Deauville 5PS Deauville five-point FDG-PET scale for lymphoma

{
  "categories": [
    {
      "outcome_code": "1",
      "visual_definition": "no_abnormal_FDG_uptake_above_background"
    },
    {
      "outcome_code": "2",
      "visual_definition": "lesion_uptake_at_or_below_mediastinal_blood_pool"
    },
    {
      "outcome_code": "3",
      "visual_definition": "lesion_uptake_above_mediastinum_and_at_or_below_liver"
    },
    {
      "outcome_code": "4",
      "visual_definition": "lesion_uptake_moderately_above_liver"
    },
    {
      "outcome_code": "5",
      "visual_definition": "lesion_uptake_markedly_above_liver_or_new_site_consistent_with_lymphoma"
    }
  ],
  "applicability": {
    "intended_use": "Visual FDG-PET response assessment for FDG-avid lymphoma within a declared Lugano or protocol-specific framework.",
    "classification_units": [
      "one_lesion_at_one_timepoint",
      "patient_level_response_after_longitudinal_synthesis"
    ],
    "required_context": [
      "lymphoma_subtype_and_baseline_FDG_avidity",
      "baseline_or_nadir_comparator",
      "interim_or_end_of_treatment_timepoint",
      "treatment_and_scan_timing",
      "technical_comparability",
      "valid_mediastinal_and_liver_references",
      "all_lesions_and_new_sites"
    ],
    "outside_scope": [
      "non_FDG_avid_lymphoma_without_an_explicit_protocol",
      "generic_solid_tumor_response",
      "treatment_selection_from_score_alone",
      "standalone_histologic_diagnosis",
      "individual_outcome_probability"
    ]
  },
  "visual_scoring_protocol": {
    "comparison_order": "Compare each relevant focus first with mediastinal blood pool and then with normal liver uptake on the same examination.",
    "score_1": "No abnormal uptake attributable to lymphoma.",
    "score_2": "Uptake no greater than mediastinal blood pool.",
    "score_3": "Uptake greater than mediastinal blood pool but no greater than liver.",
    "score_4": "Uptake moderately greater than liver.",
    "score_5": "Uptake markedly greater than liver and/or one or more new FDG-avid sites whose pattern is consistent with lymphoma.",
    "X_qualifier": "Use X for a new focus considered unlikely to represent lymphoma. X is a descriptive qualifier, not a sixth ordinal score and not progression.",
    "highest_lesion_rule": "For patient-level reporting, identify the most metabolically active relevant lesion and preserve lesion-level heterogeneity; do not average scores."
  },
  "reference_region_and_quality_gate": {
    "mediastinum": "Use a reproducible mediastinal blood-pool reference that avoids focal disease and major artifact.",
    "liver": "Use normal liver parenchyma away from focal disease, artifact or abnormal diffuse uptake; record when liver uptake is unsuitable as a reference.",
    "comparability": "Review uptake time, administered activity, glucose, scanner/reconstruction, motion, attenuation correction and treatment interval before interpreting longitudinal change.",
    "confounders": [
      "infection_or_inflammation",
      "recent_surgery_or_radiotherapy",
      "growth_factor_or_marow_activation",
      "brown_fat_or_muscle_activity",
      "physiologic_or_excreted_tracer",
      "thymic_rebound",
      "second_malignancy"
    ],
    "indeterminate_behavior": "When reference regions or a new focus are unreliable, return an indeterminate or X-qualified interpretation with the reason instead of forcing a score or progression state."
  },
  "Lugano_response_synthesis": {
    "complete_metabolic_response_CMR": "Scores 1, 2 or 3 in nodal and extranodal sites, with or without a residual mass, constitute complete metabolic response under standard Lugano interpretation.",
    "partial_metabolic_response_PMR": "Score 4 or 5 with uptake reduced from baseline and no qualifying new progressive disease. At interim this represents responding disease; at end of treatment it represents residual metabolic disease.",
    "no_metabolic_response_NMR": "Score 4 or 5 with no significant change in uptake from baseline or nadir, after accounting for technical comparability.",
    "progressive_metabolic_disease_PMD": "Score 4 or 5 with increased intensity or extent from baseline or nadir and/or a new FDG-avid focus whose pattern is consistent with lymphoma.",
    "no_score_only_progression": "A score of 4 or 5 without longitudinal direction and new-lesion adjudication cannot by itself distinguish PMR, NMR and PMD."
