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Response Assessment in Oncology

Oct 13 | 2:00 PM

KREST, Kochi in association with IRIA, Kottayam has planned an amazing session on ‘Response Assessment in Oncology’ with Dr.Pankaj Sharma. The role of imaging in the clinical setting as well as in the drug development process is expanding rapidly. Imaging technology now exists that is capable of detecting tumor response within hours. In parallel with this advance, a new array of more targeted and specific therapies are being developed. This paradigm shift in turn demands a more sophisticated way of quantifying response. There is a need to update and modify the current response evaluation criteria in solid tumors. Response assessment by imaging is now intimately involved with all stages of the drug development process, from exploratory drug discovery through clinical trials, as well as in clinical use. Join us and gain some thought provoking insights!

[Music] good evening everyone [Music] this evening we are back with another turf expansion program on onko imaging by crest kochi and cortain city chapter of kerala iria we have dr chandra shekaran keshavadas professor at the sri chitra tirunal institute for medical sciences tiruvantapura sir is the national ira academy coordinator and kerala ira central council member and the candidate for igri editor post he is a great academician and a very great person for the post i invite professor keshav for the opening remarks over to you sir thank you very much judy for those nice words and thank you dr sharma uh it is indeed a pleasure that you are our eminent speaker today for the crest program which is being conducted along with um ira cotton the kota mct branch so uh actually pankaj does not need much introduction to a radiology community he has been giving several lectures especially in onco radiology he is an expert in this particular field the onco radiology and presently he is working as a associate professor of radiology at the prestigious or india institute of medical sciences in rishikesh he is going to speak on a very important topic that is response assessment in oncology so there is a big role that radiologists play in the management of these patients with oncological diseases we are looking at biomarkers which could be mri biomarkers ct biomarkers pet biomarkers and then there are a lot of new now tools which are coming up by which we can actually assess how the patient is progressing on your treatment whether it is radiation treatment surgery post surgery or chemotherapy whether the patient is responding quite well and how will be the prognosis of the patient all these with the availability of radio mix and all these newer techniques in molecular imaging actually there is a huge amount of change in the way things are happening today with precision medicine coming up i am very sure that this field is really going to take off and radiologists will have a lot of things to contribute especially onco radiologists those who are actually doing day-to-day work in cancer hospitals will have a lot to contribute in this particular field with these words i call upon dr pankaj sharma i'm sure what he is going to teach will be extremely useful uh for all of us over to you dr pankaj i think judy will introduce you before that dr judy yes sir thank you sir topic this evening is the response assessment in oncology by dr pankaj sharma so that is the associate professor in radiology at ames rishikesh has undergone post-doctoral fellowship in gastroenterology from sgpgi lucknow he is the present national ira treasurer and is the national vice president candidate so has been awarded the president appreciation award at iria 2019 and the academic excellence award from delhi iria i invite dr pankaj sharma for his talk in the response in oncology to interact with all the kerala friends and press coacheed team thank you for next 45 or 50 minutes i will be talking about response assessment in oncology cancer treatment needs to be monitored and we have to decide whether to continue change or abundant treatment based on risk cost and there has to be a common language to report the results of cancer treatment especially for drug trans in phase 2 or phase 3. over or overall survival is the gold standard that shows that treatment benefit in oncology however it is limitation it's a very late response which we are seeing so for clinical trials we require other response criteria that is humor objective response rate why because it is important to report the results of clinical trials and for clinical decision making in routine practice and for these uh the criteria which were first introduced were anatomic response criteria developed mainly for cytotoxic chemotherapy that is wh o criteria and resist criteria when we talk about the who criteria then who criteria was first published in 1979 and uh thereafter miller all over all in 1981 to confirm the overall response rate and these wh of criteria was used until 2000 and uh in which a criteria we take bi-dimensional measurement we take the longest diameter in whatever oblique plane it is and are perpendicular to it like the image you can see the longest diameter is a and the perpendicular two is b so according to who criteria the the measurement which will be doing for this mass or module will be a into b and it's the multiplication of longest diameter by the greatest perpendicular diameter when we talk about the total tumor load of a patient then its sum of products of perpendicular diameter for multiple lesions but see what is the limitation limitation is it's a very time consuming procedure and carries the risk of measurement errors then if we talk about resist criteria then in a resist we take only unit dimensional measurement the longest diameter