Multidisciplinary Team Conference Research Articles

Assessment by a multidisciplinary team conference affects treatment strategy and overall survival in patients with synchronous colorectal liver metastases

BackgroundThe aim of this retrospective observational study was to investigate the geographical or sex differences in patients with synchronous colorectal liver metastases (sCRLM) in terms of assessment by a multidisciplinary team conference (MDT), curative treatment, and overall survival. MethodAll sCRLM patients in the South-East Health Care Region of Sweden from 2009 to 2015 were included (n = 615). Data were derived from the Swedish Colorectal Cancer Registry, Swedish Registry of Liver and Bile Surgery and medical records. ResultsPatients who had a hepatobiliary unit (HBU) at the nearest hospital were more likely to undergo liver surgery (HBU+, 37% (n = 106), compared to HBU−, 22% (n = 60); p = 0.001) and had a better median survival (p < 0.001). No sex differences were observed. In multivariate Cox regression analyses of overall survival, assessment by an MDT that included a liver surgeon was independently linked to better survival (HR 0.574, 0.433–0.760). ConclusionThere were no sex differences in access to liver surgery or overall survival, however, there were geographical inequalities, where residency near a hospital with HBU was associated with increased overall survival and the possibility to receive liver surgery. Assessment at MDT with liver surgeon present was associated with greater survival, indicating its important role for treatment.

Percutaneous Image-Guided Cryoablation of Endophytic Renal Cell Carcinoma

PurposeEndophytic renal cancer treatment is a challenge. Due to difficulties in endophytic tumor visualization during surgical extirpation, image-guided percutaneous cryoablation (PCA) is an attractive alternative. The minimally invasive nature of PCA makes it favorable for comorbid patients as well as patients in which surgery is contraindicated. Oncological outcomes and complications after PCA of endophytic biopsy-proven renal cell carcinoma (RCC) were reviewed in this study.Materials and MethodsPatients were included after a multidisciplinary team conference from January 2015 to November 2021. Inclusion criteria were endophytic biopsy-proven T1 RCC treated with PCA with one year of follow-up. Complications were reported according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system and the Clavien-Dindo classification (CDC) system. Major complications were defined as a grade ≥ 3 according to the CDC.ResultsFifty-six patients were included with a total of 56 endophytic tumors treated during 61 PCA sessions. The median RENAL nephrometry score was 9 (IQR 2), and the mean tumor size was 25.7 mm (SD ± 8.9 mm). Mean hospitalization time was 0.39 (SD ± 1.1) days. At a mean follow-up of 996 days (SD ± 559), 86% of tumors were recurrence free after one PCA. No patients progressed to metastatic disease. According to the CIRSE classification, 10.7% (n = 6) had grade 3 complications, and 5.4% (n = 3) had CDC major complications.ConclusionThis study demonstrates that PCA of endophytic biopsy-proven T1 RCC is safe with few major complications and excellent local tumor control rates at almost three-year mean follow-up.Level of Evidence 3Retrospective cohort study.Graphic

Prospective Assessment of Fluorine-18-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography (FDG-PET/CT) for Early Identification of Checkpoint-Inhibitor-Induced Pseudoprogression.

The activity of immune checkpoint inhibitors (ICIs) in patients with metastatic melanoma is often monitored using fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) scans. However, distinguishing disease progression (PD) from pseudoprogression (PsPD), where increased FDG uptake might reflect immune cell activity rather than tumor growth, remains a challenge. This prospective study compared the efficacy of dual-time point (DTP) FDG-PET/CT with modified response criteria (PERCIMT) in differentiating PsPD from PD. From July 2017-January 2021, 41 patients suspected to have PsPD on an evaluation scan were prospectively included (29 evaluable). A subsequent DTP FDG-PET/CT scan was conducted within 14 days, followed by a confirmatory FDG-PET/CT scan. Additionally, PERCIMT were applied. DTP FDG-PET/CT identified 24% with PsPD and 76% with PD. Applying PERCIMT criteria, 69% showed PsPD, while 31% had PD. On follow-up, 10 patients (34%) demonstrated confirmed PsPD, while 19 (66%) exhibited PD. The sensitivity and specificity of DTP FDG-PET/CT were 20% and 74%, respectively, and for PERCIMT this was 80% and 37%, respectively. Our findings suggest limited efficacy of DTP FDG-PET/CT in distinguishing PsPD from PD in ICI-treated patients with metastatic melanoma. The use of PERCIMT could complement clinical assessment and be incorporated in multidisciplinary team conferences for enhanced decision-making.

