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Abdominal imaging t responses y menu
 

Abdominal imaging t responses y menu

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    Abdominal imaging t responses y menu Abdominal imaging t responses y menu Presentation Transcript

    • 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
    • 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
    • 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 §  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 Target ↑ 60% Non Target New Lesions
    • 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
    • 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 Tumour Size
    • 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       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  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    
    • 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 §  §  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
    • 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 patients classified as Child B8. §  Complication : ischaemic cholangitis
    • Radio embolisation §  90 Y Developing indication, despite cost (12000€ + procedures). §  Available for multilocular HCC, including portal vein invasion. §  Delayed response
    • 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 §  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
    • 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.  
    • 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.
    • Is cancer patient different? Is the radiologist a member of the clinical team?