1. Le point sur les
critères modernes
d’évaluation en
cancérologie
An update on
modern criteria for
the evaluation of
tumour response
Yves Menu, Carmela Garcia Alba
Radiologie, Hôpital Saint Antoine, Paris/FRANCE

2. 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

3. mRECIST
RECIST
WHO
Choi
EASL
IRRC
Cheeson

4. How often are they used in
practice of oncologic imaging?
yes
No

5. Treatment Options
§ Systemic
cytotoxic chemotherapy
§ Targeted
therapies
§ Endovascular
therapy
§ Percutaneous
(or intraoperative) ablation

6. Treatment Options
§ Systemic
cytotoxic chemotherapy
§ Targeted
therapies
§ Endovascular
therapy
§ Percutaneous
(or intraoperative) ablation

7. 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

8. 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

9. Systemic Chemotherapy
§
Progressive Disease/ RECIST:
§
§
§
↑≥ 20% sum of diameters, as compared with NADIR
OR New Lesions
OR unequivocal progression of Non Targets
Target
↑ 60%
Non
Target
New
Lesions

10. NADIR
ž NADIR
: the smallest size of target
tumors obtained by the treatment
— NADIR is the reference for Progression
— NADIR is NOT necessarily the last
examination

11. NADIR
100
90
80
70
60
50
40
30
20
10
0
NADIR
PD (+33%)
Tumour Size
Baseline
TP 1
TP 2
TP 3
TP 4

12. NADIR
100
90
80
70
60
50
40
30
20
10
0
NADIR
PD (+25%)
SD (+15%)
SD (+15%)
SD (+15%)
Baseline
TP 1
TP 2
TP 3
TP 4
Tumour Size

13. Treatment Options
§ Systemic
cytotoxic chemotherapy
§ Targeted
therapies
§ Endovascular
therapy
§ Percutaneous
(or intraoperative) ablation

14. 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

15. 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

16. 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

17. Antiangiogenic treatment
Response: Attenuation (UH) ≥ 15%
No change in size
↓Attenuation
>50%

18. Antiangiogenic treatment
Recurrence: new enhancing nodule

19. mRECIST
ž Designed
for
HCC

20. mRECIST

21. Hypovascular
HCC
Courtesy
Filipe
Caseiro-­‐Alves

22. mRECIST: Partial response

23. Parameters
out
of
a
slope…
Signal
F
Ktrans
υe
υp
Delay

24. Blood
Volume
Permeability
Perfusion
Index
Time
to
Peak

25. Blood
Volume
Treatment
with
Sorafenib
12-­‐2008
01-­‐2009

26. Significance
of
changes
ž Significant
changes
if
variation
is
>
30-­‐50%
*
ž Mild
to
poor
agreement
between
softwares
(deconvolution
and
Patlak
analysis)**
ž Variation
according
to
the
volume
coverage
***
*
Marcus
et
al,
Crit
Rev
Oncol
Hematol
2008
**
Goh
et
al,
Radiology
2007
***
Ng
et
al,
Radiology
2006

27. Treatment Options
§ Systemic
cytotoxic chemotherapy
§ Targeted
therapies
§ Endovascular
therapy
§ Percutaneous
(or intraoperative) ablation

28. Endovascular therapy
§
(Traditional) Chemoembolisation: cTACE
§
DC Beads
§
Radio embolisation: RE Y90

29. cTACE
§
Combination of Doxorubicin and Lipiodol®:
§
LIPIODOL seen on CT as hyperattenuationg, and
hyperintense on T1 MRI

30. cTACE
§
MRI proved to be more accurate to evaluate tumour
response than CT
§
MRI protocol includes
§
§
DWI – ADC*
§
§
Fat Sat T2 FSE/TSE
Dynamic 4 phases
First evaluation at 1 month, and later every 3/4 months.
Retreatment possible according to initial results

31. cTACE
How would you rate the response in this case?
Pre treatement
Post treatement

32. cTACE
RECIST à SD

33. cTACE
mRECIST: PR

34. cTACE
Pre treatment CT
Lipiodol uptake, necrosis with haemorrhage. (↓ size)
No enhancement : CR?

35. cTACE

36. DC Beads
§
Calibrated particles (300–500 µm) filled with
Doxorubicin
§
Better tolerance than cTACE, possible in patients
classified as Child B8.
§
Complication : ischaemic cholangitis

37. Radio embolisation
§
90
Y
Developing indication, despite cost (12000€ +
procedures).
§
Available for multilocular HCC, including portal vein
invasion.
§
Delayed response

38. Radio embolisation
90
Y
Fibrosis of the liver related to radiation, atrophy
Not to be
confused
with local
recurrence

40. Sangro
et
al
J
Hepatol
2011

41. Treatment Options
§ Systemic
cytotoxic chemotherapy
§ Targeted
therapies
§ Endovascular
therapy
§ Percutaneous
(or intraoperative) ablation

42. 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?

43. 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

44. What are the « normal » changes?
Necrosis and haemorrhage
Peripheral enhancement

45. What are the « normal » changes?
Long term shrinking
1 month
6 months
1 year

46. Is there any recurrence?
Recurrence
1 year
3 years

47. Is there any recurrence?
Technically difficult RFA
Multiple accesses .
Seeding on needle tract

48. 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

49. Follow-up
ž 20
years
ago
— 80%
of
patients
for
CT
were
new
patients
ž Today
— 60%
of
patients
come
for
the
Follow-­‐Up
of
cancer…
ž 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.

51. Empathy
ž
ž
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.

52. Is cancer patient different?
Is the radiologist a member of the clinical team?