Despite multi-disciplinary team discussions the socioeconomic disparities persist in the oncological treatment of non-metastasized colorectal cancer

BackgroundThe introduction of national guidelines should eliminate previously observed associations between socioeconomic status (SES) and colorectal cancer treatment. The aim of the study was to investigate whether inequalities remain. MethodsCRCBaSe, a register-linkage originating from the Swedish Colorectal Cancer Registry, was used to identify information on patient and tumour characteristics, for 83,460 patients with stage I-III disease diagnosed 2008–2021. SES was measured as disposable income (quartiles) and the highest level of education. Outcomes of interest were emergency surgery, multidisciplinary team (MDT) conference discussion, and oncological treatment. Differences in treatment between SES groups were explored using multivariable logistic regression adjusted for year of diagnosis, age at diagnosis, sex, civil status, comorbidities, tumour location and stage. ResultsPatients in the highest income quartile had a lower risk of emergency surgery (OR 0.73 95%CI 0.68–0.80), a higher chance of being discussed at the preoperative (OR 1.39 95%CI 1.28–1.51) and postoperative MDT (OR 1.41 95%CI 1.30–1.53), receiving neoadjuvant (OR 1.15 95%CI 1.06–1.25) and adjuvant treatment (OR 2.04 95%CI 1.88–2.20). Higher education level increased the odds of MDT discussion but was not associated with oncological treatment. The proportion of patients discussed at the MDT increased, with almost all patients discussed since 2016. Despite this, treatment differences remained when patients diagnosed since 2016 were analysed separately. ConclusionThere were significant differences in how patients with different SES were treated for colorectal cancer. Further action is required to investigate the drivers of these differences as well as their impact on mortality and, ultimately, eliminate the inequalities.

Application of multidisciplinary team conference for neuromodulation candidates facilitates patient selection and optimization.

Psychological evaluation is required by insurance companies in the United States prior to proceeding with a spinal cord stimulation or a dorsal root ganglion stimulation trial. Since January 2017, we implemented a Multidisciplinary Team Conference for Neuromodulation in our center to facilitate the collaboration between pain physicians and psychologists and to optimize screening of neuromodulation candidates. This study aims to report the impact of this team conference on improvement of neuromodulation outcome in our center. Appropriateness of neuromodulation were discussed in the team conference after initial visit with the pain specialist and psychological evaluation. For this study, we prospectively and retrospectively collected data on neuromodulation candidates who went through the team conference and those who did not as controls. We discussed 461 patients in the team conference sessions from January 2017 to July 2023. Out of these, a spinal cord stimulator or a dorsal root ganglion stimulator trial was performed in 164 patients with 80.5% (132 cases) trial success rate leading to 140 implants. Out of these implants, 26 (18.6%) explanted and 21 (15%) required revision in 41 (29.3%) patients. We performed neuraxial neuromodulation trial for 70 patients without going through the team conference from January 2016 to July 2023 with a trial success rate of 45.7% (32 cases). In this group, 7 (21.9%) and 6 (18.8%) patients underwent explant and revision. The differences between the groups were statistically significant for trial success rate (odds ratio of 4.9 with p-value of <0.01) but not for explant (odds ratio of 0.8 with p-value of 0.627) or revision (odds ratio of 0.8 with p-value of 0.595). Implementing Multidisciplinary Team Conference increased trial success rate in our center. Team conference provides therapeutic benefit for patients, and also provides the opportunity for an educational discussion for trainees.

A randomised trial of [18F]PSMA-1007-PET/CT versus NaF-PET/CT for staging primary prostate cancer: A trial protocol.

Prostate-specific membrane antigen (PSMA)-positron emission tomography/contrast-enhanced computed tomography (PET/CT) is a sensitive imaging modality for prostate cancer (PCa). Due to lack of knowledge of the patient benefit, PSMA-PET/CT is not yet recommended in the European guidelines for staging and treatment planning of patients with newly diagnosed PCa. We will investigate the potential difference in progression-free survival (PFS) and quality of life (QoL) of using PSMA-PET/CT versus sodium fluoride (NaF)-PET/CT for staging and treatment planning in patients with newly diagnosed PCa. This is a prospective randomised controlled multicentre trial carried out at three centres in the Region of Southern Denmark. The primary endpoint is PFS. Secondary endpoints are residual disease, stage migration, impact on treatment strategies, stage distribution, QoL and diagnostic accuracy measures. Patients eligible for the study have newly diagnosed unfavourable intermediate- or high-risk PCa. A total of 448 patients will be randomised 1:1 into two groups: (A) a control group staged with Na[18F]F-PET/CT and (B) an intervention group staged with [18F]PSMA-1007-PET/CT. A subgroup in the intervention group will have a supplementary blinded Na[18F]F-PET/CT performed for the purpose of performing accuracy analyses. QoL will be assessed at baseline and with regular intervals (3-12 months) during the study period. Treatment decisions are achieved at multidisciplinary team conferences based on the results of the respective scans and according to current Danish guidelines. The Regional Committees on Health Research Ethics for Southern Denmark (S-20190161) and the Danish Medicines Agency (EudraCT Number 2021-000123-12) approved the study, and it has been registered on clinicaltrials.gov (Record 2020110469).

