Risk Assessment in Diffuse Large B-Cell Lymphoma by Combining Baseline Metabolic Tumor Volume and Peking Criteria When Evaluating Series 18F-Fluorodeoxyglucose Positron Emission Tomography Scans

Abstract

This study aimed to determine the predictive and prognostic value of baseline metabolic tumor volume (MTV) and the Peking criteria from serial positron emission tomography (PET) scans in diffuse large B-cell lymphoma, including 300 newly diagnosed patients who were prospectively treated with 2-4 cycles of standard first-line treatment (clinicaltrials.gov identifier: NCT02928861). PET/computed tomography (CT) examinations were performed at baseline, after two (PET-2) or four cycles (PET-4). PET during the interim was evaluated using Deauville 5-point scales (5-PS), ΔSUVmax criteria, and the Peking criteria which interpreted based on the maximum standard uptake of the liver (SUVmax-liver). Peking criteria had better accuracy, positive predictive value (PPV), and specificity than other two methods. The MTV and Peking criteria both significantly predicted progression-free survival (PFS) and overall survival (OS). An MTV > 191 cm2 and Peking criteria of PET-2 and PET-4 > 1.6-fold SUVmax-liver was used as the cutoff for a positive result. PET-4 achieved higher accuracy, PPV, and specificity for 2-year PFS (83.3%, 86.7%, and 98.4%, respectively) and OS (92.6%, 73.3%, and 97.2%, respectively) than PET-2. Various prognostic models containing different risk factors were established via Cox regression analysis. The MTV and PET-2/PET-4 results were used to categorized patients into low-risk, intermediate-risk, and high-risk prognostic groups (with 0, 1, and 2 risk factors, respectively) (P < 0.0001). High burden MTV and positive PET-2 and PET-4 (>1.6-fold SUVmax-liver) could identify high-risk patients with 2-year PFS and OS of 0.0% and 26.3% (95% confidence interval [CI]: N/A to 54.3%). When PET-2 and PET-4 were evaluated by 5-PS, the 2-year PFS and OS from high risk patients of three-parameters model achieved 31.4% (95%CI: 6.9%-55.9%) and 42.7% (95%CI: 14.6%-70.7%). In conclusion, combining baseline MTV and any regular response on PET/CT evaluated using the Peking criteria can improve prognostic value. Serial PET/CT from baseline MTV to PET-4 may have relatively greater predictive power for poor prognosis in diffuse large B-cell lymphoma.

Clinical trial registration: ClinicalTrials.gov, identifier (NCT02928861).

Keywords: Peking criteria; diffuse large B-cell lymphoma; metabolic tumor volume; positron emission tomography; risk assessment.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Yuan, Zhang, Chen, Wei, Zhu, Song, Yang, Zhu and Wang.

Figures

Figure 1

Progression-free survival (PFS) and overall survival (OS) analysis. Kaplan–Meier analysis of PFS and OS according to positron emission tomography (PET) after two cycles of therapy (PET-2) (A, B) and after four cycles of therapy (PET-4) (C, D). PET-2 and PET-4 investigated by the three image interpretations were strong prognostic factors for both PFS and OS (all P < 0.001). The Peking criteria was superior 5-PS and ΔSUVmax criteria in terms of predicting prognosis.

Figure 2

Survival curves by new model of three PET parameters by using Peking criteria or Deauville 5-point scales (5-PS). Kaplan–Meier analysis of progression-free survival (PFS) and overall survival (OS) by the new prognostic model by combining baseline metabolic tumor volume (MTV), PET after two cycles of therapy (PET-2) and PET after four cycles of therapy (PET-4): low-risk, no risk factor; intermediate-risk, 1 or 2 risk factors; high-risk, 3 risk factors. With Peking criteria, the respective 2-year PFS and OS of the 3 groups were 85.3% (95% CI, 79.2%–91.4%) and 94.6% (95% CI, 90.3%–98.8%) for low-risk patients (yellow curve); 58.6% (95% CI, 46.1%–71.0%) and 79.4% (95% CI, 68.2%–90.6%) for intermediate-risk patients (blue curve); and 0.0% and 26.3% (95% CI, N/A to 54.3%) for high-risk patients (purple curve) (A, B). For 5-PS, 2-year probabilities of low-, intermediate-, and high-risk groups were 85.7%, 65.1%, 31.4% for PFS (C), and were 95.5%, 84.1%, 42.7% for OS (D).

Figure 3

Histograms of SUVmax-lesion/SUVmax-liver for progression-free survival (PFS) and progression disease (PD) in PET after two cycles of therapy (PET-2) (A) and PET after four cycles of therapy (PET-4) (B). The SUVmax-lesion/SUVmax-liver was SUVmax ratio between the tumor and liver. For PET-2 and PET-4, interim PET was evaluated by 1.6-fold of SUVmax-liver in the Peking criteria and 1.0-fold of SUVmax-liver in Deauville 5-point scales. The Peking criteria was better than 5-PS in distinguishing false positive lesions.