The conundrum of Hodgkin lymphoma nodes: to be or not to be included in the involved node radiation fields. The EORTC-GELA lymphoma group guidelines.
OBJECTIVE
To develop easily applicable guidelines for the determination of initially involved lymph nodes to be included in the radiation fields.


METHODS
Patients with supra-diaphragmatic Hodgkin lymphoma. All the imaging procedures were carried out with patients in the treatment position. The prechemotherapy PET/CT was coregistered with the postchemotherapy CT simulation for planning purposes. Initially involved lymph nodes were determined on fused prechemotherapy CT and FDG-PET imaging data. The initial assessment was verified with the postchemotherapy CT scan.


RESULTS
The classic guidelines for determining the involvement of lymph nodes were not easily applicable and did not seem to reflect the exact extent of Hodgkin lymphoma. Three simple steps were used to pinpoint involved lymph nodes. First, FDG-PET scans were meticulously analysed to detect lymph nodes that were overlooked on CT imaging. Second, any morphological and/or functional asymmetry was sought on CT and FDG-PET scans. Third, a decrease in size or the disappearance of initially visible lymph nodes on the prechemotherapy CT scan as compared to the postchemotherapy CT scan was considered as surrogate proof of initial involvement.


CONCLUSIONS
All the radiological procedures should be performed on patients in the treatment position for proper coregistration. It is highly advisable that all CT and/or CT/PET scans be performed with IV contrast. Using the above-mentioned three simple guidelines, initially involved lymph nodes can be detected with very satisfactory accuracy. It is also emphasized that the classic guidelines (2, 3, 4) can always be used when deemed necessary.
Girinsky
Theodore
T
Department of Radiation Oncology, Institute Gustave Roussy, Villejuif, France. girinsky@igr.fr
Specht
Lena
L
Ghalibafian
Mithra
M
Edeline
Veronique
V
Bonniaud
Guillaume
G
Van Der Maazen
Richard
R
Aleman
Berthe
B
Paumier
Amaury
A
Meijnders
Paul
P
Lievens
Yolande
Y
Noordijk
Evert
E
Poortmans
Philip
P
D003287:Contrast Media; D019788:Fluorodeoxyglucose F18; D006689:Hodgkin Disease / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000532:radiotherapy*; D006801:Humans; D015182:Lymphatic Irradiation / Q000379:methods*; D008207:Lymphatic Metastasis / Q000000981:diagnostic imaging; D017410:Practice Guidelines as Topic; D019275:Radiopharmaceuticals; D016019:Survival Analysis; D014055:Tomography, Emission-Computed; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D003287:Contrast Media; D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18