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J Clin Oncol. 2019 May 21:JCO1801799. doi: 10.1200/JCO.18.01799. [Epub ahead of print]

Positron Emission Tomography Score Has Greater Prognostic Significance Than Pretreatment Risk Stratification in Early-Stage Hodgkin Lymphoma in the UK RAPID Study.

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1 King's College London and Guy's and St Thomas' PET Centre, Kings College London, King's Health Partners, London, United Kingdom.
2 Cancer Research UK and University College London Cancer Trials Centre, University College London, London, United Kingdom.
3 University of Sheffield and Weston Park Hospital, Sheffield, United Kingdom.
4 St George's, University of London, London, United Kingdom.
5 Cancer Research UK Centre, University of Southampton, Southampton, United Kingdom.
6 University College Hospital London, London, United Kingdom.
7 Aberdeen Royal Infirmary, Aberdeen, United Kingdom.
8 Nottingham City Hospitals National Health Service (NHS) Trust, Nottingham, United Kingdom.
9 Mount Vernon Hospital, Middlesex, United Kingdom.
10 Institute of Cancer Sciences and the Christie NHS Foundation Trust, University of Manchester, Manchester, United Kingdom.



Accurate stratification of patients is an important goal in Hodgkin lymphoma (HL), but the role of pretreatment clinical risk stratification in the context of positron emission tomography (PET) -adapted treatment is unclear. We performed a subsidiary analysis of the RAPID trial to assess the prognostic value of pretreatment risk factors and PET score in determining outcomes.


Patients with stage IA to IIA HL and no mediastinal bulk underwent PET assessment after three cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine; 143 PET-positive patients (PET score, 3 to 5) received a fourth doxorubicin, bleomycin, vinblastine, and dacarbazine cycle and involved-field radiotherapy, and 419 patients in complete metabolic remission were randomly assigned to receive involved-field radiotherapy (n = 208) or no additional treatment (n = 211). Cox regression was used to investigate the association between PET score and pretreatment risk factors with HL-specific event-free survival (EFS).


High PET score was associated with inferior EFS, before (P < .001) and after adjustment (P = .01) for baseline risk stratification. Only patients with a postchemotherapy PET score of 5 (uptake ≥ three times maximum liver uptake) had an increased risk of progression or HL-related death (hazard ratio, 9.4 v score of 3; 95% CI, 2.8 to 31.3 and hazard ratio, 6.7 v score of 4; 95% CI, 1.4 to 31.7). Patients with a PET score of 5 also had inferior progression-free and overall survival. There was no association between European Organisation for Research and Treatment of Cancer or German Hodgkin Study Group risk group and EFS, before or after adjusting for PET score (all P > .4).


In RAPID, a positive PET scan did not carry uniform prognostic weight; only a PET score of 5 was associated with inferior outcomes. This suggests that in future trials involving patients without B symptoms or mediastinal bulk, a score of 5 rather than a positive PET result should be used to guide treatment escalation in early-stage HL.


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