this is resist and we if you are talk about resist 1.0 then in resist we we talk about target and non-target legions target leeches are selected based on their size and they are represented to lesions of all involved organs and should be measured by repeated measurement so maximum of five lesions per organ are measured in resist 1.0 and maximum of 10 lesions in total are measured and all other lesions are non-target lesions so this is the difference between wh criteria and resist who we measure longest and uh multiply it by the perpendicular uh diameter and resist we take only the longest diameter then what is the non uh measurement we take our dimensions as 10 mm for any lesion except what are non-miserable lesions non-measurable lesions are lesions that we can cannot be truly measured and these include brain lesions bone lesions lepton mental disease ascites pleural diffusion pericardial diffusion inflammatory breast disease cystic lesions or disease documented by indirect evidence only lab values like in this image plural efficient which is a non-measurable issue if we talk about resist model version 1.1 then what are the changes done first and foremost changes maximum number of target lesions per organ were reduced in uh resist one point one from five to two so maximum two lesions per organ are measured and this is one point one second difference is maximum the number of lesions in the entire body reduced from 10 to 5 third most important difference is lymph node in resistance 1.0 lymph nodes were not measured however increases 1.1 lymph nodes are measured with and here you have to measure short axis diameter if the short axis diameter is more than 15 mm then it's a measurable lymph node and it's a pathological and accessible as target engine however if the short axis diameter of lymph node is between 10 to 15 mm then it is included as a non-measurable non-target lesion and if the lymph node short axis diameter is less than 10 mm then it's considered a normal link so objective response rate in resist one point one is the result of combination of pure tumor response in target and non-target teachers and if there is any new lesion then the objective response is always progressive disease so this is how we measure criteria for target lesions if it's a tumor in ct scan long exit dimension emitter should be more than 10 mm if it's a chest x-ray long axis diameter should be more than 20 mm and here you measure the longest diameter however in lymph node you measure short axis diameter and you take it as target if the short x diameter is more than 15 mm and selection of legions choose one to five target lesions equally distributed or affected when maximum of two per organs preferably choose the largest lesions and preferably choose well described regions that are easy to measure then how to measure lymph node correctly as you can see the correct method is you take the maximum diameter and perpendicular to that you take the lymph node short axis diameter so it should not be oblique and if it's if it's a like in second image if it's if it's a lymph node where you have different dimensions then you should measure like this uh the maximum short axis diameter and not in the midline and not on the side so the this is the how we should measure correctly lymph node then uh difference between who resistant 1.1 i've already told who you may measure by dimensional diameter and uh in resist 1.1 you 1.0 you measure the the unidimensional measurement our maximum lesions your target lesions you take is as 10 in total whereas resist 1.1 you measure 5 in total and lymph node short axis diameter you measure in raises 1.1 then what are the target measurement rules for splitting lesions if a conflict leach splits to form discrete lesions then the longest diameter of each lesion will be measured and added to the short sum of longest diameter and the child dishes will be labeled with the letter next to parent number like in here if there are this lesion spread then you you we have to measure all the the long axis diameter in split ledges and is the sum of the lesions which we will take in for seeing the response uh another case where uh there are multiple target legions here you take the longest diameter of each legion separately and add the diameters it's the sum of longest diameter in this image or this is imaging of 82 year old woman with colon cancer metastasizing to liver sorry and we have two images where it is showing how to measure on the left side we are measuring the the the legion which is splitting in the in a single dimension this is not the correct way if there are two lesions which are merging with each other then we have to take longest diameter of each lesion and add the these diameters to consider the response what are the rules for lesions that merge if a lesion becomes confluent the longest diameter of the resulting lesion will be calculated and recorded under one of the original target lesions 0 mm will be entered for the other target lesion like in this case uh this is actually image in atr woman showing multiple apatic metastases from colorectal and the two legions in segment four appeared to be separate and baseline examination but were collisioned at the follow-up regulation so the when the the lesions are separate then uh the longest diameter of each third legion it was measured and sum of total of this diameters was calculated how when the lesions have merged together then we have to take the the longest diameter of the mud lesion to see the response rate then assessment of lymph node as i have told on the left side there is a target region so this is complete response for this case then what about the legions with enhancing ring in lesions with enhancing cream we have to include the rim in measurement for basis