Clinical Scorecard: Key Imaging Guidelines for Lymphoma: Recommendations from the European Society of Oncologic Imaging

At a Glance

Key Highlights

• [18F]FDG-PET/CT is preferred for staging and treatment response in most lymphomas due to high FDG avidity
• CT is used for staging and response assessment in non-FDG-avid lymphomas such as SLL/CLL and some indolent NHL
• The 5-point Deauville score on PET is recommended for treatment response assessment in FDG-avid lymphomas

Guideline-Based Recommendations

Diagnosis

• Use [18F]FDG-PET/CT for staging Hodgkin lymphoma and aggressive or FDG-avid indolent NHL
• Use contrast-enhanced CT for staging non-FDG-avid lymphomas like SLL/CLL
• Perform biopsies to rule out bone marrow involvement in all lymphoma subtypes except Hodgkin lymphoma

Management

• Apply the Ann Arbor or Lugano staging systems based on imaging findings
• Use PET/CT for early detection of treatment response in FDG-avid lymphomas
• Use CT to assess lesion size changes in non-FDG-avid lymphomas
• Consider PET/CT if Richter transformation is suspected in SLL/CLL, with SUVmax > 5 indicating suspicion

Monitoring & Follow-up

• Use the 5-point Deauville score to compare FDG uptake in lymphoma lesions versus reference tissues on PET for response assessment
• Use CT to monitor lesion size changes in non-FDG-avid lymphomas
• MRI may be used for CNS lymphoma and as a problem-solving tool for equivocal bone marrow lesions

Risks

• Potential misinterpretation if PET/CT is not used in FDG-avid lymphomas
• Limited sensitivity of CT alone in detecting metabolic changes in lymphoma
• Access and availability issues for PET/CT may lead to reliance on CT in some settings

Patient & Prescribing Data

Patients with various lymphoma subtypes including Hodgkin lymphoma, aggressive and indolent Non-Hodgkin lymphomas

Imaging guides staging, treatment response assessment, and biopsy decisions; PET/CT detects metabolic response earlier than CT, influencing treatment adjustments

Clinical Best Practices

• Select imaging modality based on lymphoma subtype FDG avidity: PET/CT for FDG-avid, CT for non-FDG-avid
• Perform PET and contrast-enhanced CT on the same scanner when possible, using non-contrast CT for PET attenuation correction
• Avoid terms 'primary' and 'metastasis' in lymphoma reporting; use 'nodal' and 'extranodal manifestations' instead
• Consider MRI for CNS lymphoma and equivocal bone marrow lesions; whole-body MRI may be used in vulnerable populations
• Use a long-axis diameter > 1.5 cm to define suspicious lymph nodes
• Apply the Ann Arbor or Lugano staging systems consistently for lymphoma staging

References

• WHO Classification of Lymphoid Neoplasms
• Lugano Classification for Lymphoma Staging
• PRoLoG Consensus on Lymphoma Imaging