Abstract
This review aims to comprehensively evaluate the current role of F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in paediatric Hodgkin lymphoma (HL) and non-Hodgkin lymphomas (NHL) across diagnosis, staging, treatment response assessment, and prognostication. Emphasis is placed on quantitative metabolic parameters such as maximum standardized uptake values, metabolic tumor volume, total lesion glycolysis (TLG), quantitative PET index (qPET), and maximum tumor dissemination distance (Dmax), highlighting their clinical applicability and subtype-specific prognostic implications. The contribution of PET/CT to initial staging in HL and FDG-avid NHL subtypes, as well as the prognostic value of interim and end-of-treatment scans, are detailed considering contemporary national and international guidelines. Furthermore, the prognostic relevance of metabolic PET parameters in pediatric NHL subtypes, including anaplastic large cell lymphoma, diffuse large B-cell lymphoma, and Burkitt lymphoma, is summarized. Emerging approaches such as radiomics, low-dose imaging strategies [PET/magnetic resonance (MR), AI-based CT-free PET], and novel CXCR4-targeted tracers like Pentixafor are also discussed. FDG PET/CT remains integral to clinical decision-making in pediatric lymphomas, guiding management from baseline evaluation through follow-up. Novel parameters such as TLG, qPET and Dmax, together with dose-reduction strategies like PET/MR, may lay the foundation for future risk-adapted protocols and personalized treatment strategies.
Keywords: Pediatric lymphoma, FDG PET/CT, MTV, TLG, qPET, Dmax, radiomics, Pentixafor, Hodgkin lenfoma, Non-Hodgkin lenfoma
References
Kutluk MT, Yeşilipek A. Pediatric cancer registry in Turkey 2009-2021 (TPOG & TPHD). Journal of Clinical Oncology.40(16_suppl):e22020-e.
McCarten KM, Nadel HR, Shulkin BL, Cho SY. Imaging for diagnosis, staging and response assessment of Hodgkin lymphoma and non-Hodgkin lymphoma. Pediatr Radiol. 2019;49:1545-1564.
Buhtoiarov IN. Pediatric lymphoma. Pediatr Rev. 2017;38:410-423.
Rauf MS, Khan ZA, Zahir MN, et al. Comparison of 18F-labelled fluoro-2-deoxyglucose-PET with conventional computed tomography for staging and response assessment in paediatric and adult patients with nodular lymphocyte-predominant Hodgkin’s lymphoma. Nucl Med Commun. 2021;42:899-906.
Younes A, Hilden P, Coiffier B, et al. International Working Group consensus response evaluation criteria in lymphoma (RECIL 2017). Ann Oncol. 2017;28:1436-1447.
Kartal MO, Kartal AS, Kurucu B, Özyörük D, Şahin G, Gülaldi NCM. Prognostic impact of quantitative changes between baseline and interim 18 F-FDG PET/CT in pediatric classic Hodgkin lymphoma. Clin Nucl Med. 2025;50:e407-e416.
Lyra V, Chatziioannou S, Kallergi M. Clinical perspectives for (18)F-FDG PET imaging in pediatric oncology: μetabolic tumor volume and radiomics. Metabolites. 2022;12:217.
Tie X, Shin M, Lee C, et al. Automatic quantification of serial PET/CT images for pediatric Hodgkin lymphoma using a longitudinally aware segmentation network. Radiol Artif Intell. 2025;7:e240229.
Zhou Y, Hong Z, Zhou M, et al. Prognostic value of baseline (18) F-FDG PET/CT metabolic parameters in paediatric lymphoma. J Med Imaging Radiat Oncol. 2020;64:87-95.
Kurch L, Hasenclever D, Kluge R, et al. Only strongly enhanced residual FDG uptake in early response PET (Deauville 5 or qPET ≥ 2) is prognostic in pediatric Hodgkin lymphoma: Results of the GPOH-HD2002 trial. Pediatr Blood Cancer. 2019;66:e27539.
Lopci E, Meignan M. Deauville score: the Phoenix rising from ashes. Eur J Nucl Med Mol Imaging. 2019;46:1043-1045.
Kurch L, Landman-Parker J, Georgi TW, et al. Quantitative Deauville scoring to uncover prognostic information from (18)F-FDG PET-based response assessment: data from the EuroNet-PHL-C1 trial. J Nucl Med. 2025;66:1331-1337.
Pacella S, Landoni C, Bonacina M, et al. The prognostic role of qPET in interim-PET in paediatric Hodgkin lymphoma. Journal of Nuclear Medicine. 2022;63(supplement 2):3125.