measurement what to do if the target lesions are follow up are seen and these lesions are too small to measure if the target lesion is still visible but less than 5 mm it should be assigned a default measurement of iron so the resist 1.1 is very clear if the lesions are less than 5 mm then as a default we have to assign it as a measurement of 5 mm then correct sequence store to be selected for for lesion is very important if the uh like in this case there are different phases so this lesion should be measured either in photovenus phase where you can see the correct dimensions of the lesion what about uh if the if the lesion is seen involving lung pancreas then correct windowing is important see if you have if you are making the lesion in a mediastinal window what will happen is you will only measure the solid component of the nodule but you will not be able to uh your measure the adjoining sub solid component or the alveolar precipitation so always always size of salty permanent module should be measured on lung window otherwise you will measure if the nodule dimension is wrong then what are if a sub solid uh in this case there is a sub solid lesion that is increase in size which indicates an increase of malignancy in this so along with the dimension we have to also see the solid components now which is uh how we measure these days and most important concept is the concept of change to be considered from nadir not from baseline c the this legion at baseline the maximum dimension is 40 at fall of one the maximum dimension is 20 and fallout 2 it is 25 and at fall of 3 it is 30 so if we compare fall of 2 with the baseline then percentage percentages is minus 37 but this is not correct we are amazing we have to measure from nadine means the shortest diameter which is in this case was 20 so if you measure follow up two to eight comparison with follow up one that percentage change in the is plus 20 percent however if we consider we may compare follow up two with baseline then percentage changes minus 40 percent so if if it's if it's a uh you measure with the baseline then you will honestly at fault two say that it's it's a it's a response is there partial response is there however actually it's a progressive disease if we compare it from nadi so concept of nadir is very important and partial response uh and progressive disease should be told not based on the baseline but comparison to nadine like in this case see what what can happen in some sometimes is on response to treatment the nodule or mass can temporarily reduce in size in between and then again go so what what we are going to do here here in this case what happens is more in most lung cancers grow at a steady state and there is temporary regression and growth can occur it is postulated that a transient decrease in size may be related to development of fibrous component or collapse of fibers accordingly a decrease in size requires continued imaging reassessment to confirm long-stay stability or resolution so here if we compare with the nadine then the it it is in uh there is a somewhat uh increase however it compared with baseline then there is no change so what are the limitations of resist 1.1 first is like in this case if it's a cystic lesion [Music] according to resist if we measure only the maximum dimension then there is no change but actually what what is happening here is uh the system ball there is increased thickness there is modularity so in these cases resist 1.1 will not be ideal to measure and we should be uh putting a suspicion for lung cancer in this case with increased thickness and increased nodularity see another case here what is happening is if you see the maximum dimension it is not much in how the solid component is uh there is so much increase in solid component of this uh lesion so it's a high risk for melanche and this will be the limitation of resist 1.1 so similarly third case c here here the treatment has been done the embolization has been done for this this lesion when we compare pre-embolization with o symbolization image the change in size is not much our seed enhancing component is so much reduced in co-symbolization and if we use resist criteria then this criteria will not work in this case similarly another case here ablation has been done for uh renal uh lesion and if we compare with pre-ablation and post ablation then enhancement is so much reduced in post application uh renal lesion however the change in size is not much so resist 1.1 will not be efficient we have a seeing response in this case another case here there is a nodule where rf has been done for this lesion so if we go by resist criteria then then it will be increa then it will be failed response and progressive disease how what is actually happening is there is surrounding ground lasting there is uh well described rim of consolidation and this patient has effectively be treated with rf so resist 1.1 will not be working so different criteria have been introduced for seeing the response rate for different tumors like for hepatocellular carcinoma m resist has been ur has been introduced for hcc and this is uh developed based on a new concept of viable human what do you mean by viable tumor viable tumor is defined as a showing inter tumor rtl enhancement by contrast agent during dynamic situ or mrna so major tumor enhancement is a surrogate marker of a viable tumor and complete response is the disappearance of any intra-tumor arterial enhancement in our target legion and progressive diseases increase of at least 20 percent in sum of diameters of viable type religions and when we talk about overall response rate its combined assessment of target legions not target legends and new legions so the different criteria has been introduced for a hcc first introduced was esl criteria