The Multidisciplinary Vascular Team Conference: The Emperor’s New Clothes Revisited or an Indispensable Part of Modern Medicine?

The Multidisciplinary Vascular Team Conference: The Emperor’s New Clothes Revisited or an Indispensable Part of Modern Medicine?

RETROSPECTIVE STUDY OF ULTRASONOGRAPHIC AND FNAC CORRELATION OF THYROID LESIONS WITH HISTOPATHOLOGY

INTRODUCTION: Thyroid diseases, a common clinical problem have prevalence rate of 4–7% in the general population. Fine-needle aspiration cytology (FNAC) is a minimally invasive, accurate diagnostic tool which can differentiate neoplastic from non-neoplastic lesions and reduces the number of unnecessary thyroidectomies, but has limitations . Our study was a retrospective an METHODOLOGY: alysis of 124 cases of thyroid lesions over a period of 3 years from April2019 to April 2022. The FNAC ndings were reviewed and data was compared with the histopathological, imaging ndings and data was analysed. Majority of the pat RESULTS: ients were females in the age group of 41–60 years with a mean age of 42 years and most were non-neoplastic lesions. 76 cases were diagnosed as colloid nodular goitre and benign cystic lesions by FNAC. 44 cases were diagnosed as neoplastic lesions (follicular neoplasm, papillary carcinoma, and suspected malignancy) by FNAC. 18 of these cases were non neoplastic lesions, 24 were papillary carcinoma, 2 were follicular carcinoma on histopathological examination . Statistical analysis of neoplastic lesions showed sensitivity, specicity, accuracy, false positive rate, false negative rate, positive predictive value, and negative predictive value of FNAC to be 69.09%, 90.7%, 80.8%, 9.2%, 30.9%, 86.3% and 77.6% respectively. Ultrasound was foun CONCLUSION: d to be more reliable than palpation, but denitive diagnosis can be reached only with FNAC/Biopsy. Bethesda system of reporting thyroid cytology should be meticulously followed to minimize errors and a repeat FNAC asked for discordant cases after a multidisciplinary team conference.

18F]FET-PET in children and adolescents with central nervous system tumors: does it support difficult clinical decision-making?

PurposePositron emission tomography (PET) with O-(2-[18F]fluoroethyl)-L-tyrosine ([18F]FET) is a well-established tool for non-invasive assessment of adult central nervous system (CNS) tumors. However, data on its diagnostic utility and impact on clinical management in children and adolescents are limited.MethodsTwenty-one children and young adults (13 males; mean age, 8.6 ± 5.2 years; range, 1–19 at initial diagnosis) with either newly diagnosed (n = 5) or pretreated (n = 16) CNS tumors were retrospectively analyzed. All patients had previously undergone neuro-oncological work-up including cranial magnetic resonance imaging. In all cases, [18F]FET-PET was indicated in a multidisciplinary team conference. The impact of PET imaging on clinical decision-making was assessed. Histopathology (n = 12) and/or clinical and imaging follow-up (n = 9) served as the standard of reference.ResultsThe addition of [18F]FET-PET to the available information had an impact on further patient management in 14 out of 21 subjects, with avoidance of invasive surgery or biopsy in four patients, biopsy guidance in four patients, change of further treatment in another five patients, and confirmation of diagnosis in one patient.Conclusion[18F]FET-PET may provide important additional information for treatment guidance in pediatric and adolescent patients with CNS tumors.

Developing prediction models for short-term mortality after surgery for colorectal cancer using a Danish national quality assurance database.

