Evaluation of the Implementation of the Response Assessment in Neuro-Oncology Criteria in the HERBY Trial of Pediatric Patients with Newly Diagnosed High-Grade Gliomas

BACKGROUND AND PURPOSE

HERBY was a Phase II multicenter trial setup to establish the efficacy and safety of adding bevacizumab to radiation therapy and temozolomide in pediatric patients with newly diagnosed non-brain stem high-grade gliomas. This study evaluates the implementation of the radiologic aspects of HERBY.

MATERIALS AND METHODS

We analyzed multimodal imaging compliance rates and scan quality for participating sites, adjudication rates and reading times for the central review process, the influence of different Response Assessment in Neuro-Oncology criteria in the final response, the incidence of pseudoprogression, and the benefit of incorporating multimodal imaging into the decision process.

RESULTS

Multimodal imaging compliance rates were the following: diffusion, 82%; perfusion, 60%; and spectroscopy, 48%. Neuroradiologists' responses differed for 50% of scans, requiring adjudication, with a total average reading time per patient of approximately 3 hours. Pseudoprogression occurred in 10/116 (9%) cases, 8 in the radiation therapy/temozolomide arm and 2 in the bevacizumab arm (P < .01). Increased target enhancing lesion diameter was a reason for progression in 8/86 cases (9.3%) but never the only radiologic or clinical reason. Event-free survival was predicted earlier in 5/86 (5.8%) patients by multimodal imaging (diffusion, n = 4; perfusion, n = 1).

CONCLUSIONS

The addition of multimodal imaging to the response criteria modified the assessment in a small number of cases, determining progression earlier than structural imaging alone. Increased target lesion diameter, accounting for a large proportion of reading time, was never the only reason to designate disease progression.

Establishing an International Reference Image Database for Research and Development in Medical Image Processing

Introduction: The lack of comparability of evaluation results is one of the major obstacles of research and development in Medical Image Processing (MIP). The main reason for that is the usage of different image datasets with different quality, size and Gold standard.

Objectives: Therefore, one of the goals of the Working Group on Medical Image Processing of the European Federation for Medical Informatics (EFMI WG MIP) is to develop first parts of a Reference Image Database.

Methods: Kernel of the concept is to identify highly relevant medical problems with significant potential for improvement by MIP, and then to provide respective reference datasets. The EFMI WG MIP has primarily the role of a specifying group and an information broker, while the provider user relationships are defined by bilateral co-operation or license agreements.

Results: An explorative database prototype has been implemented using the MySQL database software on the Web. Templates for provider user agreements have been worked out and already applied for own ‘pre-RID-MIP’ co-operations of the authors.

Discussion and Conclusion: First steps towards a comprehensive reference image database have been done. Issues like funding, motivation, management, provision of Gold standards and evaluation guidelines are to be solved. Due to the interest from research groups and industry the efforts will be continued.

Response Assessment in Pediatric Neuro-Oncology: Implementation and Expansion of the RANO Criteria in a Randomized Phase II Trial of Pediatric Patients with Newly Diagnosed High-Grade Gliomas

Determination of tumor response to treatment in neuro-oncology is challenging, particularly when antiangiogenic agents are considered. Nontumoral factors (eg, blood-brain barrier disruption, edema, and necrosis) can alter contrast enhancement independent of true tumor response/progression. Furthermore, gliomas are often infiltrative, with nonenhancing components. In adults, the Response Assessment in Neuro-Oncology (RANO) criteria attempted to address these issues. No such guidelines exist yet for children. The ongoing randomized phase II trial, A Study of Avastin (bevacizumab) in Combination With Temolozomide (TMZ) and Radiotherapy in Paediatric and Adolescent Patients With High-Grade Glioma (HERBY), will establish the efficacy and safety of the antiangiogenic agent bevacizumab for the first-line treatment of newly diagnosed high-grade glioma in children (n = 121 patients, enrollment complete). The primary end point is event-free survival (tumor progression/recurrence by central review, second primary malignancy, or death). Determination of progression or response is based on predefined clinical and radiographic criteria, modeled on the RANO criteria and supported by expert pseudoprogression review and the use of standardized imaging protocols. The HERBY trial will also compare conventional MR imaging (T1-weighted and T2/fluid-attenuated inversion recovery sequences) with conventional MR imaging plus diffusion/perfusion imaging for response assessment. It is anticipated that HERBY will provide new insights into antiangiogenic-treated pediatric brain tumors. HERBY will also investigate the practicality of obtaining adequate quality diffusion/perfusion scans in a trial setting, and the feasibility of implementing standard imaging protocols across multiple sites. To date, 61/73 (83.6%) patients with available data have completed diffusion-weighted imaging (uptake of other nonconventional techniques has been limited). Harmonization of imaging protocols and techniques may improve the robustness of pediatric neuro-oncology studies and aid future trial comparability.

