Prognostic model using 18F-FDG PET radiomics predicts progression-free survival in relapsed/refractory Hodgkin lymphoma

Transplant and Nontransplant Salvage Therapy in Pediatric Relapsed or Refractory Hodgkin Lymphoma: The EuroNet-PHL-R1 Phase 3 Nonrandomized Clinical Trial

Importance

The current standard-of-care salvage therapy in relapsed/refractory classic Hodgkin lymphoma (cHL) includes consolidation high-dose chemotherapy (HDCT)/autologous stem cell transplant (aSCT).

Objective

To investigate whether presalvage risk factors and fludeoxyglucose-18 (FDG) positron emission tomography (PET) response to reinduction chemotherapy can guide escalation or de-escalation between HDCT/aSCT or transplant-free consolidation with radiotherapy to minimize toxic effects while maintaining high cure rates.

Design, Setting, and Participants

EuroNet-PHL-R1 was a nonrandomized clinical trial that enrolled patients younger than 18 years with first relapsed/refractory cHL across 68 sites in 13 countries in Europe between January 2007 and January 2013. Data were analyzed between September 2022 and July 2024.

Intervention

Reinduction chemotherapy consisted of alternating IEP (ifosfamide, etoposide, prednisolone) and ABVD (adriamycin, bleomycin, vinblastine, dacarbazine). Patients with low-risk disease (late relapse after 2 cycles of first-line chemotherapy and any relapse with an adequate response after 1 IEP/ABVD defined as complete metabolic response on FDG-PET and at least 50% volume reduction) received a second IEP/ABVD cycle and radiotherapy (RT) to all sites involved at relapse. Patients with high-risk disease (all primary progressions and relapses with inadequate response after 1 IEP/ABVD cycle) received a second IEP/ABVD cycle plus HDCT/aSCT with or without RT.

Main Outcomes and Measures

The primary end point was 5-year event-free survival. Secondary end points were overall survival (OS) and progression-free survival (PFS). PFS was identical to event-free survival because no secondary cancers were observed. PFS data alone are presented for simplicity.

Results

Of 118 patients analyzed, 58 (49.2%) were female, and the median (IQR) age was 16.3 (14.5-17.6) years. The median (IQR) follow-up was 67.5 (58.5-77.0) months. The overall 5-year PFS was 71.3% (95% CI, 63.5%-80.1%), and OS was 82.7% (95% CI, 75.8%-90.1%). For patients in the low-risk group (n = 59), 41 received nontransplant salvage with a 5-year PFS of 89.7% (95% CI, 80.7%-99.8%) and OS of 97.4% (95% CI, 92.6%-100%). In contrast, 18 received HDCT/aSCT off protocol, with a 5-year PFS of 88.9% (95% CI, 75.5%-100%) and OS of 100%. All 59 patients with high-risk disease received HDCT/aSCT (and 23 received post-HDCT/aSCT RT) with a 5-year PFS of 53.3% (95% CI, 41.8%-67.9%) and OS of 66.5% (95% CI, 54.9%-80.5%).

Conclusion and Relevance

In this nonrandomized clinical trial, FDG-PET response-guided salvage in relapsed cHL may identify patients in whom transplant-free salvage achieves excellent outcomes. HDCT/aSCT may be reserved for primary progression and relapsed cHL with inadequate response.

Trial Registration

ClinicalTrials.gov Identifier: NCT00433459.

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The predictive power of 18F-FDG PET/CT two-lesions radiomics and conventional models in classical Hodgkin's Lymphoma: a comparative retrospectively-validated study

In a previous preliminary study, radiomic features from the largest and the hottest lesion in baseline 18F-FDG PET/CT (bPET/CT) of classical Hodgkin's Lymphoma (cHL) predicted early response-to-treatment and prognosis. Aim of this large retrospectively-validated study is to evaluate the predictive role of two-lesions radiomics in comparison with other clinical and conventional PET/CT models. cHL patients with bPET/CT between 2010 and 2020 were retrospectively included and randomized into training-validation sets. Target lesions were: Lesion_A, with largest axial diameter (Dmax); Lesion_B, with highest SUVmax. Total-metabolic-tumor-volume (TMTV) was calculated and 212 radiomic features were extracted. PET/CT features were harmonized using ComBat across two scanners. Outcomes were progression-free-survival (PFS) and Deauville Score at interim PET/CT (DS). For each outcome, three predictive models and their combinations were trained and validated: - radiomic model "R"; - conventional PET/CT model "P"; - clinical model "C". 197 patients were included (training = 118; validation = 79): 38/197 (19%) patients had adverse events and 42/193 (22%) had DS ≥ 4. In the training phase, only one radiomic feature was selected for PFS prediction in model "R" (Lesion_B F_cm.corr, C-index 66.9%). Best "C" model combined stage and IPS (C-index 74.8%), while optimal "P" model combined TMTV and Dmax (C-index 63.3%). After internal validation, "C", "C + R", "R + P" and "C + R + P" significantly predicted PFS. The best validated model was "C + R" (C-index 66.3%). No model was validated for DS prediction. In this large retrospectively-validated study, a combination of baseline 18F-FDG PET/CT two-lesions radiomics and other conventional models showed an added prognostic power in patients with cHL. As single models, conventional clinical parameters maintain their prognostic power, while radiomics or conventional PET/CT alone seem to be sub-optimal to predict survival.

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