Le point sur les
critères modernes
d’évaluation en
cancérologie
An update on
modern criteria for
the evaluation of
tumour ...
Introduction
§ 

Choosing the right treatment is an
increasingly complicated issue
§ 
§ 
§ 

§ 

From « one size fits...
mRECIST
RECIST

WHO

Choi
EASL

IRRC

Cheeson
How often are they used in
practice of oncologic imaging?

yes

No
Treatment Options
§  Systemic

cytotoxic chemotherapy

§  Targeted

therapies

§  Endovascular

therapy

§  Percutaneo...
Treatment Options
§  Systemic

cytotoxic chemotherapy

§  Targeted

therapies

§  Endovascular

therapy

§  Percutaneo...
Cytotoxic : Only size matters
§ 

RECIST: size and only size
§ 

§ 

Sum of largest diameters

Portal phase CT or MRI
§...
Systemic Chemotherapy
§ 

Criteria for response
§ 

↓≥ 30% of Sum of Diameters, as compared to BASELINE

§ 

No new les...
Systemic Chemotherapy
§ 

Progressive Disease/ RECIST:
§ 
§ 
§ 

↑≥ 20% sum of diameters, as compared with NADIR
OR Ne...
NADIR
ž  NADIR

: the smallest size of target
tumors obtained by the treatment
—  NADIR is the reference for Progression...
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
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
...
Treatment Options
§  Systemic

cytotoxic chemotherapy

§  Targeted

therapies

§  Endovascular

therapy

§  Percutaneo...
Antiangiogenic treatment
§ 

Initially dedicated to specific tumours:
§ 
§ 

§ 

GIST: Gleevec®
HCC: Sorafenib and Sun...
Antiangiogenic treatment
à 

RECIST non relevant for response

à 

Replace tumour size with viability

à 

Requires enh...
Antiangiogenic treatment
§ 

« Choi » criteria (GIST)
§ 

Portal Phase
§ 
§ 

§ 

Size decrease ≥ 10%
OR attenuation ...
Antiangiogenic treatment
Response: Attenuation (UH) ≥ 15%
No change in size

↓Attenuation
>50%
Antiangiogenic treatment
Recurrence: new enhancing nodule
mRECIST	
  	
  
	
  
ž  Designed	
  for	
  HCC	
  
mRECIST	
  
Hypovascular	
  HCC	
  

Courtesy	
  Filipe	
  Caseiro-­‐Alves	
  
mRECIST: Partial response
Parameters	
  out	
  	
  of	
  a	
  slope…	
  

Signal	
  

F	
  
Ktrans	
  

υe	
  

υp	
  
Delay	
  
Blood	
  Volume	
  

Permeability	
  

Perfusion	
  Index	
  

Time	
  to	
  Peak	
  
Blood	
  Volume	
  
Treatment	
  with	
  Sorafenib	
  

12-­‐2008	
  

01-­‐2009	
  
Significance	
  of	
  changes	
  
ž  Significant	
  changes	
  if	
  variation	
  is	
  >	
  30-­‐50%	
  *	
  
ž  Mild	
  ...
Treatment Options
§  Systemic

cytotoxic chemotherapy

§  Targeted

therapies

§  Endovascular

therapy

§  Percutaneo...
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 T...
cTACE
§ 

MRI proved to be more accurate to evaluate tumour
response than CT

§ 

MRI protocol includes
§ 
§ 

DWI – A...
cTACE
How would you rate the response in this case?

Pre treatement

Post 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 pat...
Radio embolisation
§ 

90
Y

Developing indication, despite cost (12000€ +
procedures).