The benefit using an integrated electronic trial platform for a neoadjuvant therapy trial (HEDON) in primary breast cancer – results of an evaluation study

Abstract #3114

Background: At present, academic medical centers conducting investigator initiated trials (IIT) have the choice of relying on paper or going electronic regarding electronic data capture and data management solutions. Many of the electronic systems have originally been developed for requirements of the pharmaceutical industry and all of the currently available systems would thus be isolated in the existing IT setting of the medical centers.&#x2028; We here suggest an approach to integrate a data management system into existing hospital information systems (HIS) and to provide the end users (e.g. physicians, investigators, study nurses) with consolidated user interfaces and integrated systems.&#x2028; Methods: In 2005, a collaboration between the Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technical University of Munich and Siemens Medical Solutions was initiated as a pilot project.&#x2028; An integrated platform for clinical trials was developed and implemented to support the HEDON trial (Herceptin-Docetaxel-Neoadjuvant), an investigator initiated clinical phase II trial concerning primary systemic therapy of breast cancer. The HEDON trial started in February 2006 and will have recruited all of a total of 90 planned patients in the end of this year. In addition, a translational research trial (TransHEDON) evaluating therapy response markers is an essential component of the clinical trial.&#x2028; Using the integrated platform, clinical data as well as laboratory data are automatically populated from the HIS into the electronical study CRFs, after data confirmation by investigators or study nurses (depending on their defined role) using the validation buffer of the system. The existing PACS and HIS are made accessible from the platform which has special capabilities to greatly improve user interactions with all relevant systems. To quantify the benefit of such an integrated system, an integrated evaluation project was set up including the quantification time savings for all involved personnel. For a pre-defined time period, data capture and data management processes are performed paper based and electronically. This allows thorough and critical analysis of all involved processes&#x2028; Resukts; Errors that occur specially due to manually entering laboratory data can be dramatically minimized using such an electronical data capture system. Another important benefit is time savings. The data will be presented.&#x2028; Conclusion:This single-sign-on electronic platform for clinical trials has been validated in its whole and fulfils the regulatory requirements as specified by GCP or 21 CFR part 11 compliance for trials of the FDA. We consider this integrated system to be very helpful for implementation of clinical trials into a routine hospital setting.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3114.

Quality assurance for diabetic retinopathy telescreening

AIMS

TOSCA was an EU-Commission supported international research project designed to develop telescreening services in diabetic retinopathy and glaucoma. This paper describes the quality assurance methods developed for the diabetic retinopathy telescreening service within the TOSCA project.

SETTING

The study was performed in 1895 patients with diabetes between 2000 and 2002 at diabetic retinopathy screening sites in five European countries. Data were analysed centrally.

METHODS

Patients attending each clinic's diabetic retinopathy screening service received standardized retinal photography. The images and associated data were transferred electronically to a remote location for grading. Each photographer uploading images and each grader downloading images for assessment was controlled by a systematic quality management approach. The quality assurance measures defined were image quality, intragrader reliability. A cockpit chart was developed for the management and presentation of relevant results and quality measures. For the intragrader reliability tests, 10% of the images were processed for a second grading. An algorithm for calculating differences between repeated gradings was developed.

RESULTS

The assessment of image quality for the different sites showed that only 0-0.7% were unassessable. One hundred per cent agreement for both gradings was achieved in 50-85% of graded cases, depending on site and grader, and an agreement better than 95% in 71-100% of cases.

