsy specimens, touch preparations, clot sections, and aspirate smears from 13 of the 18 patients. When paired contralateral samples were reviewed, in as many as six out of ten of the pairs only one side was positive for tumor. When paired ipsilateral samples were similarly reviewed, in as many as seven out of 21 of the pairs only one specimen was positive for tumor. The biopsy specimen was the most useful of the four types of study performed, yielding positive results in 87% of the preparations. Thus, in a high percentage of patients, multiple marrow sampling revealed disease that might have been missed if fewer specimens had been obtained. Only four of our 18 patients (22.2%) had long-term remissions. Because young patients with marrow disease are at high risk and may be eligible for more intensive treatment protocols, we recommend that staging should include bilateral bone marrow biopsies and bilateral aspirates.
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Affiliation(s)
- T B Haddy
- Department of Pediatrics and Child Health, Howard University College of Medicine, Washington, D.C
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Campbell J, Seymour JF, Matthews J, Wolf M, Stone J, Juneja S. The prognostic impact of bone marrow involvement in patients with diffuse large cell lymphoma varies according to the degree of infiltration and presence of discordant marrow involvement. Eur J Haematol 2006; 76:473-80. [PMID: 16529599 DOI: 10.1111/j.1600-0609.2006.00644.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The prognostic significance of marrow involvement in diffuse large cell lymphoma (DLCL) is controversial. Factors that that have been reported to influence prognosis include the pattern and extent of marrow infiltration and histological discordance between the primary site and the bone marrow. METHODS Bone marrow biopsies from 172 patients with newly diagnosed DLCL entered in two consecutive trials of the Australasian Leukaemia and Lymphoma Group were analyzed. Progression-free (PFS) and overall survival (OS) were calculated according to the absence or presence of bone marrow involvement (BMI), the extent of lymphomatous infiltration and the presence of histological discordance between the primary site and the bone marrow. RESULTS Of 172 patients with DLCL accrued between 1982 and 1990, who were treated with CHOP or CHOP-like regimens, 47 (27%) demonstrated marrow involvement on examination of multiple levels. Seventy two percent (34/47) of patients had discordant marrow involvement (<50% large cells) and 28 had minimal (<10%) involvement; these latter patients with minimal marrow involvement (<10%) had similar PFS & OS to the 113 patients without involvement. Within the group of 47 patients with marrow involvement, an increasing percentage of BM involvement was significantly associated with an increasing percentage of concordant histology and a decreasing PFS & OS. CONCLUSIONS Minimal BMI, seen in the majority of patients with DLCL with marrow infiltration, appears not to influence the PFS & OS. However, an increasing degree of marrow involvement is associated with an increasing component of large cells and a poorer prognosis in DLCL patients, independent of other risk factors.
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Affiliation(s)
- Janine Campbell
- Division of Laboratory Services, Royal Children's Hospital, Parkville, Victoria, Australia
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Nöbauer I, Uffmann M. Differential diagnosis of focal and diffuse neoplastic diseases of bone marrow in MRI. Eur J Radiol 2005; 55:2-32. [PMID: 15950098 DOI: 10.1016/j.ejrad.2005.01.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Revised: 01/20/2005] [Accepted: 01/26/2005] [Indexed: 11/18/2022]
Abstract
Magnetic resonance imaging (MRI) has become the preferred imaging modality for the evaluation of malignant disease in the bone marrow. Compared to bone marrow aspiration and biopsy, MRI is noninvasive and provides information by sampling a large volume of bone marrow. Due to disease-related alterations in the composition of bone marrow, MRI provides a very high sensitivity, but lacks specificity for most bone marrow disorders. However, MRI can be a very valuable diagnostic tool properly placed within the clinical context.
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Affiliation(s)
- Iris Nöbauer
- Allgemeines Krankenhaus Wien, Medizinuniversität Wien, Universitätsklinik für Radiodiagnostik, Währinger Gürtel 18-20, A-1090 Wien, Austria.
