Is there a role for metabolic imaging in pediatric non-Hodgkin lymphoma?

Pediatric non-Hodgkin lymphoma (NHL) is an aggressive and heterogeneous malignancy with high rates of extranodal involvement. Accurate staging and response assessment are crucial, yet challenging. While [¹⁸F]FDG PET/CT is a cornerstone in adult NHL management, its role in pediatric cases remains under evaluation. A comprehensive review of the literature, international guidelines, and ongoing clinical trials was conducted, focusing on the diagnostic, prognostic, and therapeutic implications of [¹⁸F]FDG PET/CT in pediatric NHL. [¹⁸F]FDG PET/CT improves staging accuracy by detecting extranodal and bone marrow involvement more sensitively than conventional imaging. Its high negative predictive value supports its use in confirming complete metabolic response, potentially avoiding unnecessary biopsies. However, its positive predictive value is limited, cautioning against treatment escalation based solely on positive PET/CT results. Novel metabolic biomarkers such as metabolic tumor volume (MTV) and total lesion glycolysis (TLG) show promise for prognostic stratification but suffer from methodological variability and lack of standardization. Ongoing clinical trials aim to validate PET/CT's role in therapy response evaluation and optimize its clinical application. [¹⁸F]FDG PET/CT is a valuable imaging modality for pediatric NHL, particularly in FDG-avid subtypes. Despite promising results, broader clinical adoption requires standardized imaging protocols and prospective multicenter validation to establish robust diagnostic and prognostic utility.