Rofo 2020; 192(03): 235-245
DOI: 10.1055/a-1015-6869
© Georg Thieme Verlag KG Stuttgart · New York

Radiological Monitoring of Modern Immunotherapy: A Novel Challenge for Interdisciplinary Patient Care

Article in several languages: English | deutsch
Simon Lennartz
1  University of Cologne, Faculty of Medicine and University-Hospital Cologne, Department of Diagnostic and Interventional Radiology
2  Else-Kröner-Forschungskolleg Clonal Evolution in Cancer, University-Hospital Cologne, Cologne, Germany
Stefan Diederich
3  Department of Radiology, Marien-Hospital Düsseldorf, Düsseldorf, Germany
Christian Doehn
4  Urologikum Lübeck, Lübeck, Germany
Bernhard Gebauer
5  Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
Viktor Grünwald
6  Clinic for Internal Medicine (Tumor Research) and Clinic for Urology, University-Hospital Essen, Essen, Germany
Mike Notohamiprodjo
7  Department of Diagnostic and Interventional Radiology, University-Hospital of Tübingen, Tübingen, Germany
8  Die Radiologie, Munich, Germany
Wieland Sommer
9  Department of Radiology, LMU-University-Hospital, Munich, Germany
9  Department of Radiology, LMU-University-Hospital, Munich, Germany
Heinz-Peter Schlemmer
11  Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
Thorsten Persigehl
1  University of Cologne, Faculty of Medicine and University-Hospital Cologne, Department of Diagnostic and Interventional Radiology
› Author Affiliations
Further Information

Publication History

30 April 2019

19 August 2019

Publication Date:
28 January 2020 (online)


Background Immunotherapy represents an effective therapeutic approach for many malignant diseases that were previously difficult to treat. However, since immunotherapy can lead to atypical therapy response patterns in the form of pseudo-progression or mixed responses and comprise an altered spectrum of adverse reactions, they present a new challenge for oncologic imaging. Detailed knowledge in this area is essential for oncologic clinical radiologists, since the radiological report is a cornerstone of response assessment, and increasingly influences therapy regimens and coverage by health insurances.

Method This white paper is based on an expert meeting in Frankfurt am Main and subsequent discussions between the authors. Based on the iRECIST criteria, it is intended to provide orientation for a response assessment of oncologic patients undergoing immunotherapy that can be applied in the clinical routine.

Results Radiological therapy monitoring outside clinical studies is subject to inherent limitations, but should be performed based on iRECIST criteria, according to the opinion of the expert panel. It should be taken into account that immunotherapies can in principle lead to pseudo-progression and autoimmunological side effects. Since radiological follow-up is currently the only method to accurately distinguish real progressive disease from pseudo-progression, clinically stable patients with disease progression under immunotherapy should undergo additional short-term follow-up imaging according to the suspected diagnosis. Biopsy should be used cautiously and predominately in curative settings.

Conclusion For response assessment of immunotherapy in clinical studies, the new iRECIST criteria were published in 2017. Outside studies, the application of iRECIST criteria in the clinical routine is subject to several limitations. The recommendations implied in these criteria can, however, be used in conjunction with the current literature as a guideline in clinical practice and outside studies.

Key points:

  • Novel immunotherapies can cause atypical response patterns like pseudo-progression

  • Compared to real progressive disease, pseudo-progression occurs rather rarely, yet can influence therapy

  • Short-term follow-up according to iRECIST can help to distinguish pseudo-progression from real progression

  • Hence, radiological follow-up outside clinical studies should be oriented towards iRECIST criteria

Citation Format

  • Lennartz S, Diederich S, Doehn C et al. Radiological Monitoring of Modern Immunotherapy: A Novel Challenge for Interdisciplinary Patient Care. Fortschr Röntgenstr 2020; 192: 235 – 244