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

WHO

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

§  Systemic cytotoxic chemotherapy

§  Targeted therapies

§  Endovascular therapy

§  Percutaneous (or intraoperative) ablation

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

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

examination

NADIR

0102030405060708090

100

Baseline TP 1 TP 2 TP 3 TP 4

Tumour Size

NADIR PD (+33%)

NADIR

0102030405060708090

100

Baseline TP 1 TP 2 TP 3 TP 4

Tumour Size

NADIR PD (+25%)

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

SD (+15%)

Treatment Options

§  Systemic cytotoxic chemotherapy

§  Targeted therapies

§  Endovascular therapy

§  Percutaneous (or intraoperative) ablation

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

Antiangiogenic treatment

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

Antiangiogenic treatment

§  « 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%

Antiangiogenic treatment

Recurrence: new enhancing nodule

mRECIST      � Designed  for  HCC  

mRECIST  

Hypovascular  HCC  

Courtesy  Filipe  Caseiro-­‐Alves  

mRECIST: Partial response

Parameters  out    of  a  slope…  

Delay  

Signal  

υp  

F  Ktrans  

υe  

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

§  Systemic cytotoxic chemotherapy

§  Targeted therapies

§  Endovascular therapy

§  Percutaneous (or intraoperative) ablation

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

cTACE

RECIST à SD

cTACE

mRECIST: PR

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

No enhancement : CR?

cTACE

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

§  Systemic cytotoxic chemotherapy

§  Targeted therapies

§  Endovascular therapy

§  Percutaneous (or intraoperative) ablation

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?