Development, Practice Patterns, and Early Clinical Outcomes of a Multidisciplinary Liver Cancer Clinic

Abstract

Multidisciplinary care has been associated with improved survival in patients with primary liver cancers. We report the practice patterns and real world clinical outcomes for patients presenting to the Johns Hopkins Hospital (JHH) multidisciplinary liver clinic (MDLC). We analyzed hepatocellular carcinoma (HCC, n = 100) and biliary tract cancer (BTC, n = 76) patients evaluated at the JHH MDLC in 2019. We describe the conduct of the clinic, consensus decisions for patient management based on stage categories, and describe treatment approaches and outcomes based on these categories. We describe subclassification of BCLC stage C into 2 parts, and subclassification of cholangiocarcinoma into 4 stages. A treatment consensus was finalized on the day of MDLC for the majority of patients (89% in HCC, 87% in BTC), with high adherence to MDLC recommendations (91% in HCC, 100% in BTC). Among patients presenting for a second opinion regarding management, 28% of HCC and 31% of BTC patients were given new therapeutic recommendations. For HCC patients, at a median follow up of 11.7 months (0.7-19.4 months), median OS was not reached in BCLC A and B patients. In BTC patients, at a median follow up of 14.2 months (0.9-21.1 months) the median OS was not reached in patients with resectable or borderline resectable disease, and was 11.9 months in patients with unresectable or metastatic disease. Coordinated expert multidisciplinary care is feasible for primary liver cancers with high adherence to recommendations and a change in treatment for a sizeable minority of patients.

Keywords: cancer treatment; chemotherapy; cholangiocarcinoma; hepatocellular carcinoma; liver cancer; radiation therapy; staging.

Figure 1.

Patient selection flow diagram. Data were abstracted from 101 HCC patients and 76 BTC patients; all were first-time encounters to JHH MDLC (i.e. none were follow up). BTC indicates biliary tract cancer; CCA, cholangiocarcinoma; HCC, hepatocellular carcinoma; MDLC, multidisciplinary liver clinic.

Figure 2.

Liver multidisciplinary liver clinic (MDLC) algorithm. MDLC includes physicians from multiple specialties (hepatology, interventional radiology, medical oncology, palliative care, pathology, radiation oncology, radiology, and surgical oncology). All referrals are screened by a dedicated full-time MDLC triage nurse. AFP indicates alpha fetoprotein; BTC, biliary tract cancer; CBC, complete blood count; CEA, carcinoembryonic antigen; CMP, complete metabolic panel; CT C/A/P, computerized tomography scan of chest, abdomen, and pelvis; HBV, hepatitis B virus; Ab, antibody; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; IHC, immunohistochemistry; INR, international normalized ratio; MRI, magnetic resonance imaging; NGS, next generation sequencing.

Figure 3.

Hepatocellular carcinoma treatment algorithm. These pathways were broadly based on the BCLC framework. We divided BCLC C into C1 (advanced stage due to macrovascular invasion) versus C2 (advanced stage due to extrahepatic disease). BCLC indicates Barcelona cancer liver clinic; CTP, Child-Turcotte Pugh score; EBRT, external beam radiation therapy; HCC, hepatocellular carcinoma; TACE, transarterial chemoembolization; Y90, Yttrium-90 radioembolization.

Figure 4.

Intrahepatic and perihilar cholangiocarcinoma treatment algorithm. Patients are classified based on surgical resectability. Stage 0 is resectable without high risk features. Stage 1 is resectable with high risk for micrometastases, such as cT4 or cN1 disease. Stage 2 is borderline resectable due to predicted R1 or R2 surgical outcome due to low FLR volume or vascular involvement. Stage 3 is unresectable due to very locally advanced distance or distant metastases. CCA indicates cholangiocarcinoma; Cis, cisplatin; EBRT, external beam radiation therapy; FLR, future liver remnant; Gem, gemcitabine; N1, node positive; R0, margin negative resection; R1, microscopic residual disease after resection; R2, macroscopic residual disease after resection.

Figure 5.

Hepatocellular carcinoma treatment outcomes. Excluding patients who immediately enrolled into hospice (n = 8) per MDLC recommendations, OS based on (A) CTP score (mOS was 8.1 and 3 months in CTP B and C, respectively) and (B) BCLC stage (median OS was 11.2 and 12.7 months in C1 and C2, respectively). Excluding patients who did not receive oncologic treatment (n = 14), OS based on (C) type of treatment received since MDLC (mOS in the systemic only group was 6 months) and (D) surgical resection (mOS was 12.7 months in the absence of resection). (E) DFS in patients who underwent resection (n = 13). Abbreviations: BCLC; Barcelona clinic liver cancer; CTP, Child-Turcotte Pugh score; DFS, disease free survival; MDLC, multidisciplinary liver clinic; mOS, median overall survival.

Figure 6.

Biliary tract cancer treatment outcome. Excluding patients who immediately enrolled into hospice (n = 6) per MDLC recommendations, OS based on (A) resectability stage (mOS was 11.9 in Stage 3). Excluding patients who did not receive oncologic treatment (n = 11), OS based on (B) type of treatment received since MDLC (mOS in the systemic only group was 12.5 months) and (C) surgical resection (mOS not reached in either group). (D) DFS in patients who underwent resection (n = 15), projected median DFS was 15 months. BTC indicates biliary tract cancer; DFS, disease free survival; MDLC, multidisciplinary liver clinic; mOS, median overall survival.