Response%20Evaluation%20of%20Gastrointestinal%20Stromal%20Tumors%20(GIST) - PowerPoint PPT Presentation

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Title: Response%20Evaluation%20of%20Gastrointestinal%20Stromal%20Tumors%20(GIST)


1
Response Evaluation of Gastrointestinal Stromal
Tumors (GIST)
  • Haesun Choi, M.D.
  • Diagnostic Imaging
  • The University of Texas MD Anderson
  • Cancer Center, Houston, TX

2
Gastrointestinal Stromal Tumor(GIST)
3

4
Computed Tomography (CT) and Magnetic Resonance
Imaging (MRI) are the best currently available
and most reproducible methods for measuring the
target lesions
Thessasse et al. JNCI 92(3) 205, 2000
5
Fluorine-18-fluorodeoxyglucose Positron Emission
Tomography (FDG PET)
6
8/9/02
10/28/02
7
Pre-Treatment
Pre-Treatment
8
Computed Tomography(CT)
9
Gastric GIST
Metastatic GIST
10
Small bowel GIST
Metastatic GIST
11
6/01 HU 63 3.3 cm
8/01 HU 38 2.3 cm
10/01 HU 32 1.9 cm
12
2 Months Post
Pre-Treatment
13
5 Days Post
Pre-Treatment
14
30 HU
43 HU
Pre-Treatment
2 Months Post
15
Methods and Materials (I)
  • CT vs. PET
  • PET EORTC1999
  • Tumor size (cm)
  • Tumor density (HU)
  • Overall tumor status (OTS)
  • Total patients 36
  • CT and PET 29
  • within a week of each other
  • Total lesions 173
  • Liver 116
  • Peritoneum 52
  • Pleura 5

16
Subjective Tumor Response Evaluation OTS
Size
  • tumor vessels
  • solid tumor
  • nodules
  • tumor density

17
2 Months Post
Pre-Treatment
18
Objective Tumor Response Evaluation
Pre-treatment
8 Wks Post-treatment
19
Size vs. SUV
No. Patients by Changes in SUVmax No. of Patients by Changes in Size No. of Patients by Changes in Size No. of Patients by Changes in Size No. of Patients by Changes in Size Total No. of Patients
No. Patients by Changes in SUVmax PD SD PR CR Total No. of Patients
Grade 1 0 2 0 0 2
Grade 2 1 5 0 0 6
Grade 3 0 1 0 0 1
Grade 4 1 15 4 0 20
Note. - The data were analyzed for the 29
patients who underwent both CT and FDG PET.
Based on RECIST Based on modified EORTC 1999
criteria
20
Methods and Data Analysis (II)
  • Total patients 40
  • CT and PET
  • Good Response
  • Decrease in SUVmax
  • gt70
  • lt2.5
  • Good Response 33 (83)
  • 30 (75) PET CR
  • 3 (8) 70 - 99 decrease, decrease to a value
    lt2.5
  • Poor Response7 (17)
  • 5 (12) stable
  • 2 (5) increased SUVmax

(Van den Abbeele AD, et al, ASCO 2002)
21
Changes in Size and HU on CT vs. Tumor Response
on FDG PET
Total number of patients 40
Tumor response by PET Patients with ? 10 decrease in size () Patients with ? 15 decrease in HU () ? 10 decrease in size or ? 15 decrease in HU ()
Good (n33) 31 (94) 27 (82) 32 (97)
Poor (n7) 0 (0) 0 (0) 0 (0)
n number of patients
22
Modified CT Criteria
PET response SUV lt 2.5, 70
CT response HU ? -15, Size ? -10

















































P 0.03























P 0.03





Responder
Responder
Non-responder
Non-responder
Months
Months
Time to Progression by PET and modified CT
criteria
23
Time to Progression RECIST
N98
P 0.1
Response Rate 45
24
Time to Progression Modified CT
N98
P 0.0002
Response Rate 83
25
Surveillance
26
Progression
  • Increase in tumor size
  • Appearance of a new lesion at the site of primary
    tumor
  • Appearance metastatic lesions

27
Pre-Treatment
2 Months Post
8 Months Post
11 Months Post
28
10 Months Post
17 Months Post
21 Months Post
27 Months Post
29
Progression in GIST
  • Increase in tumor size
  • Appearance of a new lesion at the site of primary
    tumor
  • Appearance metastatic lesions

Appearance of new intra-tumoral nodules
30
We do need FDG PET.
31
30 HU
43 HU
Pre-Treatment
2 Months Post
32

Conclusions
  • RECIST underestimates the tumor response.
  • Subjective evaluation using changes in tumor
    nodules, density, tumor vessels, in addition to
    change in size is the best criteria on CT and is
    reproducible.
  • CT density alone can be a good indicator in
    early, quantitative tumor response evaluation.

33
Conclusions
  • Objective evaluation using a combination of
    tumor density (?15 change) and modified tumor
    size criteria (?10 change) is promising in early
    tumor response evaluation and has a prognostic
    value.
  • FDG PET should be performed whenever the CT
    findings are inconclusive or inconsistent with
    the clinical presentation.

