Evolution of lymphoma staging and response evaluation: current limitations and future directions

The accurate detection and precise assessment of therapeutic responses is critical to the optimal management of patients with lymphoma. Over the past 50 years, dramatic advances in technology have established imaging as the cornerstone of disease evaluation. However, the appropriate application of current techniques requires acknowledgement of their strengths and weaknesses, and appreciation of the full diversity of lymphoid neoplasms. The role of anatomical and functional imaging in detection, treatment escalation/de-escalation and prognostication of patients with lymphoma can be misinterpreted. The development of disease assessment criteria, without an appreciation of the limitations of current imaging technologies, reflects a potential overreach of imaging science. Furthermore, the introduction of various novel therapies adds to the complexity of disease monitoring. In this Perspectives, the authors evaluate the available evidence in this rapidly evolving field and propose a reporting framework, named 'Specialist Integrated Haematological Malignancy Imaging Reporting' (SIHMIR), with a goal of providing a robust and adaptable system for lymphoma assessment. We predict a future model of multimodal disease assessment using novel molecular and imaging techniques, and highlight the key outstanding research questions in this field.