The majority of colorectal cancer surgeries are performed electively, and treatment is often decided at the multidisciplinary team conference. Although the average 30-day mortality rate is low, there is substantial population heterogeneity from young, healthy patients to frail, elderly patients. The individual risk of surgery can vary widely, and tailoring treatment for colorectal cancer may lead to better outcomes. This requires prediction of risk that is accurate and available prior to surgery. Data from the Danish Colorectal Cancer Group database was transformed into the Observational Medical Outcomes Partnership Common Data Model. Models were developed to predict the risk of mortality within 30, 90, and 180days after colorectal cancer surgery using only covariates decided at the multidisciplinary team conference. Several machine-learning models were trained, but due to superior performance, a Least Absolute Shrinkage and Selection Operator logistic regression was used for the final model. Performance was assessed with discrimination (area under the receiver operating characteristic and precision recall curve) and calibration measures (calibration in large, intercept, slope, and Brier score). The cohort contained 65,612 patients operated for colorectal cancer in the period from 2001 to 2019 in Denmark. The Least Absolute Shrinkage and Selection Operator model showed an area under the receiver operating characteristic for 30-, 90-, and 180-day mortality after colorectal cancer surgery of 0.871 (95% CI: 0.86-0.882), 0.874 (95% CI: 0.864-0.882), and 0.876 (95% CI: 0.867-0.883) and calibration in large of 1.01, 0.98, and 1.01, respectively. The postoperative short-term mortality prediction model showed excellent discrimination and calibration using only preoperatively known predictors.

Prediction of survival in patients with colorectal liver metastases- development and validation of a prognostic score model

BackgroundMetastatic spread of colorectal cancer to the liver impacts prognosis. Advances in chemotherapy have resulted in increased resectability rates and thereby improved survival in patients with colorectal liver metastases (CRLM). However, criteria are needed to ensure that patients selected for hepatic resection benefit from the invasive therapy. The study aimed to construct a predictive model for overall survival (OS) in patients with CRLM, based on preoperatively available information. MethodsThe retrospective cohort study reviewed all patients with CRLM discussed at multidisciplinary team conference at Karolinska University Hospital, Stockholm, Sweden, 2013–2018. Independent prognostic factors for OS were identified, based on which a score model was generated. The model was validated on patients treated for CRLM at Hôpital Universitaire Paul Brousse, Villejuif, France, 2007–2018. Calibration and discrimination methods were used for internal and external validation. ResultsThe Swedish development cohort included 1013 patients, the French validation cohort 391 patients. Poor OS was significantly associated with age>60years (hazard ratio (HR) 3.57 (95%CI 2.18–9.94)), number of CRLM (HR 4.59 (2.83–12.20)), diameter of largest CRLM>5 cm (HR 2.59 (1.74–5.03)), right-sided primary tumour (HR 2.98 (2.00–5.80)), extrahepatic disease (HR 4.14 (2.38–15.87)) and non-resectability (HR 0.77 (0.66-0.90)). The C-statistic for prediction of OS was .74, in the development cohort and 0.69 in the validation cohort. ConclusionThe presented predictive score model can adequately predict OS for patients at the initial diagnosis of CRLM. The prognostic model could be of clinical value in the management of all patients with CRLM, by predicting individualized survival and thereby facilitating treatment recommendations.

Reducing length of stay for patients undergoing transcatheter aortic valve replacement using a prescreening approach.

As transcatheter aortic valve replacement (TAVR) becomes a preferred treatment option for patients with aortic valve stenosis, and demand for TAVR increases, it is imperative that length of stay (LOS) is reduced while maintaining safety and effectiveness. As TAVR procedures have become less invasive and more streamlined, current protocols have not been updated to reflect today's postprocedure requirements. The next-day discharge (NDD) protocol was established using available literature. A convenience sample was evaluated for NDD protocol inclusion during aortic multidisciplinary team conference using predetermined inclusion and exclusion criteria. Length of stay for NDD protocol participants was compared with LOS from a retrospective convenience sample of patients undergoing TAVR in the time frame mirroring NDD protocol initiation of the year prior. Patients meeting inclusion criteria were enrolled in the NDD protocol with a goal of discharge to home on postprocedural day 1 by 2:00 p.m. The NDD protocol included preprocedure expectation setting, prescheduled same-day postprocedure imaging, and discharge priority on postprocedure day 1. There is a significant difference in LOS between the NDD eligible retrospective and prospective groups. The prospective group has a significantly lower LOS than the retrospective group (M = 1.6 vs 2.1, respectively; p = .0454). An NDD protocol can help reduce LOS after TAVR in appropriately selected patients. Further protocol revision will be required to optimize LOS outcomes.

