Information about monitoring after therapies for hcc by Dr Dhaval Mangukiya. Details of Monitoring after therapies for HCC, Staging, Management of Hepatocellluar Carcioma, Limitation, RECIST criteria, Assessment, Target lesion, Special recommendations etc. https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Monitoring after therapies for HCC
(RFA, TACE, TAE and TARE).
Dhaval Mangukiya
(Dept of Surgical Gastroenterology)

2. STAGING
• OKUDA
(Tumour size, Ascites, Albumin, Bilirubin)
• CLIP
(Child-Pugh stage, Tumour morphology, AFP,
Portal vein thrombosis)
• TNM
• BCLC (PST, Tumour status, Tumour stage,
Okuda stage, Liver function status)

3. Management of Hepatocellular
Carcinoma
• Most algorithms distinguish between
• Early HCC - Curative intent possible
• Intermediate-Advanced HCC - Curative
intent not possible, but not terminal
• Advanced/Terminal HCC - Palliative
options only

6. In the early 1980s
• World Health Organization (WHO) developed
recommendations in an attempt to
standardize criteria for response assessment,
• Adopted as the standard method for
evaluating tumor response
• Miller AB, Hoogstraten B, Staquet M, Winkler A. Reporting results of cancer
treatment. Cancer 1981;47:207–14.

7. Limitation
• Measuring in two dimensions and then
calculating their products and their sums is
laborious and has the risk of error
• Measuring methods and selection of target
lesions were not clearly described in the WHO
guidelines

8. • In 1998, new Response Evaluation Criteria in
Solid Tumors (RECIST) were proposed by the
RECIST working group
• Therasse P, Arbuck SG, Eisenhauer EA, Wanders J, Kaplan RS, Rubinstein L, et al. New
guidelines to evaluate the response to treatment in solid tumors. European
Organization for Research and Treatment of Cancer, National Cancer Institute of the
United States, National Cancer Institute of Canada. J Natl Cancer Inst 2000;92:205–16.

11. RECIST criteria
• Do not take into account changes in tumor
viability
– In patients with hepatocellular carcinoma (HCC),
the objective of all effective locoregional therapies
is to obtain necrosis of the tumor, regardless of
the shrinkage of the lesion.

12. European Association for the Study of
the Liver (EASL) , in 2000
• Estimating the reduction in viable tumor
volume (recognized as nonenhanced areas
using dynamic imaging techniques) should be
considered the optimal method for assessing
local response to treatment in patients with
HCC

14. • DEB TACE
• RFA/PEI
• Multiphasic study (nonenhanced, arterial, portal
and late venous phases) performed with a helical
CT scanner
• Tumor response was evaluated 1 month after
treatment in all patients and at 3 months after
the procedure
• Comparison: Tumor Response Evaluated by EASL
Guidelines and RECIST

15. RECIST evaluates
• Only unidimensional tumor measurements
and disregards the extent of necrosis, which is
the objective of all effective locoregional
therapies widely used for HCC, including
ablation and intra-arterial procedures like
chemoembolization.

16. • Use of combined size and necrosis criteria
might lead to a more accurate assessment of
response to Yttrium-90 radioembolization
than size criteria alone.
• Keppke AL, Salem R, Reddy D, et al. Imaging of hepatocellular carcinoma
after treatment with yttrium-90 microspheres. AJR Am J Roentgenol.
2007;188:768-775.

17. In summary
• RECIST has no value in the assessment of
tumor response after locoregional therapies in
patients with HCC

18. In 2008, American Association for the
Study of Liver Diseases (AASLD)
• Adapted the concept of viable tumor–tumoral
tissue showing uptake in arterial phase of
contrastenhanced radiologic imaging
techniques—to formally amend RECIST.

19. AASLD-JNCI
• (Journal of the National Cancer Institute)
guidelines
• Formal modification
• To translate the concept of viable tumor
mRECIST for HCC.

21. • Measurable (lesions that can be accurately
measured in at least one dimension as 1 cm
with a spiral CT scan)
or
• Nonmeasurable [all other lesions, including
small lesions (longest diameter <1 cm with
spiral CT scan) and truly nonmeasurable
lesions]

22. “Target lesion” using mRECIST
• RECIST measurable lesion (i.e., the lesion can
be accurately measured in at least one
dimension as 1 cm or more).
• The lesion is suitable for repeat measurement.
• The lesion shows intratumoral arterial
enhancement on contrast-enhanced CT or
MRI.

23. • Only well-delineated, arterially enhancing
lesions can be selected as target lesions for
mRECIST.
• Infiltrative-type HCC should be considered as a
“nontarget lesion” when the mass shows ill-
defined borders and therefore does not
appear to be suitable for accurate and repeat
measurements

24. • HCC lesions previously treated with
locoregional or systemic treatments may or
may not be considered as suitable to be
selected as target lesions for mRECIST:

25. Special recommendations
• Portal vein thrombosis
• Porta hepatis lymph node
• Pleural effusion and ascites

26. (A) Measurement of longest overall tumor diameter according to
conventional RECIST
(B) Measurement of longest viable tumor diameter according to
mRECIST for HCC.

28. Assessment of response in HCC
• should be based mRECIST (recommendation 2B)
• Use of changes in serum levels of biomarkers for assessment of response
(i.e. AFP levels) is under investigation
• Dynamic CT or MRI are recommended tools to assess response one month
after resection, locoregional or systemic therapies (recommendation 1A)
• Follow-up strategies for detection of recurrence include one imaging
technique every 3 months to complete at least two years.
• Afterwards, regular ultrasound is recommended every 6 months.
• Assessment of time to progression is recommended with CT and/or MRI
every 6-8 weeks
* (TTP- A measure of time after a disease is diagnosed (or treated) until the
disease starts to get worse.)

29. CR – completeresponse; PR – partial response; IR – incomplete response;
SD – stable disease; PD – progressive disease

31. • No conclusions regarding the value of FDG PET
for assessment of response to interventional
therapy
• Contrast-Enhanced Sonography for
Hepatocellular Carcinoma
• Byung Ihn Choi Jae Young Lee Joon Koo Han Jeong Min Lee Se Hyung Kim
• Department of Radiology, Institute of Radiation Medicine, Seoul National
University College of Medicine, and Clinical Research Institute, Seoul National
University Hospital, Seoul, Korea