PET/MRI for staging patients with Hodgkin lymphoma: equivalent results with PET/CT in a prospective trial

M Picardi, C Cavaliere, R Della Pepa, E Nicolai, A Soricelli, C Giordano, N Pugliese, M G Rascato, I Cappuccio, G Campagna, C Cerchione, E Vigliar, G Troncone, M Mascolo, M Franzese, R Castaldo, M Salvatore, F Pane, M Picardi, C Cavaliere, R Della Pepa, E Nicolai, A Soricelli, C Giordano, N Pugliese, M G Rascato, I Cappuccio, G Campagna, C Cerchione, E Vigliar, G Troncone, M Mascolo, M Franzese, R Castaldo, M Salvatore, F Pane

Abstract

To compare FDG-PET/unenhanced MRI and FDG-PET/diagnostic CT in detecting infiltration in patients with newly diagnosed Hodgkin lymphoma (HL). The endpoint was equivalence between PET/MRI and PET/CT in correctly defining the revised Ann Arbor staging system. Seventy consecutive patients with classical-HL were prospectively investigated for nodal and extra-nodal involvement during pretreatment staging with same-day PET/CT and PET/MRI. Findings indicative of malignancy with the imaging procedures were regarded as lymphoma infiltration; in case of discrepancy, positive-biopsy and/or response to treatment were evidenced as lymphoma. Sixty of the 70 (86%) patients were evaluable having completed the staging program. Disease staging based on either PET/MRI or PET/CT was correct for 54 of the 60 patients (90% vs. 90%), with difference between proportions of 0.0 (95% CI, -9 to 9%; P=0.034 for the equivalence test). As compared with reference standard, invasion of lymph nodes was identified with PET/MRI in 100% and with PET/CT in 100%, of the spleen with PET/MRI in 66% and PET/CT in 55%, of the lung with PET/MRI in 60% and PET/CT in 100%, of the liver with PET/MRI in 67% and PET/CT in 100%, and of the bone with PET/MRI in 100% and PET/CT in 50%. The only statistically significant difference between PET/MRI and PET/CT was observed in bony infiltration detection rates. For PET/CT, iodinate contrast medium infusions' average was 86 mL, and exposure to ionizing radiation was estimated to be 4-fold higher than PET/MRI. PET/MRI is a promising safe new alternative in the care of patients with HL.

Keywords: Hodgkin lymphoma; PET/CT; PET/MRI.

Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Consort diagram. PET/MRI and PET/CT enable equivalent determination of the tumor stage. FDG-PET, 18F-fluoro-deoxy-glucose positron emission tomography; CT, computed tomography; MRI, magnetic resonance imaging; US, ultrasonography; CE-US, contrast-enhanced ultrasonography; i.v., intravenous. *Routine staging procedures: see supplemental Appendix 1
Fig. 2
Fig. 2
Revised Ann Arbor staging according to the Lugano Classification. Based on the reference standard, final disease stage was I for 8 patients (14%), II for 22 patients (37%; IIE for 2 of them), III for 11 patients (18%; IIIs for 2 of them), and IV for 19 patients (31%; IVs for 7 of them). No overrated stage was observed, owing to the stringent imaging criteria for malignant findings, i.e., positive-PET combined with positive-CT and/or positive-MRI. PET, 18F-fluoro-deoxy-glucose positron emission tomography; MRI, unenhanced magnetic resonance imaging; CT, full-dose contrast enhanced computed tomography
Fig. 3
Fig. 3
Coronal CT (a), coronal PET from PET/CT (b), fused coronal PET/CT (c), coronal STIR (d), coronal PET from PET/MRI (e), and fused coronal PET/MRI (f). FDG-avid left iliac bony lymphomatous lesion (above acetabulum; arrows) can be observed in the PET images obtained from both the PET/CT and the PET/MRI scans. However, no anatomic correlate is visible on CT, whereas it is clearly visible in the STIR image (see Supplemental Appendix Table 2 and Supplemental Appendix 3)
Fig. 4
Fig. 4
Graph depicts the diagnostic sensitivity of each imaging technique in detecting bone focal lesions involved by lymphoma according to lesion size (long axis). NS, not significant; MRI, magnetic resonance imaging; FDG-PET, 18F-fluoro-deoxy-glucose positron emission tomography; CT, computed tomography

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