FIG 4.

Management algorithm at initial radiographic progression (A) without and (B) with new lesions. (A) If initial radiographic progression does not involve new lesions, management depends first on whether the patient is clinically stable. If the patient has not experienced clinical decline and the physician and patient decide to continue treatment, the lesions that are enlarging (if they are accessible and can be safely injected) should be injected. Lesions that were previously classified as noninjected may be reclassified as injected at this time, although the target and nontarget categories must be strictly preserved. (B) If progression involves new lesions that are accessible and can be safely injected, they should be prioritized for injection. New lesions that are measurable can contribute to a new lesion sum of diameters for an overall response assessment that resembles RECIST for immunotherapeutic trials (iRECIST). New lesions that are injected can be evaluated as part of the iterative assessment process for injected lesions but may not contribute to the target noninjected (T-NI) tumor burden. PD, progressive disease; NT-I, nontarget injected; NT-NI, nontarget noninjected; T-I, target injected.