CONCLUSIONS

A telemedicine-supported quality assurance process is practical and advantageous. The cockpit charts have proven to be useful tools when monitoring the performance of a telescreening service. Grader feedback showed high satisfaction with the quality assurance process.

Synergy between medical informatics and bioinformatics: facilitating genomic medicine for future health care

In this paper, we review the results of BIOINFOMED, a study funded by the European Commission (EC) with the purpose to analyse the different issues and challenges in the area where Medical Informatics and Bioinformatics meet. Traditionally, Medical Informatics has been focused on the intersection between computer science and clinical medicine, whereas Bioinformatics have been predominantly centered on the intersection between computer science and biological research. Although researchers from both areas have occasionally collaborated, their training, objectives and interests have been quite different. The results of the Human Genome and related projects have attracted the interest of many professionals, and introduced new challenges that will transform biomedical research and health care. A characteristic of the 'post genomic' era will be to correlate essential genotypic information with expressed phenotypic information. In this context, Biomedical Informatics (BMI) has emerged to describe the technology that brings both disciplines (BI and MI) together to support genomic medicine. In recognition of the dynamic nature of BMI, institutions such as the EC have launched several initiatives in support of a research agenda, including the BIOINFOMED study.

Feasibility of using the TOSCA telescreening procedures for diabetic retinopathy

AIMS

The TOSCA project was set up to establish a tele-ophthalmology service to screen for diabetic retinopathy (DR) in Europe. The aim of this study was to determine the feasibility of establishing telemedicine-based digital screening for detecting DR and to evaluate the satisfaction of both patients and healthcare professionals with the screening procedures used within the TOSCA project.

METHODS

The study was a non-randomized, multicentre study carried out in four different countries over a period of 3 months. Patients (n = 390) with diabetes aged > 12 years were included. Two digital retinal images per eye (macular and nasal) were taken and exported to a central server. Patients were asked to complete a questionnaire to assess satisfaction. Accredited graders carried out grading remotely and the results were reported back to the referring centre. Previously graded patient data chosen randomly to represent examples of both DR and no DR were also sent anonymously to the grading centre at a frequency of approximately every 10 patients.

RESULTS

Most (99%) of the images were assessable enabling a retinopathy grade to be assigned to the patient. Patients found the retinal photography procedures acceptable; only 6% in one centre would not recommend the procedure. Healthcare professionals (photographers and graders) were also satisfied with the overall procedures. The average time taken to grade each patient was approximately 5 min.

CONCLUSIONS

This study demonstrated that it is feasible to electronically transmit and grade retinal images remotely using the TOSCA process. Built-in quality assurance procedures proved acceptable.

Establishing an international reference image database for research and development in medical image processing

INTRODUCTION

The lack of comparability of evaluation results is one of the major obstacles of research and development in Medical Image Processing (MIP). The main reason for that is the usage of different image datasets with different quality, size and Gold standard.

OBJECTIVES

Therefore, one of the goals of the Working Group on Medical Image Processing of the European Federation for Medical Informatics (EFMI WG MIP) is to develop first parts of a Reference Image Database.

METHODS

Kernel of the concept is to identify highly relevant medical problems with significant potential for improvement by MIP, and then to provide respective reference datasets. The EFMI WG MIP has primarily the role of a specifying group and an information broker, while the provider user relationships are defined by bilateral co-operation or license agreements.

RESULTS

An explorative database prototype has been implemented using the MySQL database software on the Web. Templates for provider user agreements have been worked out and already applied for own 'pre-RID-MIP' co-operations of the authors.

DISCUSSION AND CONCLUSION

First steps towards a comprehensive reference image database have been done. Issues like funding, motivation, management, provision of Gold standards and evaluation guidelines are to be solved. Due to the interest from research groups and industry the efforts will be continued.

