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Impact of imaging modality on clinical outcome in Hodgkin lymphoma in a resource constraint setting
Anu Korula1, Anup Joseph Devasia1, Uday Kulkarni1
1Department of Haematology, Christian Medical College, Vellore, India.
Insights
In resource-limited settings, clinical examination, ultrasonogram, and X-ray (C/U/X) are viable alternatives to PET-CT scans for Hodgkin lymphoma (HL) follow-up. These suboptimal imaging methods yield comparable outcomes to advanced imaging, demonstrating acceptable results for patients with HL.
Area of Science:
- Oncology
- Radiology
- Health Economics
Background:
- Hodgkin lymphoma (HL) treatment relies on risk-stratified therapy guided by PET-CT scans.
- PET-CT scans are costly ($400), posing accessibility challenges in resource-constrained environments.
- Suboptimal imaging like clinical examination, ultrasonogram, and X-ray (C/U/X) ($10) are used as alternatives.
Purpose of the Study:
- To compare clinical outcomes of HL patients with suboptimal imaging versus CT/PET-CT after chemotherapy.
- To evaluate the feasibility of using basic imaging modalities in resource-limited settings for HL management.
Main Methods:
- Retrospective analysis of 283 HL patients treated from 2011-2015.
- Response assessment by CT/PET in 185 patients and by C/U/X in 83 patients.
- Comparison of overall survival, progression-free survival, and relapse-free survival (RFS).
Main Results:
- No significant difference in advanced or bulk disease between imaging groups.
- Similar three-year overall survival (83.5%) and progression-free survival (76.7%) for all patients.
- No significant difference in RFS between CT/PET and C/U/X groups (80.1% overall; P=0.349), including early and late-stage disease.
Conclusions:
- Suboptimal imaging modalities (C/U/X) provide acceptable clinical outcomes for HL patients in resource-limited settings.
- Advanced disease stage, not imaging modality, was the primary factor affecting RFS.
- Basic imaging can be utilized effectively when PET-CT is inaccessible, ensuring comparable patient outcomes.
Abstract:
Treatment of Hodgkin lymphoma (HL) has evolved with risk-stratified therapy based on PET-CT scan at multiple timepoints. In a resource constraint setting even a single PET-CT scan ($400) is inaccessible to many patients, who are re-assessed with only clinical examination, abdominal ultrasonogram and/or x-ray (C/U/X) ($10). To compare clinical outcomes in patients with HL who have had suboptimal imaging after completion of chemotherapy for HL, with those who had a CT or PET-CT, 283 patients were treated for HL from 2011 to 2015, and 268 patients completed six cycles of ABVD therapy with response assessment modality by CT/PET in 185 patients and by C/U/X in 83. There was no difference in the number of patients with advanced (64·1% vs. 61·1%; P = 0·650) or bulk disease (8·1% vs. 7·2%). A significantly higher number of patients in the CT/PET group received IFRT (25·4% vs. 7·7%; P = 0·0005). The three-year overall survival and progression-free survival of all treated patients (n = 283) was 83·5 ± 2·3% and 76·7 ± 2·6% respectively [median follow-up 36 months (range 2-93)]. At three years, the overall relapse-free survival (RFS) was 80·1 ± 2·5%, with RFS of 77 ± 3·2% vs. 85 ± 4·0% in the CT/PET group and C/U/X groups respectively (P = 0·349). There was no difference in RFS between the two groups either in early-stage disease (88·1 ± 4·6% vs. 91·8 ± 5·6%; P = 0·671) or late-stage disease (73·9 ± 4·8% vs. 81·3 ± 6·0%; P = 0·747). The only significant factor adversely affecting RFS was advanced disease (P = 0·004). Factors not affecting RFS were age (P = 0·763), sex (P = 0·925), bulk disease (P = 0·889) and imaging modality (P = 0·352). There was no difference in relapse rates between patients who had suboptimal imaging compared to those who had a PET/CT. It is possible to use these basic imaging modalities when resources are a constraint, with acceptable outcomes.
