Impact of a single-day multidisciplinary clinic on the management of patients with liver tumours

Abstract

Purpose: Multidisciplinary cancer clinics may improve patient care. We examined how a single-day multidisciplinary liver clinic (mdlc) affected care recommendations for patients compared with the recommendations provided before presentation to the mdlc.

Methods: We analyzed the demographic and clinicopathologic data of 343 patients assessed in the Johns Hopkins Liver Tumor Center from 2009 to 2012, comparing imaging and pathology interpretation, diagnosis, and management plan between the outside provider (osp) and the mdlc.

Results: Most patients were white (n = 259, 76%); median age was 60 years; and 146 were women (43%). Outside providers referred 182 patients (53%); the rest were self-referred. Patients travelled median of 83.4 miles (interquartile range: 42.7-247 miles). Most had already undergone imaging (n = 338, 99%) and biopsy (n = 194, 57%) at the osp, and a formal management plan had been formulated for about half (n = 168, 49%). Alterations in the interpretation of imaging occurred for 49 patients (18%) and of biopsy for 14 patients (10%). Referral to the mdlc resulted in a change of diagnosis in 26 patients (8%), of management plan in 70 patients (42%), and of tumour resectability in 7 patients (5%). Roughly half the patients (n = 174, 51%) returned for a follow-up, and 154 of the returnees (89%) received treatment, primarily intraarterial therapy (n = 88, 57%), systemic chemotherapy (n = 60, 39%), or liver resection (n = 32, 21%). Enrollment in a clinical trial was proposed to 34 patients (10%), and 21 of the 34 (62%) were accrued.

Conclusions: Patient assessment by our multidisciplinary liver clinic had a significant impact on management, resulting in alterations to imaging and pathology interpretation, diagnosis, and management plan. The mdlc is an effective and convenient means of delivering expert opinion about the diagnosis and management of liver tumours.

Keywords: Multidisciplinary care; interventional radiology; liver tumours; single-day clinic; surgical oncology.

FIGURE 1

A modified Venn diagram depicts the overlap of changes in treatment, imaging, or pathology (or a combination), and diagnosis. Imaging or pathology (or both) changed in 29 patients without changes in diagnosis or treatment; in 17 patients with a change in diagnosis; in 15 with a change in treatment; in 2 with a change in both diagnosis and treatment. In 6 patients, the diagnosis changed without a change in treatment, imaging, or pathology; in 47, treatment changed without such a change; and in 3, diagnosis and treatment both changed without a change in imaging or pathology. In 2 patients, resectability changed because of a change in imaging or pathology, and in 5, resectability changed without a change in imaging or pathology. Changes in imaging include only those recorded on official radiology reports.

FIGURE 2

(A) Scan of a 56-year-old woman at an outside provider (osp) was interpreted as perfusion changes (arrow), with no mass. (B) Review of images at the multidisciplinary liver clinic (mdlc) revealed a left portal vein tumour thrombus (arrow) consistent with infiltrative hepatocellular carcinoma with portal vein involvement. The patient subsequently underwent intraarterial therapy. (C) Scan of a 28-year-old man with newly diagnosed colon cancer at an osp was interpreted as hepatic hemangiomas (arrows). (D) Review of images at the mdlc revealed T2-intense signal in the left hemi-liver lesion, with nodular enhancement compatible with hemangioma. The right liver lesion was consistent with metastatic disease, however. Patient subsequently underwent colon resection with simultaneous liver resection and received adjuvant systemic therapy. (E) Accurate diagnosis is vital in guiding therapy. This neuroendocrine neoplasm looks similar to a hepatocellular carcinoma. Careful histologic examination and special staining techniques are keys to correctly classifying this liver tumour.