Thoracic Imaging 2003 - Society of Thoracic Radiology

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Reporting Tumor Measurements in Oncologic Imaging Todd R. Hazelton, M.D. Assistant Professor of Radiology and Oncology H. Lee Moffitt Cancer Center and Research Institute At the University of South Florida Objective: To review the role of the radiologist in reporting tumor measurements in thoracic oncology with emphasis on newer RECIST criteria and older WHO criteria. In addition to clinical, biochemical, surgical, and pathologic data, evaluation of tumor response by quantitative measurements on cross-sectional imaging provides objective information regarding chemotherapy efficacy that is used both clinically and in the development of new anticancer drugs. For these reasons, radiologists should be familiar with the standards for reporting tumor measurements that have been established and are widely used in oncology for clinical trials. WHO Criteria for Reporting Tumor Response: The older World Health Organization (WHO) tumor response assessment criteria were established to standardize the recording and reporting of tumor response outcomes. 1 This system utilizes bidimensional measurements as a quantitative component in the assessment of tumor response to chemotherapy drugs. Measurements are reported in centimeters (cm) as the maximum diameter and the greatest perpendicular diameter (at a right angle) in the same plane for primary and metastatic lesions whose margins are clearly defined on CT, MRI, or other imaging study. With this technique, typically up to three lesions per organ, whose diameters are greater than the image thickness, are selected as “measurable” and bidimensional measurement values are then reported. The same acquisition technique must be utilized for follow-up studies to ensure comparability of subsequent measurements. Nonmeasurable disease sites are primary or metastatic lesions which cannot be accurately measured in two dimensions as they are either measurable in only one dimension (unidimensional) or are unmeasurable. In the WHO criteria, the percentage of the decreased or increased tumor measurements is used to determine whether there is response or progression of disease, respectively. Progression of disease (PD) occurs if the surface area approximation (product of the longest diameter by greatest perpendicular diameter) for one or more measurable lesions increases by 25% or if one or more new lesions appear. A complete response (CR) is when all lesions disappear and are absent on two different observations that are no less than four weeks apart. A partial response (PR) is noted when the measurable lesions persist, but have decreased in size by 50% or more as measured on two different observations not less than four weeks apart. When measurable disease has not increased more than 25% in size nor decreased greater than 50% in size, the classification of “no change (NC)” is given. Both measurable disease and unmeasurable disease are used in the evaluation of the patient, with assessment of response involving all parameters. In measurable disease, the poorest response designation prevails in the final response classification. 1, 2 RECIST Criteria for Reporting Tumor Response: In contrast to the standard bidimensional WHO criteria for the radiologic assessment of response of solid tumors, which were developed prior to helical CT and other digital imaging techniques, new guidelines which utilize unidimensional measurements and modern imaging techniques have been widely adopted for clinical research protocols. A special report published in 2000 outlined the new “Response Evaluation Criteria in Solid Tumors (RECIST). 3 The primary changes with the newer criteria relate to the adoption of unidimensional tumor size measurement, better defining the cut-off point for progressive disease, and specifying clear-cut guidelines about minimum lesion size and the number of lesions to evaluate when multiple ones are present. With the RECIST criteria, only patients with measurable disease at baseline are included in protocols where objective tumor response is the primary end point. Measurable disease means the presence of at least one measurable, histologically confirmed lesion that can be accurately measured in at least one dimension of 2 cm or greater for conventional radiographic, CT, and MRI techniques and 1 cm or greater with helical CT techniques. Lesions smaller than these values, as well as bone lesions, leptomeningeal disease, ascites, pleural effusion, pericardial effusion, lymphangitic carcinomatosis, cystic lesions, and abdominal masses that are not confirmed and followed by imaging techniques are considered non-measurable lesions. The recommendations favor the use of MRI and helical CT given their reproducibility and ability to consistently display measurable target lesions. Lesions on chest radiography may be used as measurable disease if they are clearly defined and surrounded by aerated lung. Ultrasound (US) should not be used to measure target