Hasenclever D, Kurch L, Mauz-Körholz C, et al. qPET - a quantitative extension of the Deauville scale to assess response in interim FDG-PET scans in lymphoma. Eur J Nucl Med Mol Imaging. 2014;41:1301-1308.
Albano D, Treglia G, Dondi F, et al. (18)F-FDG PET/CT maximum tumor dissemination (Dmax) in lymphoma: a new prognostic factor? Cancers (Basel). 2023;15.
Rosolen A, Perkins SL, Pinkerton CR, et al. Revised international pediatric non-Hodgkin lymphoma staging system. J Clin Oncol. 2015;33:2112-2118.
Gross TG, Termuhlen AM. Pediatric non-Hodgkin’s lymphoma. Curr Oncol Rep. 2007;9:459-465.
Kurch L, Kluge R. Update on FDG-PET in pediatric lymphoma. Q J Nucl Med Mol Imaging. 2024;68:58-69.
Li Z, Li C, Chen B, et al. FDG-PET/CT versus bone marrow biopsy in bone marrow involvement in newly diagnosed paediatric lymphoma: a systematic review and meta-analysis. J Orthop Surg Res. 2021;16:482.
Tzotzola V, Perez P, Attarbaschi A. European standard clinical practice recommendations for non-Hodgkin lymphoma of childhood and adolescence. Version 1.0, 04.10.2021.
El-Mallawany NK, Alexander S, Fluchel M, et al. Children’s Oncology Group’s 2023 blueprint for research: non-Hodgkin lymphoma. Pediatr Blood Cancer. 2023;70:e30565.
Barth M, Xavier AC, Armenian S, et al. Pediatric aggressive mature B-cell lymphomas, version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2022;20:1267-1275.
Seshachalam A, Karpurmath SV, Rathnam K, et al. Role of interim PET scan after 2 cycles of ABVD in pediatric Hodgkin lymphoma: retrospective multicenter study from South India. Ind J Med Paediatr Oncol. 2021;42:415-425.
Mhlanga J, Lai H, Alazraki A, et al. Imaging recommendations in pediatric lymphoma: a COG Diagnostic Imaging Committee/SPR Oncology Committee white paper. Pediatr Blood Cancer. 2023;70:e29968.
Kaya G, Salanci BV, Aydin B, Kiratli PO, editors. Interim PET in Pediatric High Grade B Lymphomas; Future is Predictable. European Journal of Nuclear Medicine and molecular imaging; 2024: springer one new york plaza, suite 4600, New York, NY, United States.
Mathew B, Vijayasekharan K, Shah S, et al. Prognostic value of 18F-FDG PET/CT-metabolic parameters at baseline and interim assessment in pediatric anaplastic large cell lymphoma. Clin Nucl Med. 2020;45:182-186.
Reiter A. Diagnosis and treatment of childhood non-Hodgkin lymphoma. Hematology Am Soc Hematol Educ Program. 2007;2007:285-296.
Haioun C, Itti E, Rahmouni A, et al. [18F] fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) in aggressive lymphoma: an early prognostic tool for predicting patient outcome. Blood. 2005;106:1376-1381.
Furth C, Steffen IG, Erdrich AS, et al. Explorative analyses on the value of interim PET for prediction of response in pediatric and adolescent non-Hodgkin lymphoma patients. EJNMMI Res. 2013;3:71.
Kurch L, Dührsen U, Hüttmann A, et al. Quantitative evaluation of interim positron emission tomography in peripheral T-cell lymphoma. EJNMMI Res. 2021;11:90.
Dang J, Peng X, Wu P, et al. Predictive value of Dmax and %ΔSUVmax of (18)F-FDG PET/CT for the prognosis of patients with diffuse large B-cell lymphoma. BMC Med Imaging. 2023;23:173.
Cottereau A-S, Nioche C, Dirand A-S, et al. 18F-FDG PET dissemination features in diffuse large B-cell lymphoma are predictive of outcome. J Nucl Med. 2020;61:40-45.
Chambers G, Frood R, Patel C, Scarsbrook A. (18)F-FDG PET-CT in paediatric oncology: established and emerging applications. Br J Radiol. 2019;92:20180584.
Mansi L, Lopci E, Cuccurullo V, Chiti A. Clinical nuclear medicine in pediatrics. Springer; 2016.
Treves ST. Pediatric nuclear medicine and molecular imaging: Springer; 2014.
Rogasch JMM, Hundsdoerfer P, Hofheinz F, et al. Pretherapeutic FDG-PET total metabolic tumor volume predicts response to induction therapy in pediatric Hodgkin’s lymphoma. BMC Cancer. 2018;18:521.