POS0059 COMPLEMENT PROTEINS ARE ELEVATED IN PATIENTS WITH axSpA COMPARED WITH RELEVANT CONTROLS OF PATIENTS WITH LOW BACK PAIN AND SpA-FEATURES WITHOUT AXSPA.

BackgroundAxial spondyloarthritis (axSpA) is associated with a certain genetic predisposition, i.e., with the presence of human leukocyte antigen (HLA)-B27. However, the pathogenesis remains largely unexplained. Animal models of ankylosing spondylitis have shown inhibition of complement to be beneficial in terms of limiting structural damage (1). The lectin pathway of complement activation serves as a key component of the innate immune system and plays a pivotal role in both homeostasis and development. The influence of complement in axSpA is mainly unexplored. We have, however, previously reported elevated plasma levels of the lectin pathway proteins L-ficolin and H-ficolin in patients with axSpA compared with blood donors (2).ObjectivesOur aim was to investigate plasma levels of lectin pathway proteins in a clinical cohort of patients with axSpA and compare them to relevant controls that we often experience significant challenges in differentiating from axSpA.MethodsPlasma samples were obtained from individuals in a cohort of patients suffering from low back pain (LBP) including: 1) 23 patients with axSpA, 2) 55 patients without axSpA experiencing SpA-features/symptoms, and 3) 64 patients with nonspecific LBP without SpA-features or MRI findings suggestive of axSpA. Diagnosis of axSpA was based on multidisciplinary team conference consensus after 3.5 years of follow-up (3). Plasma levels of 10 lectin pathway proteins (MBL, CL-L1, H-ficolin, L-ficolin, M-ficolin, MASP-1, MASP-2, MASP-3, MAp44, and MAp19) were measured by immunoassays developed in-house.ResultsPatient characteristics are shown in Table 1. Plasma levels of lectin pathway proteins L-ficolin, M-ficolin and CL-L1 differed significantly in the patient groups (p ≤ 0.03). L-ficolin and M-ficolin were elevated in axSpA-patients compared with patients with SpA-features without axSpA and nonspecific LBP patients (Figure 1). CL-L1 was elevated in axSpA-patients and patients with SpA-features without axSpA compared with nonspecific LBP patients (Figure 1). No significant differences were observed for MBL, H-ficolin, MASP-1, MASP-2, MASP-3, MAp44, and MAp19. L-ficolin levels correlated with CRP in axSpA-patients (Spearman’s rho=0.58 p=0.004). M-ficolin levels correlated weakly with CRP in nonspecific LBP patients (Spearman’s rho=0.36 p=0.003). Lectin pathway protein levels did not correlate with disease activity (ASDAS).Table 1.Patient characteristicsaxSpA (n=23)Not axSpA (n=55)Non-specific low back pain (n=64)p-valueMedian age, years (range)32 (19-40)33 (19-41)32 (18-39)0.75aMales, n (%)10 (43)37 (67)26 (41)0.01bHLA-B27 positive, n (%)17 (74)11 (20)5 (8)0.00bInflammatory back pain, n (%)18 (78)28 (51)0.03cGood response to NSAID14 (61)17 (31)0.01cSacroiliitiis on MRI acc. ASAS, n (%)22 (96)45 (82)0.11cElevated CRP, n (%)3 (13)7 (13)0.97ASDAS (range)2.5 (1.2-3.7)2.3 (0.8-3.8)0.52da compared by Kruskal-Wallis test.b all three groups compared by Chi2 test.c compared by Chi2 test.d compared by Mann Whitney U test.Figure 1.Plasma levels of L-ficolin, M-ficolin and CL-L1.ConclusionL-ficolin and M-ficolin are increased in patients with axSpA when compared with relevant control cohorts of patients with LBP or with SpA-features without axSpA. Our findings support a potential pathogenic role for complement in axSpA, however, further studies are needed to elucidate the diagnostic potential of the specific complement proteins.

