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A concept map that helps me to understand all the questions and the impact of a separate non-tumor lesion domain:
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Question 1: just because something is considered as a lesion, does that mean that it should be mapped to the lesion domains?
Two aneurysms are identified in the thoracic and abdominal regions, one is considered as "target" for study treatment and the other "non-target" for study treatment.
CVREFID provides the unique identifier for each identified aneurysm.
CVLNKID will link the CV records to other domain datasets, such as RS and CC for disease response to treatment and clinical classification data (data not shown).
CVGRPID is used to group data for target and non-target aneurysms.
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Aneurysm TU, TR and RS modeling Concept Map
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Case 1 - Subject has both TAA and AAA
The subject had a chest CT scan and an abdominal CT scan.
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TU Approach 1: TU result location findings are modeled as variables.
An evaluator examines the images of the thoracic and abdominal regions produced by the CT scan and decides whether TAA and AAA are present as well as their locations. Note for viewing simplicity, some variables are omitted from the table below.
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Note the TUTEST here is: Aneurysm Location Identification, TUORRES = Located.
- should TUTEST be: Lesion Location Identification, and TULNKID = Thoracic Aortic Aneurysm 1?
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| title | cv.xpt |
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| Name | TU |
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| hi1style | aqua |
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| hi2 | a,b,c,d |
| hi1 | 2,4,6,8 |
| hi2style | yellow |
| tableid | TU1 |
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STUDYID
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DOMAIN
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USUBJID
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TUGRPID
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TUTEST
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TUORRES
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TULOC
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TUMETHOD
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VISITNUM
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VISIT
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TUDTC
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Dissection Location Identification
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CT SCAN
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The TU/TR/RS domains were created for tumors which in themselves don't belong in any body system domains (tumor can grow and spread to any place), hence they are in their own domains. At some point, non-tumor lesion was added to TU/TR. SDTM now has body-system domains, it then begs the question whether a separate non-tumor lesion domain is needed, when most "lesions" and things that could be considered as lesions, can go into their respective body-system domains. Can the body system domains offer the "unique lesion identifier" through the use of, GRPID, REFID, or other identifier variables?
Question 2: how do you map lesions that are non-target for study treatment?
TU/TR/RS were originally built to assess tumor response to "study" treatment. Both "target" and "non-target" tumors receive the same study treatment, are then tracked and evaluated. "Target" and "non-target" tumor properties are mapped to TR and their responses to treatment are mapped to RS. Depending on the criteria used, "Target" and "non-target" tumor responses to treatment are evaluated a little differently. "Non-target" in the tumor context, does NOT mean, "not treated by study intervention".
In the CV data element projects, non-target is used to describe a lesion that will NOT be treated by a study intervention. Such a lesion may be untreated, managed by a non-study drug, or treated with a non-study device or procedure. This type of data has also been mapped into TU and TR, is this correct? If TU/TR are built to house lesion response to study treatment type of data, then I think the CV modeling is incorrect, and if so, how do we deal with it?
Example 2: Observed abnormality that's a lesion, but "non-target" for study intervention, it is not treated and continuously monitored.
A small aneurysm is revealed by the abdomen CT scan. This aneurysm is small and is considered as "non-target" for study intervention, it is untreated and continuously monitored. Not sure whether this can be mapped to TU/TR, hence mapped to CV.
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CT SCAN
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CT SCAN
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Dissection Location Identification
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CT SCAN
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CT SCAN
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CT SCAN
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CT SCAN
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TU Approach 2 - treating result location findings as individual tests
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| title | cv.xpt |
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| Name | TU |
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| hi1style | #fffae5 |
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| hi2 | 4,10,14 |
| hi1 | 3,9,13 |
| hi2style | #e3fcef |
| tableid | tu1 |
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STUDYID
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DOMAIN
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USUBJID
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TUGRPID
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TUTEST
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TUORRES
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TULOC
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TUMETHOD
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VISITNUM
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VISIT
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TUDTC
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Thoracic Aorta
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CT SCAN
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Aortic Arch to Descending aorta
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CT SCAN
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Aortic Arch to Descending aorta
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CT SCAN
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CT SCAN
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Dissection Location
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Descending aorta
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Example 3: Observed abnormality that's also a lesion and "target" for study intervention
The chest CT revealed a large aneurysm in the thoracic aorta which is "target" for study intervention. Note the use of the NSV TUFLAG to show that this abnormality is also considered as a target lesion for study intervention, tracking and/or disease response to treatment assessment. When the TUFLAG is marked with Y, measurements of the lesion should be represented in TU, TR and/or RS.
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Infrarenal aorta
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Proximal to the iliac bifurcation
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Proximal to the iliac bifurcation
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CT SCAN
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Shows the TU representation of the target lesions:
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Dissection Location
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Infrarenal aorta
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CT SCAN
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Dissection Location Detail
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Proximal to the iliac bifurcation
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CT SCAN
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Dissection Location Detail
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Proximal to the iliac bifurcation
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CT SCAN
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Diameters of the identified aneurysms are measured and are mapped to TR. LNKID is used to link TU and TR.
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Note for Tumor Findings, it is recommended not to populate TRLOC because locations of tumors have been identified in TU. Should this rule be followed for non-tumor lesion?
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| title | cv.xpt |
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| Name | TR |
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| hi1style | aqua |
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| hi1 | TRLOC |
| tableid | TR1 |
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STUDYID
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DOMAIN
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USUBJID
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TRLNKID
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TRTEST
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TRORRES
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TRMETHOD
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VISITNUM
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VISIT
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CVDTC
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The dissected descending aorta (LNKID =Dissection 1) is classified based on the Stanford Aortic Dissection System as type B.