§ 

Available for multilocular ...
Radio embolisation

90
Y

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

§  Percutaneo...
Ablation
§ 

No real criteria, mRECIST and RECIST not
applicable

§ 

Three questions to be answered
§ 

Did I « burn »...
Did I « burn » the right place?
1.  Same place
2.  Ablation area > Initial tumour
Like a surgical « resection margin »
If ...
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 ...
Follow-up

ž  20	
  years	
  ago	
  
—  80%	
  of	
  patients	
  for	
  CT	
  were	
  new	
  patients	
  
ž  Today	
  
...
Empathy	
  
ž 

ž 

Empathy scores are significantly correlated
with global ratings of clinical competence in
medical sc...
Is cancer patient different?
Is the radiologist a member of the clinical team?
Abdominal imaging t responses y menu
Abdominal imaging t responses y menu
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Abdominal imaging t responses y menu

  1. 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. 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. 3. mRECIST RECIST WHO Choi EASL IRRC Cheeson
  4. 4. How often are they used in practice of oncologic imaging? yes No
  5. 5. Treatment Options §  Systemic cytotoxic chemotherapy §  Targeted therapies §  Endovascular therapy §  Percutaneous (or intraoperative) ablation
  6. 6. Treatment Options §  Systemic cytotoxic chemotherapy §  Targeted therapies §  Endovascular therapy §  Percutaneous (or intraoperative) ablation
  7. 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. 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. 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. 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. 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. 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. 13. Treatment Options §  Systemic cytotoxic chemotherapy §  Targeted therapies §  Endovascular therapy §  Percutaneous (or intraoperative) ablation
  14. 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. 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. 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. 17. Antiangiogenic treatment Response: Attenuation (UH) ≥ 15% No change in size ↓Attenuation >50%
  18. 18. Antiangiogenic treatment Recurrence: new enhancing nodule
  19. 19. mRECIST       ž  Designed  for  HCC  
  20. 20. mRECIST  
  21. 21. Hypovascular  HCC   Courtesy  Filipe  Caseiro-­‐Alves  
  22. 22. mRECIST: Partial response
  23. 23. Parameters  out    of  a  slope…   Signal   F   Ktrans   υe   υp   Delay  
  24. 24. Blood  Volume   Permeability   Perfusion  Index   Time  to  Peak  
  25. 25. Blood  Volume   Treatment  with  Sorafenib   12-­‐2008   01-­‐2009  
  26. 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. 27. Treatment Options §  Systemic cytotoxic chemotherapy §  Targeted therapies §  Endovascular therapy §  Percutaneous (or intraoperative) ablation
  28. 28. Endovascular therapy §  (Traditional) Chemoembolisation: cTACE §  DC Beads §  Radio embolisation: RE Y90
  29. 29. cTACE §  Combination of Doxorubicin and Lipiodol®: §  LIPIODOL seen on CT as hyperattenuationg, and hyperintense on T1 MRI
  30. 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. 31. cTACE How would you rate the response in this case? Pre treatement Post treatement
  32. 32. cTACE RECIST à SD
  33. 33. cTACE mRECIST: PR
  34. 34. cTACE Pre treatment CT Lipiodol uptake, necrosis with haemorrhage. (↓ size) No enhancement : CR?
  35. 35. cTACE
  36. 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. 37. Radio embolisation §  90 Y Developing indication, despite cost (12000€ + procedures). §  Available for multilocular HCC, including portal vein invasion. §  Delayed response
  38. 38. Radio embolisation 90 Y Fibrosis of the liver related to radiation, atrophy Not to be confused with local recurrence
  39. 39. Sangro  et  al  J  Hepatol  2011  
  40. 40. Treatment Options §  Systemic cytotoxic chemotherapy §  Targeted therapies §  Endovascular therapy §  Percutaneous (or intraoperative) ablation
  41. 41. 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?
  42. 42. 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
  43. 43. What are the « normal » changes? Necrosis and haemorrhage Peripheral enhancement
  44. 44. What are the « normal » changes? Long term shrinking 1 month 6 months 1 year
  45. 45. Is there any recurrence? Recurrence 1 year 3 years
  46. 46. Is there any recurrence? Technically difficult RFA Multiple accesses . Seeding on needle tract
  47. 47. 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
  48. 48. 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.  
  49. 49. 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.
  50. 50. Is cancer patient different? Is the radiologist a member of the clinical team?
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