Abdominal imaging t responses y menu

transcript

Yves Menu, Carmela Garcia Alba Radiologie, Hôpital Saint Antoine, Paris/FRANCE

Le point sur les critères modernes

d’évaluation en cancérologie An update on

modern criteria for the evaluation of tumour response

Introduction §  Choosing the right treatment is an

increasingly complicated issue §  From « one size fits all » §  To « personalized medicine » §  A change in paradigm

§  Imaging for evaluation has to adapt to this evolving concept

RECIST

mRECIST

EASL Choi

IRRC Cheeson

How often are they used in practice of oncologic imaging?

yes No

Treatment Options

§  Systemic cytotoxic chemotherapy

§  Targeted therapies

§  Endovascular therapy

§  Percutaneous (or intraoperative) ablation

Treatment Options

Cytotoxic : Only size matters §  RECIST: size and only size

§  Sum of largest diameters

§  Portal phase CT or MRI

§  The highest tumour/liver contrast ratio

§  Better to wait until 90 sec with modern machines,

otherwise the parenchymal enhancement will be

suboptimal

Systemic Chemotherapy

§  Criteria for response §  ↓≥ 30% of Sum of Diameters, as compared to BASELINE

§  No new lesion, no PD on nontarget lesions

Sum of diameters 86 mm à 48 mm ↓ 44 %

1 year later

Systemic Chemotherapy

§  Progressive Disease/ RECIST: §  ↑≥ 20% sum of diameters, as compared with NADIR §  OR New Lesions §  OR unequivocal progression of Non Targets

New Lesions

Target ↑ 60%

Non Target

� NADIR : the smallest size of target tumors obtained by the treatment �  NADIR is the reference for Progression �  NADIR is NOT necessarily the last

examination

0102030405060708090

Baseline TP 1 TP 2 TP 3 TP 4

Tumour Size

NADIR PD (+33%)

0102030405060708090

Baseline TP 1 TP 2 TP 3 TP 4

Tumour Size

NADIR PD (+25%)

SD (+15%) SD (+15%)

SD (+15%)

Treatment Options

Antiangiogenic treatment

§  Initially dedicated to specific tumours:

§  GIST: Gleevec®

§  HCC: Sorafenib and Sunitinib

§  Later extended to other tumours like lung

cancer and colon cancer

§  Favours ischemia, necrosis and apoptosis

à  RECIST non relevant for response

à  Replace tumour size with viability

à  Requires enhanced CT/MRI for evaluation with

a combination of arterial and portal phase

§  « Choi » criteria (GIST)

§  Portal Phase

§  Size decrease ≥ 10%

§  OR attenuation decrease by (UH) ≥ 15%

§  mRECIST

§  Arterial phase

§  Measurement « RECIST-like » of enhancing tumour

Antiangiogenic treatment Response: Attenuation (UH) ≥ 15%

No change in size

↓Attenuation>50%

Recurrence: new enhancing nodule

mRECIST � Designed for HCC

mRECIST

Hypovascular HCC

Courtesy Filipe Caseiro-‐Alves

mRECIST: Partial response

Parameters out of a slope…

Signal

F Ktrans

Blood Volume Perfusion Index

Permeability Time to Peak

12-‐2008 01-‐2009

Blood Volume Treatment with Sorafenib

Significance of changes

�  Significant changes if variation is > 30-‐50% * � Mild to poor agreement between softwares

(deconvolution and Patlak analysis)** �  Variation according to the volume coverage

* Marcus et al, Crit Rev Oncol Hematol 2008 ** Goh et al, Radiology 2007 *** Ng et al, Radiology 2006

Treatment Options

Endovascular therapy

§  (Traditional) Chemoembolisation: cTACE

§  DC Beads

§  Radio embolisation: RE Y90

cTACE §  Combination of Doxorubicin and Lipiodol®:

§  LIPIODOL seen on CT as hyperattenuationg, and

hyperintense on T1 MRI

cTACE §  MRI proved to be more accurate to evaluate tumour

response than CT

§  MRI protocol includes

§  Fat Sat T2 FSE/TSE

§  DWI – ADC*

§  Dynamic 4 phases

§  First evaluation at 1 month, and later every 3/4 months.

Retreatment possible according to initial results

cTACE How would you rate the response in this case?

Post treatement Pre treatement

RECIST à SD

mRECIST: PR

cTACE Pre treatment CT Lipiodol uptake, necrosis with haemorrhage. (↓ size)

No enhancement : CR?

DC Beads

§  Calibrated particles (300–500 µm) filled with

Doxorubicin

§  Better tolerance than cTACE, possible in patients

classified as Child B8.

§  Complication : ischaemic cholangitis

Radio embolisation Y90 §  Developing indication, despite cost (12000€ +

procedures).

§  Available for multilocular HCC, including portal vein

invasion.

§  Delayed response

Radio embolisation Y90

Fibrosis of the liver related to radiation, atrophy Not to be confused with local recurrence

Sangro et al J Hepatol 2011

Treatment Options

Ablation

§  No real criteria, mRECIST and RECIST not

applicable

§  Three questions to be answered

§  Did I « burn » the right place?

§  What are the « normal » changes?

§  Is there any recurrence?

Did I « burn » the right place? 1.  Same place

2.  Ablation area > Initial tumour Like a surgical « resection margin »

If not, high risk for recurrence

What are the « normal » changes? Necrosis and haemorrhage

Peripheral enhancement

What are the « normal » changes? Long term shrinking

1 month 6 months 1 year

Is there any recurrence? Recurrence

1 year

3 years

Is there any recurrence? Technically difficult RFA Multiple accesses .

Seeding on needle tract

Take Home Messages

§  Be familiar with RECIST, mRECIST and Choi’s

criteria

§  Using the criteria is a major step for quality

assessment in oncologic imaging

�  20 years ago �  80% of patients for CT were new patients

�  Today �  60% of patients come for the Follow-‐Up of cancer…

� A change in paradigm �  The radiologist becomes a clinical partner for the patient

�  The radiologist needs to be patient/disease-‐oriented and not organ/technique oriented.

Follow-up

Empathy �  Empathy scores are significantly correlated

with global ratings of clinical competence in medical school.

�  Empathy scores are not correlated with performance on objective examination of knowledge in both basic and clinical sciences.

Hojat, et al., 2002, Med Educ, 36, 522-527.

Is cancer patient different?

Is the radiologist a member of the clinical team?

Abdominal imaging t responses y menu

Health & Medicine