# FDG PET then response-adapted chemotherapy

Source: https://nuclide.cc/pairings/fdg-pet-response-adapted-therapy/  
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## TL;DR

In Hodgkin lymphoma, a PET scan taken partway through chemotherapy is used to decide whether to keep the same treatment, drop a harsh drug, or step up to something stronger. Trials show this scan-guided approach keeps most patients well without adding one particular lung-damaging drug.

## Summary

RATHL (Response-Adapted Therapy in advanced Hodgkin Lymphoma; NCT00678327; Johnson et al., NEJM 2016) enrolled 1214 patients (1119 evaluable) with stage IIB-IV or bulky IIA classical Hodgkin lymphoma. All patients received two cycles of ABVD chemotherapy and then an interim FDG PET-CT scan (PET2). Patients with a negative PET2 (Deauville score 1-3; 83.7% of scanned patients) were randomised to continue ABVD or to drop bleomycin (AVD) for the remaining four cycles; those with a positive PET2 were escalated to BEACOPP-14 or escalated BEACOPP, with no randomisation in that arm.

At a median follow-up of 41 months, 3-year progression-free survival in PET2-negative patients was 85.7% with continued ABVD versus 84.4% with AVD (absolute difference 1.6 percentage points, within the prespecified non-inferiority margin), while overall survival was around 97% in both arms; the trial's practical conclusion was that bleomycin can be safely omitted after a negative interim scan, reducing pulmonary toxicity with an estimated treatment-failure risk of only 1.6%. PET2-positive patients who were escalated to BEACOPP reached a 3-year progression-free survival of 67.5%, which the investigators judged better than historical rates of continuing ABVD alone in PET2-positive disease (previously reported in the 15-45% range). Long-term follow-up (Blood 2022; JCO 2024) confirmed durability of both the de-escalation and escalation strategies.

RATHL is the paradigm case for FDG-PET-guided, response-adapted treatment and sits alongside other PET2-adapted trials (Italian GITIL/FIL HD0607, US Intergroup S0816) that validated the same principle: interim FDG-PET response predicts outcome and can be used prospectively to tailor chemotherapy intensity. The same logic (imaging mid-treatment to decide whether to change systemic therapy) generalises to other FDG-avid cancers, for example the germ-cell tumour and lymphoma literature more broadly, though the specific numbers above are for classical Hodgkin lymphoma.

## Fields

- Kind: Pairing
- Last checked: 2026-09-22
- Tags: Hodgkin lymphoma; response-adapted therapy; FDG PET
- Pairs: FDG PET + PET-adapted (response-adapted) therapy
- Type: platform
- Rationale: FDG uptake after two cycles of chemotherapy predicts long-term outcome in Hodgkin lymphoma, so an interim scan can be used prospectively to de-escalate treatment for good responders (reducing toxicity) or escalate it for poor responders (improving control).
- Evidence: RATHL (n=1214, NCT00678327): in interim-PET-negative patients, 3-year progression-free survival was 85.7% with continued ABVD vs 84.4% after dropping bleomycin (AVD), supporting safe de-escalation; interim-PET-positive patients escalated to BEACOPP reached 67.5% 3-year progression-free survival, better than historical rates with unmodified ABVD (Johnson et al., NEJM 2016).

## Sources

- Johnson P, et al. RATHL: adapted treatment guided by interim PET-CT, N Engl J Med 2016;374:2419-2429: https://thd.org.tr/thdData/userfiles/file/RATHL_Adapted_Treatment_Guided_by_Interim_PET-CT_Scan-2016_NEJM.pdf
- PMC review of PET-adapted approaches to primary therapy for advanced Hodgkin lymphoma: https://pmc.ncbi.nlm.nih.gov/articles/PMC7268111/
- Long-term follow-up of RATHL (Luminari et al., J Clin Oncol 2024): https://ascopubs.org/doi/10.1200/JCO.23.01177

## Connected records

- trials: [RATHL](https://nuclide.cc/trials/rathl/)
- key papers: [RATHL: adapted treatment guided by interim PET-CT in advanced Hodgkin lymphoma](https://nuclide.cc/key-papers/paper-rathl-interim-pet-adapted-abvd-advanced-hodgkin-nejm-2016/)
- technologies: [FDG PET](https://nuclide.cc/technologies/fdg-pet/), [PET-adapted (response-adapted) therapy](https://nuclide.cc/technologies/pet-adapted-therapy/), [Quantitative imaging biomarkers (RECIST, PERCIST, SUV, ADC)](https://nuclide.cc/technologies/quantitative-imaging-biomarkers/)
- people: [Pierre Vera](https://nuclide.cc/people/pierre-vera/)

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