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Gossmann A, Eich HT, Engert A, Josting A, Müller RP, Diehl V, Lackner KJ. CT and MR imaging in Hodgkin's disease - present and future. Eur J Haematol 2005:83-9. [PMID: 16007874 DOI: 10.1111/j.1600-0609.2005.00460.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Initial staging of Hodgkin's disease is crucial to determine the location and extent of disease, and is the hallmark for the choice of treatment. At present, the established radiological technique for staging Hodgkin's disease is computed tomography (CT). Modern multidetector row CT scanners allow fast imaging from the scull base to the groins during a single breath hold with a spatial resolution of approximately 1 mm. Both, nodal and extranodal involvement of Hodgkin's disease can be diagnosed with CT. Magnetic resonance (MR) imaging is another useful cross-sectional imaging modality for staging Hodgkin's disease. The development of fast MR imaging techniques has considerably reduced imaging time without compromising the quality of MR images. As a consequence, MR imaging is now considered to be as diagnostic as CT for staging Hodgkin's disease. The excellent soft-tissue contrast and the lack of exposure to ionizing radiation are the main advantages of MR imaging. For the detection of extranodal Hodgkin's disease, MR imaging is superior to assess involvement of the brain, the spinal cord and bone marrow; while CT allows excellent evaluation of lung disease. Common major problems in staging Hodgkin's disease are still the detection of nodal involvement in normal sized lymph nodes and residual tumor masses after therapy. In the future, newly developed lymphotropic contrast agents for MR imaging might be helpful to answer these questions.
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Affiliation(s)
- Axel Gossmann
- Department of Radiology, University of Cologne, Germany.
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Miyakoshi N, Shimada Y, Suzuki T, Hongo M, Itoi E. Magnetic resonance imaging of spinal involvement by hematopoietic malignancies requiring surgical decompression. J Orthop Sci 2003; 8:207-12. [PMID: 12665958 DOI: 10.1007/s007760300034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
To elucidate magnetic resonance imaging (MRI) findings of the spine with hematopoietic malignancies that require surgery, we retrospectively reviewed the MRI scans in these patients who underwent decompression surgery of the spinal cord or cauda equina. Preoperative MRI scans were obtained from nine patients with spinal involvement by a hematopoietic malignancy who underwent surgery: four with malignant lymphoma and five with multiple myeloma. The marrow involvement pattern, location of signal change of the vertebra, cortical destruction, vertebral fracture, epidural mass formation, paraspinal mass formation, and the wrap-around sign (spread to the extraosseous soft tissues without alteration in the shape of the affected vertebra) were determined by MRI scans. Diffuse marrow involvement (89%), anterior and posterior signal changes of the vertebra (100%), cortical destruction (100%), vertebral fracture (78%), epidural mass formation (78%), and paraspinal mass formation (100%) were commonly observed. The wrap-around sign was seen in only one patient (11%); it was due to vertebral destruction and deformity. Based on these results, we concluded that MRI findings of the spine with a hematopoietic malignancy requiring decompression surgery showed a characteristic diffuse marrow pattern; they also exhibited more expansive and destructive features than previously reported for hematopoietic malignancies without surgery.
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Affiliation(s)
- Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan
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Campbell JK, Matthews JP, Seymour JF, Wolf MM, Juneja SK. Optimum trephine length in the assessment of bone marrow involvement in patients with diffuse large cell lymphoma. Ann Oncol 2003; 14:273-6. [PMID: 12562655 DOI: 10.1093/annonc/mdg055] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The National Cancer Institute has recommended a bone marrow biopsy length of >/=20 mm for the staging and surveillance of patients with non-Hodgkin's lymphoma. However, there are few published data to support this recommendation, particularly the role of examining multiple levels. PATIENTS AND METHODS Bone marrow biopsies from 172 patients with newly diagnosed diffuse large cell lymphoma (DLCL) entered in two consecutive trials of the Australasian Leukaemia and Lymphoma Group were analysed. The original haematoxylin and eosin-stained trephine biopsy and two or more deeper sections cut at 0.1-0.2 mm intervals were assessed with respect to the morphology, extent and pattern of lymphomatous involvement. The rate of positive diagnosis was correlated with the length of the biopsy specimen and the number of sections examined. RESULTS Forty-seven biopsies (27%) demonstrated marrow involvement on examination of a mean of four trephine biopsy sections. The rate of positivity increased with the examination of multiple levels and correlated with increasing trephine length but was not dependent on the number of sites sampled. Twenty per cent of biopsies <20 mm in length were positive for lymphoma; this increased to 35% for biopsies >/=20 mm (P = 0.023). CONCLUSIONS Morphological bone marrow involvement in DLCL is optimally demonstrated by a 20-mm long trephine biopsy from a single site which is examined at multiple levels (four or more). This obviates the need for bilateral sampling, thereby reducing patient morbidity from the procedure. This study provides evidence to support the National Cancer Institute recommendations regarding trephine biopsy in the staging of DLCL, providing multiple levels are examined.