where we include a two dimensional measurement and we consider the enhanced tumor area like embraces then the three-dimensional volumetric assessment using quantitative esl has also been introduced and quantitative eesl predicts survival better than resist and resist an esl criteria in patient with hcc so see here if this is hcc and we are seeing treatment response after test if we are using resist then we will what we'll do is we will measure the maximum dimension however when we use embraces we will be missing the diameter of the enhancing component only so see how how much difference the there is if you measure using a resistance because the end resist what you are actually seeing is the viable component not the necrotic component another case where if you if you see the pre and post response so so on the left side it's a complete announcement and on the right side it is uh no enhancing component so it's if we compare come up here using uh resist criteria then it will be partial response however actually when we use criteria and we we look for viable tumor then it's a complete response so the this viable tumor concept is very important and all all to all tumors cannot be evaluated well by resist and resist it has its own complications its own limitations see this this is uh what do i mean by saying if we use different criteria see the topmost number one the t is the viable component so if if if we use the resist criteria then we we will be saying that the we will facing the maximum dimension however if you use m resist we will be amazing only the maximum dimension of the viable tumor similarly for uh who and esl criteria who we will be basing the the maximum two diamond bi-dimensional measurement whereas esl we use bi-dimensional measurement only of the viability so white component only we are amazing and we if we talk about the three dimensional measurement then uh volumetric resist we measure the entire tumor however in quantity esl we measure total volume of the enhancing component only so uh quantitative esa wl uh esl is the best response uh prior to criteria to be used as compared to esl and embraces cardio and hcc see another case here what is happening is ct and dsm is pre and post above is the ct and dsm prior to this and below is the image after this so after this what we are seeing is this uh the p is a contrast image and the post ct image is a non-contrast what is happening is there is lipidal deposition in the liver tumor and when we have to assess response we have to use contrast synthesis image and we have to look for a viable tumor the enhancing component and in many cases ct may be not the best mode modality and mri will help like see in this case above there is arterial delays with ct so artillery arterial phase delay we are not able to properly see the enhancing component whereas when we see the c image it's a t2 weighted image and when we go to d image there is enhancing t1 weighted image where you are still very well seen the enhancing viable component and e is the subtracted image and uh f is nice t1 weighted image in daily phase so see uh seeing viable tumor after trait treatment in hcc mrvalu is a better modality to use as compared to ct because ct due to report all the depositions the ultrasound is also a modality which is uh being used these days very frequently by intervention radiologist to see the viable components so in as compared to city catastrophes mri and contrast ns ultrasound will be better to use so the this slide is showing the uh how we can predict and as you can see quantitative esl is a 3d criteria and at least 70 percent three percent increase in enhanced tumor volume should be they are there to say it has progressive disease whereas if you look after the esl which is 2d criteria there should be only at least 25 percent increase in a product of maximum diameter and perpendicular of an s so we will label a lesion as a progressive disease uh at less big increase in size uh dimensions in esl and as compared to quantitative esl which is 3d criteria so quantitative esl is a better criteria to use as compared to m resist and and esl then how to use look after response assessment for mesothelioma the ambassador for mesothelioma what we do is we measure the tumor thickness perpendicular to the fixed structure such as the chest wall or vertebral column in two position on same transverse current so you you don't measure the maximum dimension how you measure maximum or thickness at two positions at six structures such as chest one or multiple column and sum of two by seventy excel section 6 measurements are defined as a plural unit dimensional measure so this is how you measure for mesothelioma then what about the digest and just what you are you do is you use uh treatment like emitting name missile and here what the criteria you use is cha choi criteria in soi criteria you look after two things either there should be a ten 10 decrease in the tumor size or there should be 15 percent decrease in density on contrast and density to say it is a response so response you see look after two criteria first is either there is 10 percent decrease in tumor size or there is 15 percent decrease in density on contrast and acidity uh for looking response of ingest after giving emitting a missile and this has been found to be reproducible more sensitive and more precise than resist criteria and correlate it significantly with time to tumor cognition and disease specific survival then what about response rate when we use antivascular endothelial growth factors monoclonal antibodies bodies like becoming this or an anti-epidermal growth factor receptor see this case here is ct of the abdomen showing liver metastasis at time of diagnosis and second is ct of the abdomen showing decrease in liver liver lesions