PET Beim Hodgkin Lymphom Freitag, 30.11.2007 Düsseldorf 34. Jahrestagung der RWGN Carsten Kobe für die Deutsche Hodgkin Studiengruppe (GHSG)
Suggested changes due to FDG PET Stage or treatment 22/88 Pat.(25%) 30/186 (16%) Treatment strategy 16/88 Pat. (18%) Therapy intensification 9/88 Pat. (10%) Therapy intensification 9/44 Pat. (20%) 14/123 (11%) early stages (Ia-IIB) 10-20 % Therapy intensification in early stages - Substantial impact of FDG PET in Staging HL Naumann et al., 2004, Rigacci et al., 2007
Staging Hodgkin Lymphoma Involvement: left Axilla and bone marrow *a) large mediastinal mass; b) extranodal disease; c) high ERS; d) 3 or more areas
Staging Hodgkin Lymphoma Involvement: Cervical, lung hilum, mediastinum, paraaortal
Pitfalls Thymic uptake Brown fat Castellucci et al., Nucl. Med. Comm., 2005
Prognostic significance of FDG-PET after completed therapy Author Study Pat. Observation PFS @ 1 PFS @ 1 Overall [n] [months] PET+ [%] PET- [%] PPV/NPV [%] De Witt 2001 Weihrauch 2001 Spaepen 2001 Prospective 37 26 75 100 66/100 Prospective 29 28 40 95 60/84 Retrospective 60 31 40 95 100/91
HD15 (advanced stages) A 8x BEACOPP esk. B 6x BEACOPP esk. Restaging (CT) C 8x BEACOPP 14 CR, CRr, PR < 2.5 cm PR 2.5 cm PET Panel (GHSG Cologne) NPV PET? PET - follow up PET + 30 Gy Radiotherapy
> 2.5 cm PET negative
> 2.5 cm PET positive
Additional Radiotherapy?
PET after 2 Cycles ABVD Hodgkin Lymphoma Hutchings et al., Blood.2006 ;107(1):52-9.
PET after 2 Cycles ABVD Hodgkin Lymphoma Gallamini et al., J Clin Oncol 2007. 3746-3752
PET after 2 Cycles BEACOPP Hodgkin Lymphoma Patients in unfavourable and advanced stages 2x BEACOPP esc. 54 Pat. PET PET - 4x BEACOPP std. n=43 PET + 4x BEACOPP esc. n=11 12 months follow-up 42/43 EVS 8/11 EVS Dann EJ et al., Blood 2007, 109:905-9
PET after 2 Cycles BEACOPP Hodgkin Lymphoma HD18 (advanced stages) 2 x BEACOPP esc PET-Panel (GHSG Cologne) PET positiv R PET negativ R 6 x BEACOPP esc. 6 x BEACOPP esc. + Rituximab 6 x BEACOPP esc. 2 x BEACOPP esc. Radiotherapy PET positive PR > 2.5 cm
PET after 2 Cycles ABVD Hodgkin Lymphoma HD16 (early stages) 2 x ABVD PET-Panel (GHSG Cologne) PET positiv R PET negativ R 2 x ABVD 2 x ABVD IF Radiotherapy 30 Gy 2 x ABVD 2 x ABVD
PET Vergütung I ICD10: C81.- OPS 301: 3-742 DRG: R 65B Kostengewicht 0,237 (Grouper), 1-Tages DRG 640 (Annahme: Baserate 2.700) Rechtsgrundlage BSG 26.09.2006: stationär zulässig, wenn keine vertragsärztliche Behandlung und medizinisch notwendig in HD16 und HD18 wird nach VdAK die GKV entsprechende stationäre Aufenthalte nicht als Fehlbelegung einordnen
PET Vergütung II Fazit für Onkologen/Nuklearmediziner: Verwaltung informieren Verhandlungen mit den Krankenkassen zu Beginn 2008!
Acknowledgement GHSG: M Dietlein (1) J Franklin (2) A Pluetschow (2) HT Eich (3) M Fuchs (4) A Gossmann (5) B Pfistner (2) V Diehl (2) A Engert (4) PET centers: J Markova (6) O Belohlavek (7) H Schicha (1) H Amthauer (8) W Brenner (9) M de Wit (10) WH Knapp (11) A Bockisch (12) M Weckesser (13) R Lorenz (14) M Schreckenberger (15) R Bares (16) J Sciuk (17) F Grunwald (18) U Haberkorn (19) O Sabri (20) J Marienhagen (21) CM Kirsch (22) K Scheidhauer (23) R Tiling (24) (1) Department of Nuclear Medicine, University of Cologne, (2) German Hodgkin Study Group, University of Cologne (3) Department of Radiation Oncology, University of Cologne (4) Department I of Internal Medicine, University of Cologne (5) Department of Radiology, University of Cologne (6) Oddeleni klinicke hematologie FN KV, Prague, Czech Republic (7) PET Center, Na Homolce Hospital, Prague, Czech Republic (8) Klinik fur Strahlenheilkunde, Charite Universitatsmedizin Berlin (9) Department of Nuclear Medicine, University Medical Center Hamburg- Eppendorf (10) Department of Medicine, University Hospital Hamburg-Eppendorf (11) Department of Nuclear Medicine, Hannover University Medical School (12) Department of Nuclear Medicine, University of Duisburg-Essen (13) Department of Nuclear Medicine, University Hospital Muenster (14) Department of Nuclear Medicine, University of Wuerzburg (15) Department of Nuclear Medicine, Gutenberg University Hospital (16) Department of Nuclear Medicine,University of Tuebingen (17) Department of Nuclear Medicine, Klinikum Augsburg (18) Department of Nuclear Medicine, Hospital of the J.W.G.-University, Frankfurt (19) Department of Nuclear Medicine, University Hospital Heidelberg (20) Department of Nuclear Medicine, University of Leipzig (21) Department of Nuclear Medicine, University of Regensburg (22) Department of Nuclear Medicine, Saarland University Medical Center, Homburg (23) Department of Nuclear Medicine, Klinikum rechts der Isar, Technical University Munich (24) Department of Nuclear Medicine, Ludwig-Maximilians-University, Munich
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