恶性淋巴瘤的疗效评价——国际工作组标准与修订标准的比较

Response Assessment of Malignant Lymphoma:International Working Group Criteria vs Revised Response Criteria

背景及目的：取得完全缓解以期获得长期生存是我们治疗恶性淋巴瘤的最终目标。常规CT评价淋巴瘤疗效具有难以鉴别小淋巴结性质、区别活动性病灶及纤维组织增生等缺陷，正电子发射断层显象（PET）在鉴别病灶的良、恶性，治疗前的分期以及治疗的疗效评价和疗效监测等方面具有无创性、高敏感性和准确性等优点，国际淋巴瘤协调计划的专家们被召集起来对淋巴瘤的评价标准进行修订更新。本研究拟评价相对于国际工作组标准（IWG），结合PET的疗效评价修订标准是否更能准确评价恶性淋巴瘤疗效。方法：2001年1月-2007年1月，113例（男性76例，女性37例）患者人选本研究，中位年龄是40岁（5岁-79岁）。所有病例均经病理学证实为NHL或HL，并按WHO进行分型。按Ann Arbor临床分期，I期患者14例；II期患者34例；Ⅲ期患者39例；Ⅳ期患者26例。化疗以含有蒽环类的药物为主，按常规的方法和剂量进行放疗。所有患者在化疗结束后均进行了PET的检测。结果：IWG标准，62例患者CRu，4名患者CR，41例患者PR，1例SD，5例PD；根据修订标准，80例患者CR，22例患者PR，2例SD，9例PD，没有患者CRu。多变量分析显示，PET检查为有意义的独立预后因素（P=0．0049）。按两种评价标准评价为CR的患者的PFS无统计学差异；而按修订标准评价的非CR患者的PFS低于按IWG评价标准评价的非CR患者（P=0，01）。修订标准评价的非CR患者的PFS明显低于CR患者（P=0．00）。T细胞淋巴瘤患者按修订标准评价的CR和非CR的患者PFS无统计学差异（P=0．797）。结论：与IWG标准相比，修订标准为淋巴瘤患者提供了一种更精确的疗效评价体系。对于不可治愈或FDG敏感性不确定的患者，尤其是T细胞淋巴瘤，PET的应用仍值得商榷。

Objective： Functional imaging with 18 F fluorodeoxyglucose （FDG） positron emission tomography （PET） has been proposed as a more accurate alternative in the staging, restaging and therapy monitoring of patients with malignant lymphoma. The Imaging subcommittee＇s charge was to develop guidelines for performing and interpreting FDG -PET for treatment assessment in lymphoma, to ensure there liahility of the method both in the context of clinical trials and in clinical practice. In the present study we investigated whether a response classification based on revised Response criteria provides a more accurate response assessment than International Working Group Criteria （IWG criteria） in patients with malignant lymphoma. Methods：Between January 2001 and January 2007, 113 patients with histologically proven NHL or HL （age range, 5-79 years; mean age, 40 years） at Cancer Center, Sun Yat-Sen University. Lymphoma was classified histologically according to the World Health Organisation Classification. PET and CT staging was based on the Ann Arbor chnical staging classification. Results： On the basis of the IWG criteria, 62 patients had a CR, 4 had a CRu, 41 had a PR, 1 had SD, and 5 had PD. In comparison, by Revised response criteria, 80 patients had a CR, 22 had a PR, 2 had SD, 9 had PD, and zero had a CRu The most pronounced discordance was observed in the CRu by IWG criteria designation, in which all 4 CRu designations by IWG patients were reclassified as CR （n =2） or PR （n =2） by Revised response criteria. Non-CR patients by IWG criteria and revised response criteria classifications with poorer outcome compared with CR patients （ P = 0. 01 ）. Non-CR patients by re, vised response criteria classifications with poorer outcome compared with CR patients （P = 0. 00）. However, in different histologic type analysis, there was no significant difference in T-cell lymphoma between CR and Non-CR by Revised response criteria Classifications （P = 0. 797）. Conclusion： Compared with IWG criteria, the revised response criteria provides a more accurate response classifica- tion in patients with malignant lymphoma. For incurable and most variably FDG-avid lymphomas, especially, T-cell lymphoma, the use of PET remains controversial.