lesions for objective tumor response. With the RECIST criteria, it is important for the radiologist to properly select and document “target” and “non-target” lesions. For target lesions, representative measurable lesions up to a maximum of five per organ and ten in total should be identified and recorded at baseline. These lesions should be selected with regard to their size, with longer diameter lesions favored, as well as lesions which are suitable for accurate, repeated measurements on imaging follow-up. All other lesions or sites of disease should be identified as non-target lesions and should also be recorded at baseline. These lesions are not measured, but the presence or absence of each should be reported on all follow-up examinations. Response criteria with RECIST for target lesions includes complete response (CR) with the disappearance of all lesions, partial response (PR) with at least a 30% decrease in the sum total of the longest diameters of the target lesions compared to baseline, progressive disease (PD) with the appearance of new lesions or at least a 20% increase in the sum total of the longest diameters of the target lesions compared to the smallest sum total of longest diameters since treatment started, and stable disease (SD) where there is neither significant tumor shrinkage nor growth to qualify as PR or PD, respectively. 3 Applications in Thoracic Oncology: While new protocols will typically utilize the RECIST criteria to assess solid tumor response to drug therapy, some older protocols may still be active which used the older WHO criteria. 219 WEDNESDAY
WEDNESDAY 220 Therefore, radiologists should be familiar with both criteria and their role in oncologic imaging. A meta-analysis of the data in eight studies of different solid tumors where the two different criteria were separately applied and reanalyzed demonstrated generally good correlation in that unidimensional measurement of maximal tumor diameter was felt to be sufficient to assess significant change in tumor size. 4 Similar results have been obtained in studies of lung cancer response where the unidimensional and bidimensional criteria were compared. 5,6 In these studies, there was generally good correlation between the final assessments, with a small number of differences noted in the some response categories. Interestingly, in the study by Werner- Wasik et al., which also included comparison with tumor volume, the validity of the RECIST criteria were confirmed and volume did not appear to represent a significantly superior method for evaluating tumor response. REFERENCES : 1. Who handbook for reporting results of cancer treatment. Geneva (Switzerland): World Health Organization Offset Publication No. 48.; 1979. 2. General forms and guidelines. In: Southwest Oncology Group Clinical Research Associate Manual. Vol. II; 2002. 3. Therasse P, et al. New guidelines to evaluate the response to treatment in solid tumors. J Natl Cancer Inst; 92(3): 205-216. 4. Eisenhauer JK, et al. Measuring response in solid tumors: unidimensional versus bidimensional measurement. J Natl Cancer Inst 1999;91(6):523-528. 5. Cortes J, et al. Comparison of unidimensional and bidimensional measurements in metastatic non-small cell lung cancer. Br J Cancer 2002;87:158-160. 6. Werner-Wasik M, et al. Assessment of lung cancer response after nonoperative therapy: tumor diameter, bidimensional product, and volume. A serial CT scan-based study. Int J Radiat Oncol Biol Phys 2001;51:56-61.
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The Society of Thoracic Radiology T
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Dear Friends, Welcome to Miami Beac
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Continuing Medical Education Credit
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Warren B. Gefter, MD University of
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Ernest M. Scalzetti, MD SUNY Upstat
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Registration Hours Saturday, March
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Program Committee Ella A. Kazerooni
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Small Airway Disease Americana 3 Mo
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Benjamin Felson Memorial Lecture Am
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Session 2-B Concurrent Session Clin
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Workshops (choose 1) 1:00 - 1:45 D1
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Sunday
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March 2, 2003 General Session Sunda
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SUNDAY 46 One type of direct-readou
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CT-PET Imaging Suzanne Aquino, M.D.
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SUNDAY 58 an accompanying decreased
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SUNDAY 60 Radiofrequency Ablation i
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SUNDAY 62 17. Sewell PE, Vance RB.
