Page 245 - 18F-FDG PET as biomarker in aggressive lymphoma; technical and clinical validation

Summary, discussion and future perspectives
Interim [18F]FDG PET guided de-escalation of good responders
The current Dutch guideline describes 2 patient groups where treatment could be reduced based on the interim [18F]FDG PET result.
For patients with a stage I-II non bulky (<10 cm) DLBCL and a negative interim [18F]FDG PET (Deauville 1-3) after 2 cycles of R-CHOP, patients can be treated with either 4 cycles R-CHOP or 3 cycles R-CHOP with additional involved node radiotherapy depending on the expected toxicity of radiotherapy versus the expected toxicity of anthracyclines [20]. For patients with a positive interim [18F] FDG PET treatment with 6 cycles R-CHOP is advised.
Patients with stage II-IV disease and a negative interim [18F]FDG PET after 2 cycles of R-CHOP can be treated with 6 cycles R-CHOP without 2 extra gifts of rituximab [21]. A recent study (published after the current DLBCL guideline) showed that this approach is cost-effective [22].
Escalation therapy with new (combination of ) drugs?
In the overviews described in Part I we concluded that (preliminary) reports on current chemotherapy based escalation strategies do not overcome treatment resistance in DLBCL. This was also the case for a more recent large randomized trial with escalation of treatment with a “Burkitt treatment regimen” tested in patients with a poor response at interim [18F]FDG PET after 2 cycles of R-CHOP immuno-chemotherapy [21]. Until very recent there were relatively few options for patients with relapsed/refractory DLBCL. Second-line therapy is not standard, as there is no generally preferred salvage regimen [23-26]. For physically fit patients, the current Dutch guideline recommends R-DHAP or R-GDP followed by BEAM and autologous stem cell transplantation in patients with responding disease to R-DHAP or R-GDP.
For older and frail patients unfit for autologous stem cell transplantation several palliative chemo-immunotherapy schemes exist (e.g. R-PECC [27], GEMOX-R [28], R-bendamustine [29] and R-lenalidomide [30]). The combination of GEMOX-R with nivolumab is currently investigated in the randomized phase I/ II HOVON-153 (NIVEAU) study for this patient group.
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