Tumor Response Assessment: RECIST and Beyond

  • Kieran McHughEmail author
  • Simon Kao
Part of the Pediatric Oncology book series (PEDIATRICO)


The Response Evaluation Criteria in Solid Tumors (RECIST) guidance was introduced in 2000 and revised as RECIST 1.1 in 2009. RECIST was put together with the goal of standardising and simplifying tumor response criteria. The important role of imaging in response assessment was recognised, and specific imaging guidelines were included. The significant imaging-related changes in RECIST 1.1 in comparison to RECIST 1.0 included a reduction in the number of lesions to be addressed, from a maximum of 10 to a maximum of 5 and from 5 to 2 lesions per organ; assessment of lymph node size; and clarification of what constituted disease progression. The definitions of response within the RECIST guidance are addressed within this chapter in addition to the limitations of using tumor size alone as a biomarker for tumor response. Other methods of assessing tumor response such as response to immunotherapy (iRECIST) and response on PET-CT (PERCIST) are also included.


CT MRI RECIST PET Tumor response 


  1. 1.
    Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45(2):228–47.CrossRefGoogle Scholar
  2. 2.
    Therasse P, Arbuck S, Eisenhauer EA, et al. New guidelines to evaluate the response to treatment in solid tumours. J Natl Cancer Inst. 2000;92:205–16.CrossRefGoogle Scholar
  3. 3.
    Nishino M, Jackman DM, Hatabu H, Yeah BY, Cioffredi L-A, Yap JT, et al. New response evaluation criteria in solid tumors (RECIST) guidelines for advanced non–small cell lung cancer: comparison with original RECIST and impact on assessment of tumor response to targeted therapy. AJR Am J Roentgenol. 2010;195(3):W221–8.CrossRefGoogle Scholar
  4. 4.
    WHO. Handbook for reporting results of cancer treatment, No. 48. Geneva: World Health Offset Organization; 1979.Google Scholar
  5. 5.
    Suzuki C, Jacobson H, Hatschek T, Torkzad MR, Bodén K, Eriksson-Alm Y, et al. Radiologic measurements of tumor response to treatment: practical approaches and limitations. Radiographics. 2008;28:329–44.CrossRefGoogle Scholar
  6. 6.
    McHugh K, Kao SCS. Response evaluation criteria in solid tumors (RECIST): problems and need for modifications in paediatric oncology? Br J Radiol. 2003;76:433–6.CrossRefGoogle Scholar
  7. 7.
    McHugh K, Kao SCS. Can paediatric radiologists resist RECIST (response evaluation criteria in solid tumors)? Pediatr Radiol. 2003;33(11):739–43.CrossRefGoogle Scholar
  8. 8.
    Chalian H, Tore HG, Horowitz MH, Salem R, Miller FH, Yaghmai V. Radiologic assessment of response to therapy: comparison of RECIST versions 1.1 and 1.0. Radiographics. 2011;31:2093–105.CrossRefGoogle Scholar
  9. 9.
    Padhani AR. The RECIST criteria: implications for diagnostic radiologists. Br J Radiol. 2001;74:983–6.CrossRefGoogle Scholar
  10. 10.
    Gehan EA, Tefft MC. Will there be resistance to RECIST (Response Evaluation Criteria in Solid Tumours)? J Natl Cancer Inst. 2000;92:179–81.CrossRefGoogle Scholar
  11. 11.
    Ferrari A, Miceli R, Meazza C, Casanova M, Favini F, Morosi C, et al. Comparison of the prognostic value of assessing tumor diameter versus tumor volume at diagnosis or in response to initial chemotherapy in rhabdomyosarcoma. J Clin Oncol. 2010;28(8):1322–8.CrossRefGoogle Scholar
  12. 12.
    Schoot RA, McHugh K, van Rijn RR, Kremer LC, Chisholm JC, Caron HN, et al. Response assessment in pediatric rhabdomyosarcoma: can Response Evaluation Criteria in Solid Tumors replace three-dimensional volume assessments? Radiology. 2013;269(3):870–8.CrossRefGoogle Scholar
  13. 13.