after six cycles of fall fox and becomes and third is ct scan of the abdomen uh showing further decrease in metastatic lesions after six more cycles of pembroke however what can happen sometimes there can be pseudo response like in this case what has happened is on the left is the hlt1 contrast mri of the left frontal recurrent climate before and one day after therapy of acidity ramp which is pan eg vgfr inhibitor and within 24 hours of giving this uh treatment there was signals a significant reduction in contrast enhancement as you can see on right image so it's not a true response reduction in contrast enhancement within one day of therapy is more likely to be caused by reduced vascular permeability to contrast then to a true anti-tumor effect so this is a pseudo response which we can see are after uh using therapy which which are anti-vascular endothelial growth sector targeted monoclonal antibody or anti-epidermal or growth factor receptor antibody like suitable swelling or because we come in the experiment so size this radiological amino methods may not differentiate between tumor or and the fibroid tissue due to effective biology therapy and recently new criteria morphological response based criteria have been used on based on morphology changes but defined in patients with colorectal cancer liver metastasis undergoing chemotherapy with or without becoming there and they are here we divided into three group of visions group one is homogeneous tissues with shabbat group two is intermediate with stallion and group is heterogeneous structure will fully define h so nishaka it all uh said that uh ct morphology british tumor viability and long-term surgical outcomes after chemotherapy patients with corollactal cancer liver metastasis and inter-tumor heterogeneity in the primary tumor and is vasculated angiogenic or non-angiogenic as well related lymphatic and hepatic metastasis may also result in different response to cancer like see the image a is the image before treatment b is after treatment where you have seen signified reduction in size and uh you can see some uh calcification in the lesion and the c is the response after the the complete treatment and surgery what about immunotherapy the response evaluation in mnth admin is totally different and most important factor in uh responsibility in a mother therapist any new legions we do not automatically put it as as progressive disease which i will be briefing as i have covered so immune checkpoint inhibitors like ebola which is anticipate monoclonal antibody or new layer map or pendulum or etching map are active immuno oncologists and initial uh immunological progression by resist and subsequent delay too much shrinkage this is a known response in immunotherapy and this phenomenon is termed as pseudo progression so the pseudo progression is a uh expected response in immunotherapy and during pseudo progression biopsy demonstrate inflammatory cell infiltrate edema accuracy so what happens is uh see there this case uh what this image is showing in the top most if you do use a tumor immunotherapy what can happen is a response is first uh there may be increase in glass if there will be decrease in the size there may be in the along with decreased size there will decrease in lymphocyte and there can be few few of the cancer side second response it can be progression what will happen progression is there will be increase in cancer cells there may be few lymphocytes and uh there will be increase in size however in logic response criteria what will happen increase in lymphocyte but very much decrease in cancer cell so this this is a good response how when we use resist criteria then the resist will be saying that we don't have uh much response and uh pseudo progression is an expected response in immunotherapy look into this case above is uh a city image of the heart and its chest and below is the c patient uh in liver so if we come uh c 2 a 2 b and a 2 a 2 c and 2 e what we will find is above images the the sizes increase in the middle row and then it has again decreased so this is a pseudo progression response how when we go down in liver what we see similarly there is increase in the size of the lesion so it it's a pseudo progression and then again decreasing so pseudo progression is a expected response on implant we should be taking this into consideration when we are doing this process one of the main difference as compared we resist when the immunotherapies necessary for confirmation of true progressive disease at least four weeks after the first assessment so if we do first assessment there may be pseudo progression so to consider the true progression we have to do confirmation using uh scan which is at least four weeks after the first assessment and the baseline miserable minimal target lesion size should be 5 mm into 5 mm in irsc and that is 10 mm in ir resist and i resist and irrc represents a bi-dimensional chemical category while the others are unit dimension and a pairs of new lesions treatment is incorporated into the measurement and this is different from what we use used to do in resist so i resist is a m basis version 1.1 the definition of measurable and non-measurable layer this is target and non-target lesions are the same see if we if we talk about resist one point one i i i resisted i uh i i i resist or i resist what do you mean by i raises first of all which i will con talk about this term irc was a is a two dimensional measurement which we was first assigned in 2009 and irrc means immune specific related response criteria what we do here is we measure 10 liters in total and 5 liters per organ and new lesions is included in the sum of measurement which is a division from resist and completely responsive dispense of all legions if i talk about ir resist