Multidisciplinary management of hepatocellular carcinoma: a model for therapy

Abstract

A multidisciplinary model is a useful approach in the management of hepatocellular carcinoma (HCC) to coordinate, individualize, and optimize care. The HCC Multidisciplinary Team (MDT) at Temple University Hospital was established in 2008 and comprises hepatologists, interventional radiologists, transplant surgeons, oncologists, residents, midlevel providers, and support staff. Patients may be enrolled by referral from (1) oncologists at Temple, (2) the hepatitis screening clinic recently established at Temple and staffed by hepatology residents, or (3) community practices. MDT conferences are held weekly, during which cases are discussed (based on medical history, interpretation of images, and laboratory analyses) and treatment plans are formulated. The Temple treatment algorithm follows current standards of care, guided by tumor volume and morphology, but the novel multidisciplinary interaction challenges members to tailor therapy to achieve the best possible outcomes. Patients with a solitary lesion ≤ 2 cm may receive no treatment until eligible for transplantation or locoregional therapy or resection, with imaging every 3 to 6 months to monitor tumor progression. In patients with tumors > 2 cm and ≤ 5 cm, microwave ablation therapy is used if lesions are discrete and accessible. Conventional transarterial chemoembolization (TACE) or drug-eluting bead TACE (DEB-TACE) or yttrium-90 microspheres are utilized in multifocal disease. Patients with lesions > 5 cm are candidates for TACE for downstaging the tumor. Sorafenib is typically reserved for unresectable lesions between 2 cm and 5 cm. Frequently, we administer sorafenib continuously and in combination with DEB-TACE. In our experience, sorafenib does not produce effects on the tumor vasculature or blood flow that would impair the efficacy of DEB-TACE. The literature documents improved outcomes in HCC and other cancers associated with the introduction of multidisciplinary care. The role and organization of the MDT is influenced by team culture, expertise, and process, as well as institutional and larger environmental contexts.

Keywords: HCC; coordinated care; interdisciplinary; transplant.

Figure 1

The Temple University multidisciplinary team treatment approach for patients with HCC. Abbreviations: AFP, alpha-fetoprotein; CT, computed tomography; DEB-TACE, drug-eluting bead TACE; HCC, hepatocellular carcinoma; MRI, magnetic resonance imaging; PT/INR, prothrombin time/International Normalized Ratio; TACE, transarterial chemoembolization; Y90, yttrium-90.

Figure 2

Patient flow through the Temple University MDT care model for HCC management is depicted in this flow diagram. Notes: Following intake by the MDT coordinator (A), patient data are reviewed by the MDT (B) to determine transplant eligibility. Under the direction of the transplant nurse (C), transplant candidates undergo comprehensive evaluation and multimodal screening tests (eg, serum chemistries, MRI, CT, pulmonary function, and cardiac tests). Those who are currently ineligible for transplant (D) are screened for LRT (TACE or Y90 radioembolization) and undergo further assessments to confirm eligibility (eg, arteriography, 99mTc scans). Throughout the course of care, the MDT coordinator provides support in scheduling and explaining procedures and addresses concerns and questions. Post-transplant and post-LRT, patient progress is collaboratively reviewed each week. MDT members can access and share information via the EMR system and with the assistance of the IRC, who stores images and other data in a central repository. Abbreviations: CT, computed tomography; EMR, electronic medical record; HCC, hepatocellular carcinoma; IRC, interventional radiology coordinator; LRT, locoregional therapy; MDT, multidisciplinary team; MRI, magnetic resonance imaging; TACE, transarterial chemoembolization; Y90, yttrium-90.