Journal of Liver Cancer

Review Articles

Tumor Response Evaluation after Treatment and Post-treatment Surveillance of Hepatocellular Carcinoma: Yoon, Jun Sik , Park, Soo Young; J Liver Cancer. 2018;18(1):9-16. Published online March 31, 2018; DOI: https://doi.org/10.17998/jlc.18.1.9

Abstract PDF: Hepatocellular carcinoma is one of the most prevalent malignancies and frequent causes of death worldwide. Treatment options of hepatocellular carcinoma consist of locoregional therapy, surgical resection, liver transplantation, and systemic therapy. Assessment of tumor response is required in patients receiving locoregional and systemic therapy. The Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 is widely used tumor response evaluation criteria. However, the RECIST does not reflect the extent of tumor necrosis after some locoregional therapies and molecular targeted agents. The Modified RECIST (mRECIST), which has the concept of viable tumor, was introduced in order to overcome this problem. The mRECIST were developed on the basis of RECIST version 1.1 and only tumoral tissue showing contrast uptake in arterial phase of dynamic radiologic imaging techniques was measured to assess tumor response. Recently, immune checkpoint inhibitors have emerged as a promising therapeutic modality for the treatment of hepatocellular carcinoma. To identify tumor response after immunotherapy, immune RECIST (iRECIST) has been proposed as consensusbased criteria. After achieving complete response after curative treatment, optimal surveillance was needed to detect recurrence. Individualized surveillance schedule should be considered, taking into consideration the risk factors of the patient and the risk associated with the treatment modalities.

Treatment Response Evaluation of Hepatocellular Carcinoma: Joon-Il Choi; Journal of the Korean Liver Cancer Study Group. 2012;12(1):16-22. Published online February 28, 2012

Abstract PDF: The most important and primary endpoint in oncology research is overall survival. However, other endpoints such as time-to-progression, time-to-recurrence and response rate have their roles in oncology trials and these endpoints are assessed by the imaging evaluation of tumor burden. Recently published the revised version (version 1.1) of response evaluation criteria in solid tumors (RECIST) is now the standards for the tumor response evaluation after treatment, and especially for cytotoxic agents. However, the problems are more complicated for hepatocellular carcinoma (HCC). RECIST are mainly used for the response evaluation of chemotherapeutic agents. However, for the treatment of HCC, there are some locoregional treatments and molecular targeted agents, and after these treatments, tumor necrosis remains as non-enhanced tumor areas, whereas viable tumor parts can be noted by the enhanced areas. However, these necrotic areas should be included as being tumor when we adopt the pure anatomical criteria such as RECIST and this can distort the results of the response evaluation. For overcoming this problem, some new criteria were introduced and their principle is the measurement of enhancing portion of the tumor only. However, these new criteria still have limitations and functional imaging is thought to be the future problem-solving tool for the evaluation of response for molecular targeted agents.

Response Evaluation Assessment in HCC: Modified RECIST: So Yeon Kim; Journal of the Korean Liver Cancer Study Group. 2011;11(2):111-115. Published online September 30, 2011

Abstract PDF: The accurate evaluation of response to treatment is a key aspect in cancer therapy, because an objective response may become a surrogate marker of improver survival. For cytotoxic drugs, tumor response evaluation according to the World Health Organization (WHO) criteria or the Response Evaluation Criteria in Solid Tumors (RECIST) guideline offers simple approaches based on the size of the lesions. However, considering the nature of locoregional therapy or new cytostatic agent for hepatocellular carcinoma (HCC), which do not decrease the size of the tumor but induce tumor necrosis, original WHO or RECIST criteria will not reflect clinical benefit exactly. Recently, modified RECIST assessment is proposed by AASLD-JNCI guidelines. Given that complete necrosis was well correlated with better survival, modified RECIST criteria consider changes in tumor viability, which can be measured as the area of arterial enhancement, with maintaining overall response assessment similar to RECIST. The proposed modified RECIST assessment is expected to provide a reliable method for assessing tumor response in HCC clinical trials.

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