ir resist means immune related response evaluation criterion solid tumor and this was described in 2013 and this was one dimensional measurement here you measure total five regions in total and two liters per organ and here also new lesions included is sum of measurement i'm completely supposed to dispense of collision then came in 2017 i resist i resist was immunotherapy response evaluation criterion in solid limb and here important was minimum number of relations were same five regions total two liters per organ however the important concept which came in ii [Music] immune unconfirmed progressive disease where we do first assessment and confirm it four weeks after by doing second measurement and this iupd becomes icpd icbd means immune confirmed progressive disease only if progressive diseases eventually confirm and last in 2018 in the concept of i am resist which is immune modified response criteria here also new lesion is included in the sum of measurement so so confirmation of progressive disease is important and as you can see in the last line in irises which was introduced in 2017 immunotherapy raises you have to do confirmation by doing at least four weeks after and up to eight weeks scan and similarly for im resist you have to do scan four weeks after therapy so uh coming to what i was talking here in resist 1.1 ir resist and i resist you take union dimension long axis diameter uh more than 10 mm and less than two in any one organ and maximum five lesions and in lymph node you take short axis diameter which is more than 15 ml and tumor button is sum of longest diameter and some short longest 17 short axis of lymph node however if you talk about wh and irrc then you take bi-dimensional diameter and this is the difference see in this case what is happening is uh uh there is serial measurement done in uh 2017 and february 2018 march 2018 june 2018 and august 2018 what is happening in above the when you are looking at the chest lung window the lesion has shown someone increase in size when you have given immunotherapy and then decrease so pseudo progression in between similarly for excellent left node you can see pseudo procession first and thereafter a decrease in size so eat atypical patterns of response so pseudo progression to immunotherapy are observed in approximately six to ten percent and immune diseases resist category based essentially on definition of two progressive disease after confirmative image so you have to do they are not on not only your first scan but of uh four which afterwards you have to do a conformity scan to say uh it is a two progressive disease another clinically important reflection of tumor heterogeneity is in contradictory progression of one or few set of diseases despite an overall response to systemic therapy this is concept it's called oligoprogression then what can happen in some in oligopoly progression there can be diffuse metastatic disease there is no upper limit or number of metastases and few metastases progress whereas most of the other tumors are not progressing with increasing use of immune therapy some rapid cognition described and this immunotherapy induced aspiration of human growth twofold greater increase in time less than two months is called hyper progression so we should be knowing about this term uh the pseudo progression oligo progression and hyper progression because uh the these are the responses we expect after giving immunotherapy and tumor tissue is actually a three dimensional nitrogenous mass and tumor shrinkage is not always symmetrical so metabolic response criteria using pet or fat city are actually reflecting the viability of cancer cells after anticancer treatment and metabolic response may show benefit over treatment earlier than an antibiotic synthesis possibly preventing delays in a drug up and these are very important uh response criteria which we are looking after uh when we are doing trials so in metabolic response what we do is using pattern we use radar isotope is a molecule imaging techniques such as pet and single photon emissions ct captures functional technological changes and pact can detect cancer that are smaller than demonstrated on city how it's a it has a limitation the limit of resolution for detecting cancer by 18 fpg by generally ranges between 0.4 to 1 centimeter corresponding to approximately a 100 to 8 to 197 and it is generally said that resolution of pet is very less uh if the size is less than uh 0.8 centimeter so so so so the pet only should be used when the dimension is more than 8 mm in resist one version 1.1 uh the fdg pet is included in the detection of new leeches in 2009 and uh in the same year pet response the criteria in solid tumor process was published by wall at all and simplified guide to persist one point 1.1 1.0 was published in 2016. so see the how beautifully pet city help us if we see or use only the city then we will consider that the entire legion has tumor how when we use a pet then we can very well delineate the viable uh portion of the tumor and biopsy can be taken from that side similarly uh if you compare ct and pad on ct the maximum dimension is is a larger how when we say use quad city the maximum dimension is less as the vibe as we are measuring only the bible tumor then see how pet city has this up before treatment and after treatment so there is reduction in the size by cd criteria how can we use puppet then even though the size is reduced how they have these activities are still very high so so it's a partial response not uh similarly in this case if if if we see that your tumor using pattern pet city so pet city less than 10 mm so we will not take any signal or when we use pet it's a significant lymph node another case where we can show how beautifully the pet city helps in uh detecting