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
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
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
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
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
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
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.
50.
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?