    Bagatell R, McHugh K, Naranjo A, Van Ryn C, Kirby C, Brock P, et al. Assessment of primary site response in children with high-risk neuroblastoma: an international multicenter study. J Clin Oncol. 2016;34(7):740–6.CrossRefGoogle Scholar
  14. 14.
    Carceller F, Bautista FJ, Fowkes LA, Marshall LV, Sirvent SI, Chisholm JC, et al. Response assessment in pediatric phase I trials according to RECIST guidelines: survival outcomes, patterns of progression and relevance of changes in tumor measurements. Pediatr Blood Cancer. 2016;63:1400–6.CrossRefGoogle Scholar
  15. 15.
    Aghighi M, Boe J, Rosenberg J, Von Eyben R, Gawande RS, Petit P, et al. Three-dimensional radiologic assessment of chemotherapy response in Ewing sarcoma can be used to predict clinical outcome. Radiology. 2016;280:905–15.CrossRefGoogle Scholar
  16. 16.
    MacDonald DR, Cascino TL, Schold SC Jr, Cairncross JG. Response criteria for phase II studies of supratentorial malignant glioma. J Clin Oncol. 1990;8:1277–80.CrossRefGoogle Scholar
  17. 17.
    Warren KE, Poussaint TY, Vezina G, Hargrave D, Packer RJ, Goldman S, et al. Challenges with defining response to antitumor agents in pediatric neuro-oncology: a report from the response assessment in pediatric neuro-oncology (RAPNO) working group. Pediatr Blood Cancer. 2013;60:1397–401.CrossRefGoogle Scholar
  18. 18.
    Cheson BD, Fisher RI, Barrington SF, Cavalli F, Schwartz LH, Zucca E, et al. Recommendations for initial evaluation, staging and response assessment in Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol. 2014;32:3059–68.CrossRefGoogle Scholar
  19. 19.
    Sandlund JT, Guillerman RP, Perkins SL, Pinkerton CR, Rosolen A, Patte C, et al. International pediatric non-Hodgkin lymphoma response criteria. J Clin Oncol. 2015;33(18):2106–11.CrossRefGoogle Scholar
  20. 20.
    Wahl RL, Jacene H, Kasamon Y, Lodge MA. From RECIST to PERCIST: evolving considerations for PET response criteria in solid tumors. J Nucl Med. 2009;50(S1):1225–50.Google Scholar
  21. 21.
    Tirkes T, Hollar MA, Tann M, Kohli MD, Akisik F, Sandrasegaran K. Response criteria in oncologic imaging: review of traditional and new criteria. Radiographics. 2013;33:1323–41.CrossRefGoogle Scholar
  22. 22.
    Cheson BD, Horning SJ, Coiffier B, Shipp MA, Fisher RI, Connors JM, et al. Report of an international workshop to standardize response criteria for non-Hodgkin’s lymphomas. NCI sponsored International Working Group. J Clin Oncol. 1999;17(4):1244.CrossRefGoogle Scholar
  23. 23.
    Cheson BD, Pfistner B, Juweid ME, Gascoyne RD, Specht L, Horning SJ, et al. Revised response criteria for malignant lymphoma. J Clin Oncol. 2007;25(5):579–86.CrossRefGoogle Scholar
  24. 24.
    Choi H, Charnsangavej C, Faria SC, Macapinlac HA, Burgess MA, Patel SR, et al. Correlation of computed tomography and positron emission tomography in patients with metastastic gastrointestinal stromal tumor treated at a single institution with imatinib mesylate: proposal of new computed tomography response criteria. J Clin Oncol. 2007;25:1753–9.CrossRefGoogle Scholar
  25. 25.
    Choi H. Response evaluation of gastrointestinal stromal tumors. Oncologist. 2008;13(Suppl 2):4–7.CrossRefGoogle Scholar
  26. 26.
    Dietrich C, Hartung E, Ignee A. The use of contrast-enhanced ultrasound in patients with GIST metastases that are negative in CT and PET. Ultraschall Med. 2008;29(Suppl 5):276–7.PubMedGoogle Scholar
  27. 27.
    Smith AD, Lieber ML, Shah SN. Assessment tumor response and detecting recurrence in metastatic renal cell carcinoma on targeted therapy: importance of size and attenuation on contrast-enhanced CT. AJR Am J Roentgenol. 2010;194(1):157–65.CrossRefGoogle Scholar
  28. 28.