lesions as well as specifically for uh bone tumors where in the bone we are seeing the lesion as uh oh not showing as uh very not very well uh decent number one when pet city it is lighting it is a it is a fdj so different category has been used your ct criteria versus catalina i process and now i persist criteria is you used when you using immunotherapy and as i told earlier you need to do a confirmatory scan so you need to be confirmed by second petition at four to eight weeks later an important point is not negative does not preclude the links like in this case and uh in this case with the decision list for subsolid uh religion in 57 year women with thyroid and prostate cancer because of the high clinical suspicion was malignancy transformative neural expression of performance and activity on fat city so negative that does not recruit magnesium second case uh here uh this is a patented neuroendocrine tuber in a 59 year old woman and needle biopsy conformatory carcinoid and presently 18 f fdg peta occurs in the standard management of lymphoma as a reliable markers and after two cycles of abvd lymphoma interim 18 f fdg fat is used to assess that treatment is causing patient with the list so i our ali's response is uh looked after after given two cycles of chemotherapy and practice them and in 2009 the dewalt criteria was used to interpret this increment and of treatment pet scan and dual categorize a five point scale and here a score of four and five is uh taken at the end of treatment for look after treatment failure see this important table you uh we do the end part and end of the treatment plan and our evaluation is based on both entry part and end of treatment if it's the end of the treatment uh you you are getting score a divorce score of four and five that is a treatment failure so uh at end of treatment score five indicates treatment failure even if uptake is reduced in non-actual lymphoma different categories used like leukemia criteria and uh this is also based on metabolic response pipette uh city and uh intrinsic is important to evaluate response see this how beautifully pre and post you can see the the the fdg activity has so much reduce so even though the size has not reduced how the metabolic activity reduce and this is a good treatment response another case uh where you can see the beautifully that how the petriti has helped in evaluating complete response even though both the size and the activity is reduced so however not uh all all the things can be covered by pet city and in some disease sites such as bone and brain organ specific response criteria has been developed like md anderson criteria for bone metastasis and rhinocardia for bone tumors not everything can be covered in this uh 45 or 60 minutes and uh bone lesions are not measured according to resist 1.1 only only lesions with the identificative file soft tissue component can be used as target lesions if the soft tissue component longest dimension is more than 10 mm and md anderson criteria incorporates ct and mri to assess the response of bone metastate lesions besides using plain rhetoric and skeletal synthetic and sclerosis of a previous lighting lesion on ct or progression of regression of remissible lesion on city or mrna is considered a partial response see in this case this is a 61 year old woman with history of metastatic breast cancer and a scratching bone here does not meet resist criteria for target lesion how the soft tissue component can be selected for target as target for measurement because the size is more than 10 mm and in neuron ecology initially mcdonald criteria was used and now the the renew criteria is used so see this case above is a pre of gbm and in post of gpm we are not seeing any announcement so mcdonald criteria only the uh enhancing component was uh was being measured however later on renault criteria was introduced and where you could measure both the analysing and non analysis component and the this is showing the treatment after immunotherapy and you can beautifully see how the um using renal criteria you can measure both the enhancing and non-residence component to see the response another case of uh pseudo response where after giving the uh treatment within 24 hours the response was reduced and this reduction in contrast uh is likely caused by reduced vascular permeability and it's a suitor's force then uh in the important ways as for immunotherapy radio criteria also recommend a confirmatory scan at least four weeks later to ensure a sustainable so this uh this concept is important we have to do conformity scanning after giving immunotherapy and also in renew criteria area to label it as a progressive disease so see this case here above is the pre-contrast and below is of course contrast if we are above we can if we are seeing enhancement so enhancing component as much reducing size in above images how the below image is the non energy component has increased so you know even to the enhancing components decrease how is the sum total which you take into account for rhinocardia and it's actually a progressive disease and last case which i want to show is this case see if if you consider take into total the diffusion and contrast and scale then you will be able to properly uh assess the response see when you are seeing the proportion on uh diffusion weighted imaging there is a arrow is pointing to a portion which is uh not showing diffusion restriction and this this component is showing enhancement so actually this is not the the residual tumor and we have to take both sequences and count the diffusion and the contrast enhancement to label it as a residual tumor after this aft after giving treatment otherwise we will honestly label it at the enhancing component as a residual tumor how actually it is not a residual