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Michel Meignan, Université Paris-Est Créteil, and colleagues published findings in the Journal of Clinical Oncology in August 2016 aiming to determine the prognostic impact of the Total Metabolic Tumor Volume (TMTV) measured at baseline with [18F]FDG/PET-CT scans and its added value to these models.1 In this pooled analysis, a total of 185 patients with Follicular Lymphoma (FL) had baseline scans suitable for TMTV calculation: 106 from the LYSA PET-FOL trial2, 38 from the LYSA PRIMA trial3, and 41 from the FIL FOLL05 trial4. Progression Free Survival (PFS) and Overall Survival (OS) data were available for 181 patients, with a median follow-up of 63.5 months from registration. Of the 181 patients, 159 had a post-induction PET for response assessment reported with Deauville criteria.
The authors stated that no specific study thus far has identified the prognostic benefit of TMTV in identifying patients with FL at high-risk of disease progression and early death after current immunochemotherapeutic strategies. The group concluded that TMTV is a robust pre-treatment predictor of outcome in high-tumor-burden FL patients and TMTV is a strong predictor of early progression within the first or second year after starting treatment. Combining TMTV with FLIPI2 score can identify patients at high risk of progression and so warrants further investigation and validation as a biomarker for development of first-line PET-adapted approaches in FL, contributing to developing risk-adapted individualized treatment approaches and thereby avoiding under- and over-treatment of patients with FL.
Heiko Schöder and Craig Moskowitz of the Memorial Sloan Kettering Cancer Center, New York, provided an accompanying editorial, published in the Journal of Clinical Oncology in September 20165, noting some shortcomings the results obtained by Meignan et al.
Schöder and Moskowitz state that is it probably too early to call TMTV a new prognostic biomarker in lymphoma. They also mentioned that TMTV combined with treatment response assessed on interim PET imaging, rather than FLIPI2 score, leads to better segregation of prognostic groups6. In the future, we need to determine the biologic reasons for why TMTV is associated with patient outcome and ask how these data can improve clinical practice. Schöder and Moskowitz also hypothesize that the most accurate prognostic tool will combine clinical, imaging and biologic factors and so it will be some time for a specific test to be standardized and accepted into clinical practice. Until this time, hypothesis-testing is needed for better risk stratification and treatment selection of lymphoma patients in studies exploring imaging techniques and potential biomarkers. The editorial concludes by stating that “the data provided by Meignan et al. moves us one step along in this direction.”
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