What is your approach for bulky stage I primary mediastinal B-cell lymphoma in a patient with a positive post-chemotherapy PET-CT (residual mass and Deauville 5)?

Some specific questions:

Would you recommend repeat biopsy to confirm residual disease?
How would your recommendations vary if the patient had previously received intensive chemotherapy (eg. da-EPOCH-R) vs standard chemotherapy (eg. R-CHOP)?
Should 2^nd line chemotherapy and/or transplant be considered if biopsy is positive? Or should the patient proceed to ISRT?
If the latter scenario, what RT dose would you recommend in the setting of a positive post-chemo PET-CT?

Answer from: Medical Oncologist at Academic Institution

Interpreting end-of-treatment PET in PMBL can be tricky. False positives here are very common! Fake-outs include thymic rebound masquerading as refractory disease; avidity at rim (which is almost always biopsy-neg); or residual avidity throughout residual mass which again can be biopsy negative. I w...

Comments

Radiation Oncologist at Maimonides Medical Center
Thank you so much Dr. Matasar.

Answer from: Radiation Oncologist at Academic Institution

This is a complex situation without a lot of data to guide us. While I agree mostly with Dr. Matasar, I have some additional comments:1) Did the pt respond clinically to chemo? If yes, and PET is still positive, that is better then no clinical response2) Assuming a cli...

Comments

Radiation Oncologist at Maimonides Medical Center
Thank you so much, Dr. Prosnitz.

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What is your approach for bulky stage I primary mediastinal B-cell lymphoma in a patient with a positive post-chemotherapy PET-CT (residual mass and Deauville 5)?

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