Impact of virtual reality imaging on hepatic liver tumor resection: calculation of risk

The risk involved in partial liver resections depends mainly on tumor localization, invasion of central vascular structures, and parenchymal function. The imaging techniques available today (computed tomography, magnetic resonance imaging) allow us to detect precisely the extent of tumor invasion and their relationship to central vessels. The various three-dimensional reconstruction techniques are helpful with regard to a virtual planning of liver resections. The calculation of remaining liver volumes subsequent to partial hepatectomies are considered to be an essential predictive parameter in terms for the development of postoperative liver failure. In a retrospective and a later consecutive, prospective clinical study we analyzed the postoperative risk in a series of 570 patients. In an univariate analysis 13 of 31 parameters showed significant values. In multivariate analysis only three parameters (partial hepatic resection rate, PHRR), gamma-glutamyltranspeptidase, and prothrombin activity) were independent parameters for predicting liver failure, generating the most significant values for the PHRR. In our experience the most comfortable and precise technique for evaluating PHRR is the b-spline technique.

Evaluation of telemedical services

With the rapidly increasing development of telemedicine technology, the evaluation of telemedical services becomes more and more important. However, professional views of the aims and methods of evaluation are different from the perspective of computer science and engineering or from medicine and health policy. We propose that a continuous evaluation strategy should be chosen which guides the development and implementation of telemedicine technologies and applications. The evaluation strategy is divided into four phases in which the focus of evaluation is shifted from technical performance of the system in the early phases to medical outcome criteria and economical aspects in later phases. We review the study design methodology established for clinical trials assessing therapeutic effectiveness and diagnostic accuracy and discuss how it can be adapted to evaluation studies in telemedicine. As an example, we describe our approach to evaluation in a teleconsultation network in ophthalmology.

[Teleconsultation network for ophthalmology--experiences and results]

MOTIVATION

Telemedical services for ophthalmology are developed within the OPHTEL project, which has been funded by the European Union and by the Bavarian government in the Bavaria-online initiative.

METHODS

Seven private ophthalmologists, one university eye clinic, one clinical Diabetes center and an informatics research institute are connected within a teleconsultation network. Asynchronous (based on Internet E-Mail) and synchronous (based on ISDN-mediated videoconferencing tools) types of teleconsultations are realized.

RESULTS

86 teleconsultations (62 asynchronous, 23 synchronous) took place within the first 10 months. Complex and rare eye diseases as well as interdisciplinary questions (ophthalmology--diabetology) are the main area of medical communication interest. Legal and security problems are discussed.

CONCLUSIONS

Telemedical services must be understood as a complete process of medical care on the basis of modern communication technologies, which influences also the management of this process.

[Scientific role of German ophthalmology in the European telecommunication project OPHTEL]

BACKGROUND

In Denmark, France, Germany, Great Britain and Italy, the OPHTEL project combines clinical centers of ophthalmology and internal medicine, an institute for medical informatics and health services research, a publishing company and different industrial partners in the EDP market.

AIMS

With the aid of visual telecommunication and rapid data transfer, methods and conditions will be developed and proved so that any physician can very easily obtain sufficient information for treating his patient. Thus, the regional differences in the quality of structured health service (e.g., urban/ rural) will be overcome throughout Europe. SCIENTIFIC TASKS: A multilingual diagnostic and therapeutic thesaurus has to be worked out in order to create standards for communication and quality control. Based on literature, images and image analysis in a knowledge-based data bank, a monitoring system (containing watch-dog functions) and the basic aspects of an ophthalmological patient/disease register will be investigated. (In parallel, a technical development of synchronous and asynchronous telecommunication between eye physicians is taking place in close cooperation with the regional Bavarian project Teleopathalmology in Bavaria on-line).

RESULTS

State of the art 6 months after starting the project:the knowledge-based image data bank has been founded and also an ophthalmological 8 language thesaurus and definition standard. All data transfer lines are installed.

DISCUSSION

The project is taking place amid diverging sections of medicine: ophthalmology and internal medicine, health politics and data protection, individual treatment and common interest (health care), product management and office organization. Thus, the scientific quality of the transferred ophthalmological content must undergo sophisticated controls. FUTURE STEPS: Intense cooperation with the big German associations for ophthalmology (DOG, BVA) and the European ophthalmological societies concerning EDP, classification and quality control.

[Application of information technology in orthodontics. 6. Knowledge based systems in orthodontics]

The increase of quality and efficiency in orthodontic treatment is characterized by the development of knowledge based consultations systems. These systems support the dentist to optimate treatment planing. Basis configuration and technical background of those systems are presented.