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Affiliation(s)
- J K Campbell
- Division of Laboratory Services, Royal Children's Hospital, Parkville, Victoria, Australia
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Mavromatis BH, Cheson BD. Pre- and post-treatment evaluation of non-Hodgkin's lymphoma. Best Pract Res Clin Haematol 2002; 15:429-47. [PMID: 12468398 DOI: 10.1053/beha.2002.0217] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Once the diagnosis of a non-Hodgkin's lymphoma (NHL) has been established three critical steps in patient management must follow. The first is the pre-treatment evaluation and staging to identify prognostic factors (the subject of another chapter in this volume), impending problems, such as ureteral obstruction, spinal cord compression, biliary or vena caval obstruction. This assessment directs the best therapeutic approach, and also provides a baseline against which to assess response. The second step is the treatment itself. Third, conscientious follow-up after completion of therapy to monitor for disease recurrence as well as for long-term sequelae of therapy. A careful history and physical examination are the most important components of patient evaluation. Whereas some evaluation procedures have become standard practice (e.g. chest radiographs, CT scans, gallium scan, blood chemistry and assessment of hepatic and renal function), the role of other studies is still being defined (e.g. PET scan). The increased use of systemic therapies has somewhat reduced the requirement for precise staging to determine treatment strategies, but will become more critical to identify early patients with resistant disease and those with minimal residual disease following treatment so that novel therapies can be introduced at that point.
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Wang J, Weiss LM, Chang KL, Slovak ML, Gaal K, Forman SJ, Arber DA. Diagnostic utility of bilateral bone marrow examination: significance of morphologic and ancillary technique study in malignancy. Cancer 2002; 94:1522-31. [PMID: 11920510 DOI: 10.1002/cncr.10364] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND To retrospectively evaluate the significance of morphologic examination and ancillary studies performed on bilateral bone marrow biopsy specimens, 1864 bone marrow samples were studied. METHODS Bilateral bone marrow biopsy specimens included 883 specimens that were evaluated for involvement by non-Hodgkin lymphoma (NHL); 381 specimens that were evaluated for involvement by carcinoma (CA); 362 specimens that were evaluated for involvement by Hodgkin disease (HD); 94 specimens that were evaluated for involvement by sarcoma (SA); 56 specimens that were evaluated for involvement by multiple myeloma (MM); 53 specimens that were evaluated for involvement by acute and chronic leukemia, myelodysplasia, and/or myeloproliferative disorders (LEUK); and 35 specimens that were evaluated for other reasons. RESULTS Of all 1864 specimens, 410 samples (22.0%) were positive for disease, including 77% of MM samples, 58% of LEUK samples, 29.6% of NHL samples, 14% of SA samples, 9.9% of HD samples, and 6.8% of CA samples. A discrepancy between the left and right sides was identified in 48 specimens (11.7% of positive samples). The discrepancy rate was 39% for HD samples, 29% for SA samples, 23% for CA samples, and 9.2% for NHL samples. No morphologic discrepancies between bilateral samples were found in MM samples or LEUK samples. Bilateral flow cytometric studies (n = 113 samples) were positive in 11 samples (9.7%; all morphologically positive), with two discrepancies detected between bilateral samples. Bilateral cytogenetic studies (n = 74 samples) were positive in 5 samples (7%), and there were no discrepancies. Bilateral molecular studies (n = 16 samples) were positive in 7 samples (44%), and there were 3 discrepancies. CONCLUSIONS Bilateral morphologic evaluation is useful in the evaluation of patients with NHL, HD, CA, and SA and is not indicated for patients with acute or chronic leukemia, myelodysplasia, MM, and other diseases. Bilateral flow cytometric or cytogenetic studies of bone marrow did not provide additional information in this population to justify bilateral samples. The role of bilateral molecular analysis needs to be defined further, but pooled samples for molecular studies may be adequate.
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Affiliation(s)
- Jun Wang
- Division of Pathology, City of Hope National Medical Center, Duarte, California 91010, USA
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Seneviratne L, Espina BM, Nathwani BN, Chan JA, Brynes RK, Levine AM. Clinical, immunologic, and pathologic correlates of bone marrow involvement in 291 patients with acquired immunodeficiency syndrome-related lymphoma. Blood 2001; 98:2358-63. [PMID: 11588031 DOI: 10.1182/blood.v98.8.2358] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Bone marrow involvement is reported in approximately 25% of patients with newly diagnosed acquired immunodeficiency syndrome-related lymphoma (ARL). Studied were 291 patients with ARL, diagnosed and treated at one medical center between 1984 and 1998. Clinical, immunologic, and pathologic characteristics of patients with bone marrow involvement were compared with those of patients without marrow involvement. Bone marrow involvement was present in 55 patients (19%). Small noncleaved lymphoma was diagnosed in 38% of the entire group and was the most common pathologic subtype in patients with bone marrow involvement (55% versus 34%; P =.008). Analysis of complete blood counts revealed a median hemoglobin level of 10.6 g/dL in both marrow-positive and marrow-negative groups. In contrast, a platelet count lower than 100 000/microL was more common in patients with bone marrow involvement (27% versus 11%; P =.02). Patients with marrow involvement were more likely to have leptomeningeal (cerebrospinal fluid [CSF]) lymphoma than patients whose marrows were uninvolved (24% versus 7%; P <.001) and were also more likely to have high lactate dehydrogenase (LDH) (P =.002), bone involvement (P <.001), and/or systemic B symptoms including fever, night sweats, and/or weight loss (P =.05). Median survival did not differ between marrow-positive and marrow-negative groups. On multivariate analysis, factors associated with decreased survival of marrow-positive patients included greater than 50% involvement (P =.002), systemic B symptoms (P =.008), and high-grade histologic type (P =.035). Marrow involvement in ARL correlates with small noncleaved pathology, thrombocytopenia lower than 100 000 mm(3), high LDH, and lymphomatous involvement of the CSF. Survival is statistically shorter in patients with greater than 50% marrow involvement, high-grade pathology, and/or systemic B symptoms.