34
It's Time To Re-visit Tumor Response Criteria !!
35
Acknowledgements
  • Department of Sarcoma Medical Oncology
  • Robert S. Benjamin, M.D.
  • Sarcoma Center Team
  • Department of Biostatistics
  • Marcella M. Johnson, M.S.
  • Division of Diagnostic Imaging
  • Chusilp Charnsangavej, M.D.
  • Silvana C. Faria, M.D.
  • Eric P. Tamm, M.D.
  • Evelyn M. Loyer, M.D.
  • Kazama Toshiki, M.D.
  • Division of Nuclear Medicine
  • Donald A. Podoloff, M.D.
  • Homer A. Macapinlac, M.D.

36
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37
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38
Data Analysis CT
Variables Response Analysis Response Analysis
Size (cm) RECIST PD, SD, PR, CR
Density (HU) Grade 1-4 (median13 ) G1 ? -12 (worse) G2 -11 - 11 G3 12- 31 G4 ? 32 (best)
OTR (size, density, vessels, nodules) Grade 1-4 G1 worse, G2 stable G3 better, G4 best
OTR overall tumor response
JNCI 92(3) 205, 2000
39
OTS vs. SUV
P 0.0001, Chi-Square Test
No. Patients by Change in SUVmax No. Patients by Changes in OTS No. Patients by Changes in OTS No. Patients by Changes in OTS No. Patients by Changes in OTS Total No. of Patients
No. Patients by Change in SUVmax Grade 1 Grade 2 Grade 3 Grade 4 Total No. of Patients
Grade 1 0 2 0 0 2
Grade 2 6 0 0 0 6
Grade 3 0 0 1 0 1
Grade 4 0 1 4 15 20
Statistically significant.
Note. - The data were analyzed for the 29
patients who underwent both CT and FDG PET.
40
HU vs. SUV
P 0.3088, Chi-Square Test
No. Patients by Change in SUVmax No. Patients by Changes in HU No. Patients by Changes in HU No. Patients by Changes in HU No. Patients by Changes in HU Total No. of Patients
No. Patients by Change in SUVmax Grade 1 Grade 2 Grade 3 Grade 4 Total No. of Patients
Grade 1 0 1 1 0 2
Grade 2 1 4 1 0 6
Grade 3 0 1 0 0 1
Grade 4 2 4 4 10 20
Note. - The data were analyzed for the 29
patients who underwent both CT and FDG PET.
41
ReproducibilityN 35
42
Methods and Materials (II)
  • Two radiologists who were not participated in
    initial analysis of CT images
  • Overall Tumor Status (OTS)
  • The results of two radiologists were compared
    with each other.

43
Mean HU
Size
P lt 0.0001, t-test
P lt 0.0001, t-test
Mean SUVmax
P lt 0.0001, t-test
Pre-treatment
8 Wks Post-treatment
44
Reader A vs. B
P 0.0002, Chi-Square Test, rtau 0.5782
Reader A Reader B Reader B Reader B Reader B
Reader A Grade 1 Grade 2 Grade 3 Grade 4
Grade 1 0 0 0 0
Grade 2 1 2 2 0
Grade 3 0 0 11 0
Grade 4 0 0 12 7
Statistically significant. Kendalls Tau
correlation.
Note Grades are based on OTR at 8 wks
post-treatment.
45
OTS vs. SUV
P 0.0001, Chi-Square Test
No. Patients by Change in SUVmax No. Patients by Changes in OTS No. Patients by Changes in OTS No. Patients by Changes in OTS No. Patients by Changes in OTS Total No. of Patients
No. Patients by Change in SUVmax Grade 1 Grade 2 Grade 3 Grade 4 Total No. of Patients
Grade 1 0 2 0 0 2
Grade 2 0 0 1 0 1
Grade 3 0 1 0 0 1
Grade 4 0 1 10 20 31
Statistically significant.
Note. - The data were analyzed for the 35
patients who underwent both CT and FDG PET.
46
Pre-Treatment
2 Months Post
EatoEaton 411286
24 Months Post
27 Months Post
47
Discrepancy(?) HU vs. SUVmax
  • Development of intratumoral hemorrhage
  • Definition of ROI
  • EORTC guideline

48
528671
49
KIT Receptor

Tyrosine Kinase Receptor Blocker
50

Conclusions
  • RECIST underestimates the tumor response in GIST.
  • Subjective evaluation using changes in tumor
    nodules, density, tumor vessels, in addition to
    change in size is the best criteria on CT and is
    reproducible.

51
Conclusions
  • Objective evaluation using a combination of
    tumor density (?15 change) and modified tumor
    size criteria (?10 change) is promising in early
    tumor response evaluation and has a prognostic
    value.
  • FDG PET should be performed whenever the CT
    findings are inconclusive or inconsistent with
    the clinical presentation.
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