IMAGING PITFALLS IN PEDIATRIC, ADOLESCENT, AND YOUNG ADULT HODGKIN LYMPHOMA: A SEARCH FOR CAYAHL INITIATIVE TO BRIDGE MULTIDISCIPLINARY PATIENT CARE

N. Dakhallah and J. Steglich equally contributing author.

Introduction: Hodgkin lymphoma (HL) is a highly curable malignancy in children, adolescents, and young adults (CAYA), and current treatment strategies aim to minimize adverse late effects. Many patients are enrolled in clinical trials that include centralized review for both initial and interim staging. While academic guidelines provide a structured framework, real-world clinical scenarios sometimes present imaging pitfalls that require nuanced judgment.

Methods: The Staging, Evaluation and Response Criteria (SEARCH) for CAYAHL initiative was established in 2011 to harmonize staging and response criteria in HL in CAYA. However, applying these published criteria can present challenges in situations where imaging pitfalls are encountered. This SEARCH for CAYAHL project is a transatlantic collaboration among experts in diagnostic radiology, nuclear medicine radiology, radiation oncology and pediatric oncology. A working group first identified the most frequent and relevant imaging pitfalls in HL. Through literature review, imaging and clinical experience, and the use of specific real-word cases, this effort defines and describes imaging pitfalls in HL in CAYA.

Results: Morphologic and metabolic imaging pitfalls in HL refer to the misinterpretation of findings that can occur during staging, disease evaluation, or post-treatment surveillance. These radiological findings are not indicative of disease but are rather manifestations of other causes that are specific to each tissue or organ. In this work, we explore pitfalls resulting from suboptimal imaging conditions, concurrent inflammatory, infectious, or other causes. We discuss organ specific pitfalls involving the lymph nodes, lungs, bone, bone marrow, spleen, liver and Waldeyer’s ring and present important considerations on imaging following the completion of therapy.

Conclusions: This collaborative effort aims to disseminate insights gained from decades of centralized review experience in North American and European trials to optimize patient care by integrating imaging and clinical expertise. Although not intended as a comprehensive staging guide, it highlights recurrent imaging pitfalls that may lead to diagnostic uncertainty. By encouraging interdisciplinary exchange, this work seeks to complement existing literature and serve as a troubleshooting guide for situations where clinical realities diverge from academic paradigms, ultimately paving the way for improved patient outcomes.

Keywords: Hodgkin lymphoma (pediatric, adolescent, and young adult)

Potential sources of conflict of interest:

C. Mauz-Körholz

Employment or leadership position: Institutional research grant Merck

Consultant or advisory role: Merck advisory board