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Affiliation(s)
- L Seneviratne
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles 90033, USA
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Lee J, Park CH, Kim HC, Kim HS. Dichotomy between Tc-99m MDP bone scan and fluorine-18 fluorodeoxyglucose coincidence detection positron emission tomography in patients with non-Hodgkin's lymphoma. Clin Nucl Med 2000; 25:532-5. [PMID: 10885695 DOI: 10.1097/00003072-200007000-00008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors report two cases of non-Hodgkin's lymphoma that were evaluated not only by conventional staging work-up but also additional Tc-99m MDP bone scans and fluorine-18 fluorodeoxyglucose (F-18 FDG) coincidence detection (CoDe) positron emission tomographic (PET) imaging. There were discordant results between the Tc-99m MDP bone scans and F-18 FDG CoDe PET. In the first case, the bone marrow biopsy was positive, and F-18 FDG CoDe PET was consistent with a malignancy, but the findings of the Tc-99m MDP bone scintiscan were negative. In the second case, the bone marrow biopsy was negative, but F-18 FDG CoDe PET revealed focal skeletal involvement, which improved markedly on the follow-up study after chemotherapy. If skeletal involvement has a focal distribution and is confined to the marrow cavity, both bone marrow biopsy and bone scintigraphy can be falsely negative. In this situation, F-18 FDG PET is useful and revealing.
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Affiliation(s)
- J Lee
- Department of Nuclear Medicine, Ajou University Hospital, Suwon, Korea
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Cheson BD, Horning SJ, Coiffier B, Shipp MA, Fisher RI, Connors JM, Lister TA, Vose J, Grillo-López A, Hagenbeek A, Cabanillas F, Klippensten D, Hiddemann W, Castellino R, Harris NL, Armitage JO, Carter W, Hoppe R, Canellos GP. Report of an international workshop to standardize response criteria for non-Hodgkin's lymphomas. NCI Sponsored International Working Group. J Clin Oncol 1999; 17:1244. [PMID: 10561185 DOI: 10.1200/jco.1999.17.4.1244] [Citation(s) in RCA: 2861] [Impact Index Per Article: 114.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Standardized guidelines for response assessment are needed to ensure comparability among clinical trials in non-Hodgkin's lymphomas (NHL). To achieve this, two meetings were convened among United States and international lymphoma experts representing medical hematology/oncology, radiology, radiation oncology, and pathology to review currently used response definitions and to develop a uniform set of criteria for assessing response in clinical trials. The criteria that were developed include anatomic definitions of response, with normal lymph node size after treatment of 1.5 cm in the longest transverse diameter by computer-assisted tomography scan. A designation of complete response/unconfirmed was adopted to include patients with a greater than 75% reduction in tumor size after therapy but with a residual mass, to include patients-especially those with large-cell NHL-who may not have residual disease. Single-photon emission computed tomography gallium scans are encouraged as a valuable adjunct to assessment of patients with large-cell NHL, but such scans require appropriate expertise. Flow cytometric, cytogenetic, and molecular studies are not currently included in response definitions. Response rates may be the most important objective in phase II trials where the activity of a new agent is important and may provide support for approval by regulatory agencies. However, the goals of most phase III trials are to identify therapies that will prolong the progression-free survival, if not the overall survival, of the treated patients. We hope that these guidelines will serve to improve communication among investigators and comparability among clinical trials until clinically relevant laboratory and imaging studies are identified and become more widely available.
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Affiliation(s)
- B D Cheson
- National Cancer Institute, Bethesda, MD 20892, USA.
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