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Positron emission tomography with F–fluorodeoxyglucose (FDG-PET) has become a cornerstone procedure in the modern management of Hodgkin’s lymphoma (HL) [1–4]. It offers better initial staging and risk stratification [3]. FDG-PEToften detects occult extranodal disease, notably focal bone marrow lesions [5–7]. It rendered useless routine bone marrow biopsy [3]. HL is associated with a high rate of residual masses at the end of therapy, which are difficult to characterize as residual disease or not on conventional imaging. Therefore, a major milestone was the finding that end-of-treatment FDG-PET offers excellent prediction of progression-free-survival (PFS), even in the presence of a residual mass [8–11]. This finding led to the introduction of FDG-PET imaging in response criteria for HL [12]. More recently, FDG-PET performed early during chemotherapy (interim-PET) has been used to tailor treatment. Here, we comment on results of two recently published prospective multicentre trials in which patients with advanced HL had response-adapted therapy based on interim-PET [13, 14]. These trials were triggered by observational studies showing high prognostic accuracy of interim PET [15]. For example, in one retrospective multicenter study of patients with advancedstage or early unfavorable HL, the 3-year PFS for patients with positive interim-PETafter two cycles ofABVD (score≥ 4 on the Deauville 5-point scale) was 28% and for patients with negative interim-PET 95.0% (P < .0001) [16]. In the Southwest Oncology Group (SWOG) S0816 phase II study, which included stages III and IV HL, interim PETpositive patients after two cycles of ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) were switched to escalated-BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisone). The 2-year PFS in interim PET-positive patients was 64% [13]. Again, in the RATHL study (stage II unfavorable, stage III and stage IV), the 3-year PFS in interim PETpositive patients who were switched from ABVD to a BEACOPP regimen was 67.5% [14]. These results are very encouraging as they show that interim PET allows a finely tuned treatment by restricting the use of BEACOPP to the 15% to 20% of patients who are PET-positive. BEACOPP offers higher cure rates in HL, but is also associated with a higher percentage of short-term and long-term adverse effects (hematologic toxicity, infections, infertility, secondary malignancies) [17]. In the absence of randomisation, the extent of benefit from switching to BEACOPP cannot be assessed from these trials [13, 14]. Also, the optimal strategy in these interim-PET-positive patients might evolve in light of the new therapeutic arsenal (targeted therapy, checkpoint inhibitors such as anti-PD-1 therapy, etc.) that is now available; for example, the possibilities of combining chemotherapy and targeted therapy with the anti-CD30 antibody-drug conjugate brentuximab vedotin [18]. Surprisingly, in both trials, the relapse rates in patients with a negative interim-PET were much higher than the rates expected from historical data [16]. In the SWOG S0816 study, which included only advanced stages, the 2-year PFS in interim PET-negative patients was 82% [13]. In the RATHL study, in which 42% of patients had stage-II disease, the 3-year PFS in interim PET-negative patients who continued on ABVD was 85.7% [14]. The outcome was influenced by initial riskgroup: 3y–PFS was 90% in stage II patients with adverse risk, * Elif Hindié elif.hindie@chu-bordeaux.fr

Advanced Hodgkin’s lymphoma: End-of-treatment FDG-PET should be maintained