Personalized chemotherapy of lung cancer: What the radiologist should know

Twenty Years On: RECIST as a Biomarker of Response in Solid Tumours an EORTC Imaging Group - ESOI Joint Paper

Response evaluation criteria in solid tumours (RECIST) v1.1 are currently the reference standard for evaluating efficacy of therapies in patients with solid tumours who are included in clinical trials, and they are widely used and accepted by regulatory agencies. This expert statement discusses the principles underlying RECIST, as well as their reproducibility and limitations. While the RECIST framework may not be perfect, the scientific bases for the anticancer drugs that have been approved using a RECIST-based surrogate endpoint remain valid. Importantly, changes in measurement have to meet thresholds defined by RECIST for response classification within thus partly circumventing the problems of measurement variability. The RECIST framework also applies to clinical patients in individual settings even though the relationship between tumour size changes and outcome from cohort studies is not necessarily translatable to individual cases. As reproducibility of RECIST measurements is impacted by reader experience, choice of target lesions and detection/interpretation of new lesions, it can result in patients changing response categories when measurements are near threshold values or if new lesions are missed or incorrectly interpreted. There are several situations where RECIST will fail to evaluate treatment-induced changes correctly; knowledge and understanding of these is crucial for correct interpretation. Also, some patterns of response/progression cannot be correctly documented by RECIST, particularly in relation to organ-site (e.g. bone without associated soft-tissue lesion) and treatment type (e.g. focal therapies). These require specialist reader experience and communication with oncologists to determine the actual impact of the therapy and best evaluation strategy. In such situations, alternative imaging markers for tumour response may be used but the sources of variability of individual imaging techniques need to be known and accounted for. Communication between imaging experts and oncologists regarding the level of confidence in a biomarker is essential for the correct interpretation of a biomarker and its application to clinical decision-making. Though measurement automation is desirable and potentially reduces the variability of results, associated technical difficulties must be overcome, and human adjudications may be required.

The role of radiology in the evaluation of the immunotherapy efficacy

In the last years, a great interest has arisen on immunotherapy for the treatment of advanced non-small cell lung cancer (NSCLC). Check-point inhibitor drugs are now considered clinical practice standard in different settings and their use is expected to increase significantly in the near future. As treatment options for lung cancer advance and vary, the different patterns of radiological response increase in number and heterogeneity. To correctly evaluate the radiological findings after and during these treatments is of paramount importance, both in the clinical and sperimental setting. In consideration of their peculiar mechanism, immunotherapies can determine unusual response patterns on imaging, that cannot be correctly evaluated with the traditional response criteria such as World Health Organization (WHO) and Response Evaluation Criteria in Solid Tumours (RECIST). Therefore, during these years, several response criteria [immune-related response criteria (irRC), irRECIST and iRECIST] were proposed and applied in clinical trials on immunotherapies. The aim of this review is to describe the radiological findings after immunotherapy, to critically discuss the different response criteria and the imaging of immune-related adverse events.

Strategies to engage older adults with behavioral and psychological symptoms of dementia in exercise: A multiple case study

Alzheimer’s disease (AD) affects 5.2 million Americans in 2016 and this number will increase to 14.7 million by 2050. Unfortunately, AD cannot yet be prevented, slowed, or cured. Aerobic exercise is potentially therapeutic for Alzheimer’s disease (AD) as it favorably affects brain structure and function. A critical determinant in testing its effectiveness is optimal adherence to the exercise prescription. AD symptoms, particularly behavioral and psychological symptoms of dementia (BPSD), however, make exercise delivery and adherence challenging. The purpose of this paper is to discuss the strategies used for managing BPSD during exercise using a multiple case study design. Three cases with BPSD that met the eligibility criteria were selected from the FIT-AD Trial. The FIT-AD Trial is an ongoing randomized controlled trial that tests the effects of a 6-month moderate intensity aerobic exercise on cognition and hippocampal volume in community-dwelling persons with AD. The cases included: a 77-year-old woman with mild AD, a 79-year-old woman with mild AD, and a 69-year-old man with moderate AD. The participants exhibited anxiety, repetitive questioning, irritability, hostility, extreme distractedness, resistance to instruction, and hoarding during exercise. The symptoms were effectively addressed using person-centered strategies such as routine schedules, reassurance, timely communications, distraction, small rewards, rephrasing, immediate answers, selective withdrawal from conversations that were hostile, step by step instructions, building on rapport and relationship with staff, and affirmation. They achieved 83.3%–100% attendance and 52.8%–81.7% session adherence, respectively. In conclusion, individualized strategies for BPSD are necessary to ensure optimal exercise adherence.

Overview of treatment related complications in malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is an aggressive malignant neoplasm of the pleura related to asbestos exposure. Despite recent advances in therapy for MPM, the prognosis remains poor, with considerable treatment associated morbidity. Radiological assessment plays a central role in the timely identification and subsequent management of treatment related complications in MPM. This review highlights common and uncommon complications associated with and encountered in the post treatment phase.

Evaluation of lung tumor response to therapy: Current and emerging techniques

Lung tumor response to therapy may be evaluated in most instances by morphological criteria such as RECIST 1.1 on computed tomography (CT) or magnetic resonance imaging (MRI). However, those criteria are limited because they are based on tumoral dimensional changes and do not take into account other morphologic criteria such as density evaluation, functional or metabolic changes that may occur following conventional or targeted chemotherapy. New techniques such as dual-energy CT, PET-CT, MRI including diffusion-weighted MRI has to be considered into the new technical armamentarium for tumor response evaluation. Integration of all informations provided by the different imaging modalities has to be integrated and represents probably the future goal of tumor response evaluation. The aim of the present paper is to review the current and emerging imaging criteria used to evaluate the response of therapy in the field of lung cancer.