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SUNDAY 64 cal ventilation will be r
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SUNDAY 66 radiologic, and histopath
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SUNDAY 68 application. The untreate
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SUNDAY 70 The Expanded Spectrum of
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SUNDAY 72 Hypersensitivity Pneumoni
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SUNDAY 74 Small Airway Diseases Mic
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SUNDAY 76 The “Head-cheese Sign
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SUNDAY 78 “Holes” in the Lung:
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SUNDAY 80 Pleural Effusions Gerald
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SUNDAY 82 Asbestos Related Pleural
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SUNDAY 84 Other Pleural Neoplasms S
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SUNDAY 86 Image-Guided Therapy of M
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Notes 88
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March 3, 2003 General Session 7:00
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Cardiac MRI: Established Indication
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Cardiac MRI: New Developments Gauth
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5. The volume of contrast medium re
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Acute Aortic Syndrome Ernest M. Sca
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as well as separation of the cusps
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Pulmonary Veins: Imaging for Radiof
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Imaging of Cardiopulmonary Support
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plied to the hollow fibers by an ex
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swelling of the entire leg, calf sw
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Multi-channel Pulmonary CTA: New Te
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terminate scintigrams, CT correctly
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CT Strucural and Functional Imaging
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curves (TDCs) are generated by manu
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7. Crawford T, Yoon C, Wolfson K, e
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80. Fleischmann D, Rubin GD, Bankie
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127 MONDAY
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129 MONDAY
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REFERENCES Bergin CJ, Rios G, King
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Notes 134
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March 4, 2003 General Session 7:00
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Adult Manifestations of Congenital
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will usually display the limbs of t
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Imaging of the Pericardium Paul L.
Page 111 and 112: Cardiomyopathy Martin J. Lipton, M.
Page 113 and 114: TUESDAY 150 Nuclear Cardiology Upda
Page 115 and 116: TUESDAY 152 ties. The predominant 1
Page 117 and 118: TUESDAY 154 Imaging protocols: Util
Page 119 and 120: Manpower Shortage in Radiology: Sol
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Page 127 and 128: NIBIB Update for Thoracic Radiology
Page 129 and 130: vertically along the right atrium t
Page 131 and 132: Multidetector Pediatric Chest CT: P
Page 133 and 134: The Spectrum of Pulmonary Infection
Page 135 and 136: Immune deficiency occurs frequently
Page 137 and 138: TUESDAY 180 The Internet and the Pr
Page 139 and 140: TUESDAY 182 Workshop A1: Lymphoma:
Page 141 and 142: TUESDAY 184 Digital Images: Camera
Page 143 and 144: TUESDAY 186 Analysis of Mediastinal
Page 145 and 146: Unusual Manifestations of Lung Canc
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Page 149 and 150: March 5, 2003 General Session Wedne
Page 151 and 152: WEDNESDAY 208 principle is that “
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Page 155 and 156: WEDNESDAY 212 lesions generally mim
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Page 159 and 160: WEDNESDAY 216 Small T1 Lung Cancer:
Page 161: WEDNESDAY 218 REFERENCES Seely JM,
Page 165 and 166: WEDNESDAY 222 sectional area varies
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Page 169 and 170: Metastatic Disease to Lung Gordon L
Page 171 and 172: Thoracic Metastates from Osteosarco
Page 173 and 174: STR tutorial: Use of MD CT reconstr
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Page 177 and 178: WEDNESDAY 236 Pulmonary Arterial Hy
Page 179 and 180: WEDNESDAY 238 pathological process,
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Page 183 and 184: THURSDAY 250 Pulmonary Tuberculosis
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Page 191 and 192: THURSDAY 258 Imaging of Coccidioido
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Page 195 and 196: THURSDAY 262 Inflammatory Diseases
Page 197 and 198: Virtual Endoscopy in the Thorax: Pr
Page 199 and 200: Notes 269 THURSDAY
Page 201: SECOND LEVEL THIRD LEVEL
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