Yadgarov MY, Dunaykin MM, Shestopalov GI, et al. Prognostic value of baseline and interim [(18)F]FDG PET metabolic parameters in pediatric Hodgkin’s lymphoma. Eur J Nucl Med Mol Imaging. 2024;51:1955-1964.
Semary S, Moussa E, Salama M, et al. PET/CT response assessment in pediatric Hodgkin lymphoma: does Deauville score 3 reflect negativity? J Pediatr Hematol Oncol. 2024;46:e493-e500.
Reed JD, Masenge A, Buchner A, et al. The utility of metabolic parameters on baseline F-18 FDG PET/CT in predicting treatment response and survival in paediatric and adolescent Hodgkin lymphoma. J Clin Med. 2021;10:5979.
Gillies RJ, Kinahan PE, Hricak H. Radiomics: images are more than pictures, they are data. Radiology. 2016;278:563-577.
Hatt M, Le Rest CC, Tixier F, Badic B, Schick U, Visvikis D. Radiomics: data are also images. J Nucl Med. 2019;60(Supplement 2):38S.
Hatt M, Krizsan AK, Rahmim A, et al. Joint EANM/SNMMI guideline on radiomics in nuclear medicine : Jointly supported by the EANM Physics Committee and the SNMMI Physics, Instrumentation and Data Sciences Council. Eur J Nucl Med Mol Imaging. 2023;50:352-375.
Hosseini SA, Shiri I, Ghaffarian P, et al. The effect of harmonization on the variability of PET radiomic features extracted using various segmentation methods. Ann Nucl Med. 2024;38:493-507.
Martin O, Schaarschmidt BM, Kirchner J, et al. PET/MRI versus PET/CT for whole-body staging: results from a single-center observational study on 1,003 sequential examinations. J Nucl Med. 2020;61:1131-1136.
Verhagen MV, Menezes LJ, Neriman D, et al. (18)F-FDG PET/MRI for staging and interim response assessment in pediatric and adolescent Hodgkin lymphoma: a prospective study with (18)F-FDG PET/CT as the reference standard. J Nucl Med. 2021;62:1524-1530.
Boellaard R, O’Doherty MJ, Weber WA, et al. FDG PET and PET/CT: EANM procedure guidelines for tumour PET imaging: version 1.0. Eur J Nucl Med Mol Imaging. 2010;37:181-200.
Dong X, Lei Y, Wang T, et al. Deep learning-based attenuation correction in the absence of structural information for whole-body positron emission tomography imaging. Phys Med Biol. 2020;65:055011.
Montgomery ME, Andersen FL, d’Este SH, et al. Attenuation correction of long axial field-of-view positron emission tomography using synthetic computed tomography derived from the emission data: application to low-count studies and multiple tracers. Diagnostics (Basel). 2023;13.
Montgomery ME, Andersen FL, Mathiasen R, Borgwardt L, Andersen KF, Ladefoged CN. CT-free attenuation correction in paediatric long axial field-of-view positron emission tomography using synthetic CT from emission data. Diagnostics. 2024;14:2788.
Albano D, Dondi F, Bertagna F, Treglia G. The role of [68Ga]Ga-Pentixafor PET/CT or PET/MRI in lymphoma: a systematic review. Cancers. 2022;14:3814.
Kosmala A, Duell J, Schneid S, et al. Chemokine receptor-targeted PET/CT provides superior diagnostic performance in newly diagnosed marginal zone lymphoma patients: a head-to-head comparison with [(18)F]FDG. Eur J Nucl Med Mol Imaging. 2024;51:749-755.
Mayerhoefer ME, Raderer M, Lamm W, et al. CXCR4 PET imaging of mantle cell lymphoma using [(68)Ga]Pentixafor: comparison with [(18)F]FDG-PET. Theranostics. 2021;11:567-578.
Quartuccio N, Nicolosi S, Pulizzi S, D’Oppido D, Ialuna S. The role of FAPI PET/CT in patients with lymphoma: a systematic review. Front Nucl Med. 2025;5:1589903.
Costantini DL, Vali R, McQuattie S, et al. A pilot study of 18F-FLT PET/CT in pediatric lymphoma. Int J Mol Imaging. 2016;2016:6045894.
Li J, Zhao M, Yuan L, Liu Y, Ma N. [Correlation and influencing factors of SUVmax and Ki-67 in non-Hodgkin lymphoma]. Zhongguo Shi Yan Xue Ye Xue Za Zhi. 2022;30:136-140.