Note: This test was originally created as a CVTEST, based on SDTMIG 3.4, this is now considered as a grading scale and therefore should now be represented as CC/RS. Note the RSTEST still takes the original CV domain terminology naming convention, it does not comply with QRS rules.
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| Name | RS |
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STUDYID
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DOMAIN
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USUBJID
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RSLNKID
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RSTEST
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RSORRES
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VISITNUM
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VISIT
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CVDTC
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The results for TU, TUORRES = target, non-target, or new target. This convention was designed for tumor assessment. Target and non-target have very specific definitions depending on the tumor under study. Generally for solid tumor, according to RECIST: Measurable lesions - lesions that can be accurately measured in at least one dimension with longest diameter 20 mm using conventional techniques or 10 mm with spiral CT scan.
Non-measurable lesions - all other lesions, including small lesions (longest diameter <20 mm with conventional techniques or <10 mm with spiral CT scan), i.e., bone lesions, leptomeningeal disease, ascites, pleural/pericardial effusion, inflammatory breast disease, lymphangitis cutis/pulmonis, cystic lesions, and also abdominal masses that are not confirmed and followed by imaging techniques.
Since TU is also shared by Lesion Identification, to have a result as "target" is misleading and doesn't always apply to non-tumor settings. When you say there is a target aneurysm, what does that mean? Target for treatment and response evaluation? what is the criteria that makes it a target? Usually an aneurysm larger than 5cm requires surgery. Does that mean the ones that are smaller than 5 cm are considered "non-target"? and non-target for what? surgery not needed? The values for TU responses right now, doesn't make sense for non-tumor lesion identification process. |
Case 2 - Subject has AAA but TAA is not found
The subject had a MRI that scanned his torso, from chest to abdomen. Should PRLOC be "torso", or "chest" and "abdomen"? The places where you point the probe to, are they locations of the procedure?
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| hi1style | aqua |
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| hi1 | PRLOC |
| tableid | PR1 |
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USUBJID
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PRTRT
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VISIT
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The MRI scan produced cross-sectional images of the thoracic and abdominal regions of the subject. The evaluator then examined the MRI images of the thoracic region and abdominal region, and found the presence of a large AAA, and an aneurysm in the left renal artery, but the absence of TAA.
Because when a large AAA is found, the chance of a TAA (or an aneurysm developed elsewhere) is high (the reverse holds true as well), in the presence of a diagnosed large AAA or TAA, it is recommended to also screen for the other. A TAA is synchronous if diagnosed within 2 years from the diagnosis of an AAA. All TAAs diagnosed at a later date were considered metachronous and must have had prior chest imaging that did not show the presence of TAA.
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| Name | TU |
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Show the diameter measurements of the target lesion in TR at two visits:
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| hi1style | aqua |
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| hi1 | 3,5 |
| tableid | TU3 |
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STUDYID
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DOMAIN
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USUBJID
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TUGRPID
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TUTEST
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TUORRES
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TULOC
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TUMETHOD
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VISITNUM
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VISIT
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TUDTC
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ABC
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Located
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Located
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The problem with the way TU is set up now, which is originally designed for tumor identification, and you only care about "already identified tumors", is that it only allows the creation of positive records. It doesn't allow the creation of a "pertinent negative" record. If I were to model case 2 in TU the way TU is designed now, I would lose the ability to represent the negative record for the Thoracic Region as shown above because an aneurysm is not identified in this region. This is also in part, due to the fact that the location where an object is found, is mapped to PRLOC instead of TULOC, thusly not allowing the representation of imaging location in findings.
In the original DUKE data element, the responses provided for TAA and AAA, and all other types of aneurysms all have the responses: present, absent and unknown.
The example below models TAA and AAA according to the current TU domain structure. Note i am unable to map the negative identification record.
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| title | cv.xpt |
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| Name | TU |
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STUDYID
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DOMAIN
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USUBJID
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TUTEST
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TUORRES
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TULOC
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TUMETHOD
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VISITNUM
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VISIT
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TUDTC
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Target
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What goes into TULOC?
After all this, i struggle with what values should go into TULOC. When a CT scans the chest, it produces cross-sectional images of the chest/thorax and everything in it. You can view the images in three angles: a) axial view (you are looking at the picture of the thorax from the direction of head to toe), b) the coronal view (you are looking at the images of the thorax as if you are standing in front of the person), c) sagittal view (you are looking at the picture of the thorax from the side). Hence TULOCs are populated with Thoracic Region and Abdominal Region for now. Especially in the axial view, as you move from cross-sectional images of the thorax to images of the abdomen, you are looking at sectioned images of the thoracic region to abdominal region, there is no mistake about which region you are looking at because the anatomy of both regions are so different and clearly sperpated. I think it is not wrong to populate TULOC with chest and abdomen as well, they are just not the most precise anatomical terms.
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Imaging modality for the CV-imaging project: Coronary angiography:
Thransthoracic Echocardiogram (TTE):
Transesophageal Echocardiogram (TEE):
Cine Angiography:
In addition, i just recently took a family member to have a Thyroid Ultrasound:
Referring to Richard M's email: LOC in the interventions class is "Anatomical focus of an intervention - at which part of the body an intervention is being made". This also my understanding as well.
It is easy to pinpoint a location for invasive/treatment type interventions and this aligns with my understanding of how PRLOC should be used. However, for "diagnostic imaging" procedures, where the imaging probe is placed (i.e. neck, chest, abdomen, head, etc.), Is this really the location where a intervention is "made"? |
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