Systematic re-staging in the management of non-Hodgkin's lymphomas

One hundred patients with advanced non-Hodgkin's lymphoma in apparent clinical remission after combination chemotherapy had systematic re-staging to assess the completeness of response. Eighteen of these patients were found to have residual disease, predominantly in lymph nodes (eight patients) and bone marrow (seven patients). Patients with persistent lymphoma more often had stage IV disease (72% vs 54%) and constitutional symptoms (44% vs 28%) than patients without detectable disease. Twenty of the 82 patients without demonstrable disease at re-staging have relapsed, with a mean time to relapse after re-staging of 4 months. Predominant sites of relapse were the lymph nodes (16 patients) and skin (four patients). The sites of disease detected at re-staging and at the time of relapse were predictable: in 80% of patients with nodular lymphoma and in 60% of those with diffuse lymphoma, disease was found in sites originally involved by lymphoma. Significantly fewer re-staging studies were performed on those patients who have relapsed than were performed on those who have remained in remission (P<0.05), and in some of the relapsing patients 'early relapse' appears to reflect inadequate re-staging evaluations for residual disease. All future lymphoma trials should incorporate systematic re-staging, emphasizing a thorough re-evaluation of all sites of disease determined at initial staging in order to standardize the definition of complete remission. Furthermore, such re-staging should be performed in clinical practice before treatment is stopped. The accuracy of systematic re-staging in detecting residual lymphoma may be enhanced by a more careful pretreatment evaluation for extent of disease, by individualizing re-staging procedures for particular patients, and by using new diagnostic techniques to detect occult disease.