  },
  "decisive_boundaries": {
    "score_2_to_3": "Uptake equal to mediastinum is 2; uptake above mediastinum but no greater than liver is 3.",
    "score_3_to_4": "Uptake equal to liver remains 3; uptake moderately above liver is 4.",
    "score_4_to_5": "Markedly above liver or a new lymphoma-consistent site supports 5. Preserve the qualitative basis rather than inventing a universal SUV threshold.",
    "score_5_new_site_versus_X": "A new focus consistent with lymphoma can support 5 and PMD; uptake unlikely to be lymphoma is X and requires its alternate explanation.",
    "interim_versus_end_of_treatment": "The same score 4 or 5 with decreased uptake means responding disease at interim but residual metabolic disease at end of treatment."
  },
  "protocol_and_version_boundaries": {
    "score_3": "Standard Lugano treats score 3 as CMR, but a trial designed for treatment de-escalation may predeclare a stricter positive cutoff. Name the protocol and never silently change the standard definition.",
    "proposed_2025_clarifications": "A proposed score-5 threshold based on at least twice maximum liver uptake and proposed 5a/5b subdivision remain revision proposals, not replacements for the current standard unless an adopted protocol explicitly says so.",
    "immunotherapy": "When an immunotherapy protocol invokes LYRIC or another immune-response framework, apply its indeterminate-response and confirmation rules separately rather than relabeling a Deauville score.",
    "RECIST_or_PERCIST": "RECIST and PERCIST use different measurement and synthesis rules; no numeric crosswalk to Deauville is valid."
  },
  "management_boundary": {
    "no_autonomous_change": "Do not continue, de-escalate, escalate, biopsy or stop treatment from the bare Deauville score alone.",
    "required_decision_context": [
      "histology_and_treatment_protocol",
      "interim_or_end_of_treatment_timepoint",
      "baseline_change_and_distribution",
      "clinical_status_and_laboratory_data",
      "technical_quality_and_confounders",
      "multidisciplinary_review"
    ],
    "discordant_or_new_focus": "When a new or discordant focus could be inflammatory, infectious or another malignancy, recommend targeted correlation, follow-up or tissue sampling according to whether the result would change care."
  },
  "risk_interpretation": {
    "qualitative_role": "The response state has cohort-level prognostic associations, but scores 1-5 are not calibrated malignancy probabilities or individualized progression-free-survival estimates.",
    "protocol_dependence": "Outcome meaning varies by lymphoma subtype, line of therapy, interim versus end-of-treatment timing, treatment adaptation and score cutoff.",
    "prohibited_inferences": [
      "score_1_or_2_guarantees_cure",
      "score_3_is_always_positive",
      "score_4_or_5_equals_progression",
      "score_5_proves_lymphoma_in_a_new_focus",
      "patient_specific_survival_percentage"
    ]
  },
  "agent_output_contract": [
    "Return lymphoma subtype, baseline avidity, treatment, protocol and response timepoint.",
    "Return technical comparability and validity of mediastinal and liver references.",
    "Return each decisive lesion, reference comparison, lesion score and new-site adjudication.",
    "Return the patient-level highest score and longitudinal Lugano state CMR, PMR, NMR or PMD with explicit reasoning.",
    "Separate the score, response state, protocol-specific positivity, treatment recommendation and prognosis."
  ],
  "missing_input_behavior": [
    "Without baseline or nadir comparison, return the current lesion score but withhold PMR, NMR or PMD synthesis when longitudinal direction is required.",
    "Without a valid liver or mediastinal reference, describe uptake and technical limitations rather than forcing the adjacent score.",
    "Without a declared timepoint, do not call decreased score 4 or 5 interim response versus end-of-treatment residual disease.",
    "For a new uncertain focus, use X or an indeterminate explanation and seek targeted correlation instead of automatic score 5 progression."
  ],
  "supporting_sources": [
    {
      "role": "original_scale",
      "citation": "Meignan et al. Leuk Lymphoma. 2009;50:1257-1260",
      "doi": "10.1080/10428190903040048"
    },
    {
      "role": "Lugano_standard",
      "citation": "Cheson et al. J Clin Oncol. 2014;32:3059-3068",
      "doi": "10.1200/JCO.2013.54.8800"
    },
    {
      "role": "operational_consensus",
      "citation": "Barrington et al. J Nucl Med. 2023;64:102-108",
      "doi": "10.2967/jnumed.122.264124",
      "pmcid": "PMC9902846"
    },
    {
      "role": "current_status",
      "citation": "Barrington et al. Hematol Oncol. 2025",
      "doi": "10.1002/hon.70103"
    }
  ],
  "source_locator": "Meignan et al. 2009, DOI 10.1080/10428190903040048, original scale; Cheson et al. 2014, DOI 10.1200/JCO.2013.54.8800, PET response table; Barrington et al. 2023, PMC9902846, PRoLoG technical application; Barrington et al. 2025, DOI 10.1002/hon.70103, current-standard and proposal boundary."
}