    Smith AD, Shah SN, Rini BI, Liber ML, Remer EM. Morphology attenuation, size, and structure (MASS) criteria: assessing response and predicting clinical outcome in metastatic renal cell carcinoma on antiangiogenic targeted therapy. AJR Am J Roentgenol. 2010;194(6):1470–8.CrossRefGoogle Scholar
  29. 29.
    Vancini C, Alfano DF, Abousiam RN, Totaro M, Diago NMD, Giganti M. Comparison of radiological criteria (RECIST – MASS – SACT – Choi) in antiangiogenic therapy of renal cell carcinoma. Univ J of Public Health. 2016;4(5):239–43.CrossRefGoogle Scholar
  30. 30.
    Tan D, Thomas GV, Garrett MD, Banerji U, de Bono J, Kaye SB, et al. Biomarker-driven early clinical trials in oncology: a paradigm shift in drug development. Cancer J. 2009;15:406–20.CrossRefGoogle Scholar
  31. 31.
    Wolchok JD, Hoos A, O’Day S, Weber JS, Hamid O, Lebbé C, et al. Guidelines for the evaluation of immune therapy activity in solid tumors: immune-related response criteria. Clin Cancer Res. 2009;15(23):7412–20.CrossRefGoogle Scholar
  32. 32.
    Hodi FS, Butler M, Oble DA, Seiden MV, Haluska FG, Kruse A, et al. Immunologic and clinical effects of antibody blockade of cytotoxic T lymphocyte-associated antigen 4 in previously vaccinated cancer patients. Proc Natl Acad Sci U S A. 2008;105:3005–10.CrossRefGoogle Scholar
  33. 33.
    Hodi FS, Oble DA, Drappatz J, Velazquez EF, Ramaiya N, Ramakrishna N, et al. CTLA-4 blockade with ipilimumab induces significant clinical benefits in a female with melanoma metastases to the CNS. Nat Clin Pract Oncol. 2008;5:557–61.CrossRefGoogle Scholar
  34. 34.
    Seymour L, Boggaerts J, Perrone A, Ford R, Schwartz LH, Mandrekar S, et al. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics. Lancet Oncol. 2017;18:e143–51.CrossRefGoogle Scholar
  35. 35.
    Olsen ØE, Jeanes AC, Sebire NJ, Roebuck DJ, Michalski AJ, Risdon RA, et al. Changes in computed tomography features following preoperative chemotherapy for nephroblastoma: relation to histopathological classification. Eur Radiol. 2004;14:990–4.CrossRefGoogle Scholar
  36. 36.
    Malempati S, Weigel B, Ingle AM, Ahern CH, Carroll JM, Roberts CT, Reid JM, Schmechel S, Voss SD, Cho SY, Chen HX, Krailo MD, Adamson PC, Blaney SM. Phase I/II trial and pharmacokinetic study of cixutumumab in pediatric patients with refractory solid tumors and Ewing sarcoma: a report from the Children’s Oncology Group. J Clin Oncol. 2012;30(3):256–62.
  37. 37.
    Fowkes LA, Koh DM, Collins DJ, Jerome NP, MacVicar D, Chua SC, et al. Childhood extracranial neoplasms: the role of imaging in drug development and clinical trials. Pediatr Radiol. 2015;45:1600–15.CrossRefGoogle Scholar
  38. 38.
    Smith TA. FDG uptake, tumour characteristics and response to therapy: a review. Nucl Med Commun. 1998;19:97–105.CrossRefGoogle Scholar
  39. 39.
    Park JR, Bagatell R, Cohn SL, Pearson AD, Villablanca JG, Berthold F, et al. Revisions to the international neuroblastoma response criteria (INRC): a consensus statement from the NCI-clinical trials planning meeting. J Clin Oncol. 2017;35(22):2580–7.CrossRefGoogle Scholar
  40. 40.
    Mullen EA, Chi YY, Hibbitts E, Anderson JR, Steacy KJ, Geller JI, Green DM, Khanna G, Malogolowkin MH, Grundy PE, Fernandez CV, Dome JS. Impact of surveillance imaging modality on survival after recurrence in patients with favorable-histology Wilms Tumor: a report from the children’s oncology group. J Clin Oncol. 2018:JCO1800076. [Epub ahead of print].
  41. 41.
    Saini S. Radiologic measurement of tumor size in clinical trials: past, present, and future. AJR Am J Roentgenol. 2001;176:333–4.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Radiology DepartmentGreat Ormond Street Hospital for ChildrenLondonUK
  2. 2.Department of Radiology, Carver College of MedicineThe University of IowaIowa CityUSA

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