tumor so uh what what are other criteria which now researchers are looking after the researchers are now looking at the clinical benefit response which is a very important concept which has been now introduced and it's an alternative to objective tumor response because objective tumor response also takes a lot of time and many times the patient will actually clinically have a clinical benefit uh on however when we take into account objective tumor response the the you will label it as patient uh as a failure of response to treatment so if the patient has symptomatic benefits even without objective response if the patient is decreasing pain increase in performance status and weight gain then these are clinical benefit response which many researchers are looking after in these days and these are relevant in advance cancer like in case of gastric cancer and pancreatic cancer where after giving treatment there may be a decrease in price there can be increase in performance status uh there may be increase in weight gain and patient may be symptomatically benefited and patient have a better clinical benefit response how when we take objective intimate response then we will honestly label it as treatment failure so uh so i will and uh and my conclude by saying that objective response is the goal center that shows that in treatment benefit in oncology but it's a very late response criteria and assessment of tumor objective response rate is important to report the result of clean cut trial and for clinical decision making routine practice the wh and resist criteria were anatomic based criteria and now if we consider the tumor tissue attribute human rasterization across the fibrosis and into interval leverage tumors engagement or not always be symmetrical especially in the era of biologics therefore an atmos response criteria may not be the optimal for biological agents some diseases cite some digital therapies consequently modification of uh resist acquired shy criteria and morphology response category based on the concept of evolution of a viable tumor and and this viable tumor is based on contrast enhancement areas and changes in tumor density and anatomy assessment unknown may take two or three months to detect morphology changes or shrinkage however metabolic response assessment by pets can be show changes as at least eight days after start of treatment and in your cases like lymphoma uh where entry uh we do interim practice completion but to see the response uh evaluation consequently modification of resist shy criteria and morphology response criteria based on concept of evaluation of viable tumor and new imaging techniques such as diffusion weighted imaging dynamic and transcendence mri and perfusion seriousity may add constant information to morphologic evolution especially in hepatic and practical tumors and quantitative multimodality imaging and oncology such as multi-parametric mri the plant hybrid facility plant mri and nutritional impact other than fdg such as traditional image oxygen status receptor status of coefficient may provide a more comprehensive and more accurate characterization of tumor phenotypes and fine lines finally radiology image pattern analysis radiomix and by computer related distraction and very artificial intelligence particularly deep learning have developed uh remarkable progress in image recognition tasks and are expected to identify wide applications in the evolution for treatment response and normally and now clinical response criteria especially for the customer stomach and practice which are which researchers are seriously looking after as many times the patient may be symptomatically better but when you consider update or then object response criteria may be lacking so there are many uh there is a big topic and response evolution and you have to uh do response relation which [Music] thank you sir thank you sir for the excellent presentation on response assessment in oncology uh thank you sarah and uh that was uh dr pankaj sharma sir associate professor from ames rishikesh in his talk on response assessment in oncology thank you sir i now i now request so i now request chapter of iri kerala and chairman of kerala iria turf expansion team for the vote of thanks thank you dr judy for invitation and good evening all it was an excellent session from dr congratula in the treatment response in oncology hong kong imaging actually this is a great area for most of the radios especially for me so uh that was an excellent session [Music] has depicted a very clear picture of the images that will help various in and i thank all the participants of today's expansion program on behalf of a tough expansion committee of ira kerala state ira and not at the at least our anchor dr judy the evergreen anchor thank you dr excellent conductor session and that's all i thank all the leaders of ira and the radiologists who are present here for the today's expansion program thanks a lot thank you everyone

BEING ATTENDED BY

Dr. Darius Justus & 203 others

SPEAKERS

dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapuram

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dr. Pankaj Sharma

Dr. Pankaj Sharma

Associate Professor of Radiodiagnosis | AIIMS, Rishikesh

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dr. Jose Kuruvilla

Dr. Jose Kuruvilla

Consultant Neuroradiologist, Thiruvananthapuram

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapur...

+ Details
dr. Pankaj Sharma

Dr. Pankaj Sharma

Associate Professor of Radiodiagnosis | AIIMS...

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dr. Jose Kuruvilla

Dr. Jose Kuruvilla

Consultant Neuroradiologist, Thiruvananthapur...

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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