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Some facts about the population
� 500 - 700 000 deaths per year (worldwide) � 15% are detected at a « curative » stage � Less than 50 % of countries in the world
are equiped for relevant curative treatment � 5-7 % have the benefit of the curative
treatment
Rationale for targeted therapies
� Overexpression of VEGF is one of the major features of HCC (Chow 1997) and is associated with a poor prognosis (Poon 2004)
� Microvascular density is a factor for recurrence after resection (Poon 2002)
There is a price for that
� Medical price : � Hand foot syndrome +++ � Diarrhoea � Asthenia
� Economical price (per month) � China 7 300 $ � USA 5 400 $ � Brasil 5 000 $ � France 4 800 $
Patent for Nexavar will expire in 2020 (EU) and 2022 (USA)
Good candidates
� Excellent performance status � Expected survival > 6 month � Normal or moderately abnormal liver
tests � Not eligible for transplantation,
resection, ablation or TACE
Other perspectives
� Adjuvant (STORM) � Neo-adjuvant (Hoffmann, 2015,
negative) � Combined therapies (+TACE, unclear) � Other drugs
à Under evaluation
Benefit (economic) of Sorafenib related to HCC
Some practical conclusions for the oncologist � Sorafenib is mostly given to patients who
will not have a curative treatment � There is no recommendation for a second
line � Tolerance is good to excellent à No reason to prompt PD, as there is nothing else than BSC after failure of Sorafenib, excepting trials. PD if « symptomatic ».
Some practical conclusions for the Radiologist � No need to detect as early as possible
progression or recurrence � No necessity to develop complicated
algorithms for evaluation � Only call PD when absolutely
unequivocal
CT or MRI?
� MRI clearly superior � Adds a bonus of 20% for Se and Sp
However… 1. Early detection is not the main issue 2. CT is by far superior for evaluation of extra
hepatic disease 3. If MRI is performed, a plain CT should be
associated 4. Reproducibility is better with CT 5. Radiation dose is not a relevant issue in this
population
Therefore
� CT is today the work horse of evaluation � Combination CT/MRI is relevant in
patients included in a protocol � Cross-over from CT to MR is
unacceptable
07-2012
07-2012
11-2012
What are the standards? Response RECIST 1.1 mRECIST CHOI mCHOI CR 0 0 0 0
PR -30% SOD -30% SOD (viable)
Size < 10% OR
Tumour density < 15%
Size < 10% AND
Tumour density < 15%
PD +20% SOD +20% SO (Viable)
Tumour size + 10% AND
No « Density PR)
Tumour size + 10% AND
No « Density PR)
Recist 1.1
� Universally rejected for the evaluation of HCC, due to inability to evaluate the viable compartment
� Remains a « Plan B » for hypovascular lesions
mRECIST
� Adopted as THE reference standard
mRECIST
Sep 2009 97 mm
Sept 2010 32 mm
25/07/2014 12/01/2015
arterial
portal
CHOI and mCHOI � Advantages
� Simple exploration of viability � Portal phase à less dependent on the
quality of arterial acquisition � Good predictor of survival (Ronot 2014)
� Pitfalls � Dedicated to CT � mCHOI may not be relevant (Weng, 2013) � Interobserver agreement suboptimal (Ronot,
2014)
Arterial Phase
Portal Phase
25/07/2014 12/01/2015
arterial
portal
80 HU 15 HU
CHOI and mCHOI � Advantages
� Simple exploration of viability � Portal phase à less dependent on the
quality of arterial acquisition � Good predictor of survival (Ronot 2014)
� Pitfalls � Dedicated to CT � mCHOI may not be relevant (Weng, 2013) � Interobserver agreement suboptimal (Ronot,
2014)
� EASL (European Association for the Study of the Liver) � Powerful, but time
consuming � Not a « fast tool »
03/14 07/14
10/14
03-2011
11-2011 01-2014
RECIST
mRECIST
mor
phol
ogy
enha
ncem
ent
EASL/CHOI
WHO
1D 2D 3D
vRECIST
vEASL
Volume of enhancement Parameters of enhancement
Enhancement curve Histogram Texture
Endovascular treatments
§ TACE
§ DC Beads
§ Radio embolisation: RE Y90
TACE: MR>>CT (lipiodol)
TACE Evaluation of response?
Post Pre
cTACE
mRECIST: PR
Ablation
§ mRECIST and RECIST non applicable
§ MRI superior to CT
The right area?? 1. Same place
2. Ablation > initial tumour
If no margin à high recurrence rate
11/2011
01/2012, J0 post RF
11/2011
01/2012, J0 post RF
11/2011
05/2012 02/2012
Recurrence? Difficult procedure, several accesses.
Seeding
Take Home Points
§ For the evaluation of systemic therapy,
mRECIST is the standard. No need to develop
sophisticated tools for the moment
§ Concerning endovascular treatment, the
situation is more complicated. Value of
parametric images and MRI
Jun 2009 Sep 2009
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