Standardized care pathways for patients with suspected urinary bladder cancer: the Swedish experience

Objectives To compare time intervals to diagnosis and treatment, tumor characteristics, and management in patients with primary urinary bladder cancer, diagnosed before and after the implementation of a standardized care pathway (SCP) in Sweden. Materials and methods Data from the Swedish National Register of Urinary Bladder Cancer was studied before (2011–2015) and after (2016–2019) SCP. Data about time from referral to transurethral resection of bladder tumor (TURBT), patients and tumor characteristics, and management were analyzed. Subgroup analyses were performed for cT1 and cT2–4 tumors. Results Out of 26,795 patients, median time to TURBT decreased from 37 to 27 days after the implementation of SCP. While the proportion of cT2–T4 tumors decreased slightly (22–21%, p < 0.001), this change was not stable over time and the proportions cN + and cM1 remained unchanged. In the subgroups with cT1 and cT2–4 tumors, the median time to TURBT decreased and the proportions of patients discussed at a multidisciplinary team conference (MDTC) increased after SCP. In neither of these subgroups was a change in the proportions of cN + and cM1 observed, while treatment according to guidelines increased after SCP in the cT1 group. Conclusion After the implementation of SCP, time from referral to TURBT decreased and the proportion of patients discussed at MDTC increased, although not at the levels recommended by guidelines. Thus, our findings point to the need for measures to increase adherence to SCP recommendations and to guidelines.

Does 18F-FDG PET/CT change the surgical management of potentially resectable colorectal liver metastases?

Resectability assessment of patients with colorectal liver metastases is based on computed tomography and liver magnetic resonance imaging. Addition of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography has been recommended, but the impact of the added information remains unclear. The primary aim of this study was to determine how preoperative positron emission tomography/computed tomography changed management in patients with potentially resectable colorectal liver metastases. The secondary aim was to investigate whether findings on positron emission tomography/computed tomography correlated to metastatic disease in cases with extended surgery and influenced oncological outcomes. A retrospective observational study of the impact of adding positron emission tomography/computed tomography to conventional imaging in the surgical decision-making of colorectal liver metastases. All patients with colorectal liver metastases diagnosed by conventional imaging were included and assessed by a multidisciplinary team conference at Umeå University Hospital between June 2013 and December 2017. Eligibility criteria were all patients with potentially resectable colorectal liver metastases. Patients who underwent preoperative positron emission tomography/computed tomography in addition to conventional radiology were compared with those who underwent conventional imaging only. 151/220 patients underwent preoperative positron emission tomography/computed tomography. Findings on positron emission tomography/computed tomography changed the management in 10.6% of the patients. Eight patients were excluded from surgery after detection by positron emission tomography/computed tomography of extrahepatic disease. Eight patients underwent more extended surgery than initially planned due to positron emission tomography/computed tomography. Five of these positron emission tomography-positive resected sites were verified by pathology as metastatic disease. No difference in overall survival was seen following surgical resection in patients with and without a preoperative positron emission tomography/computed tomography. Preoperative positron emission tomography/computed tomography resulted in a changed surgical management in 10.6% of cases in a selected cohort.

Physician-led in-hospital multidisciplinary team conferences with multiple medical specialities present - A scoping review.

Multidisciplinary Team Conferences (MDTs) are complex interventions in the modern healthcare system and they promote a model of coordinated patient care and management. However, MDTs within chronic diseases are poorly defined. Therefore, the aim of this scoping review was to summarise the current literature on physician-led in-hospital MDTs in chronic non-malignant diseases. Following the PRISMA-ScR guideline for scoping reviews, a search on MDT interventions in adult patients, with three or more medical specialties represented, was performed. We identified 2790 studies, from which 8 studies were included. The majority of studies were non-randomised and focused on a single disease entity such as infective endocarditis, atrial fibrillation, IgG4-related disease, or arterial and venous thrombosis. The main reason for referral was confirmation or establishment of a diagnosis, and the MDT members were primarily from medical specialties gathered especially for the MDT. Outcomes of the included studies were grouped into process indicators and outcome indicators. Process indicators included changes in diagnostic confirmation as well as therapeutic strategy and management. All studies reporting process indicators demonstrated significant changes before and after the MDT. MDTs within chronic diseases appeared highly heterogeneous with respect to structure, reasons for referral, and choice of outcomes. While process indicators, such as change in diagnosis, and treatment management/plan seem improved, such have not been demonstrated through outcome indicators.

The potential use of extended criteria donors and eligible recipients in liver transplantation for unresectable colorectal liver metastases in Central Sweden.

Unresectable colorectal liver metastases (CRLM) is a condition with poor prognosis. A recent treatment alternative improving survival in patients with unresectable CRLM, has emerged with the introduction of liver transplantation (LT), yet not uncontroversial with the current organ shortage. This study aimed to retrospectively investigate the potential of declined donors with acceptable risk as liver graft donors and patients with unresectable CRLM as potential recipients. All declined donors in central Sweden and all patients with CRLM discussed at multidisciplinary team conference at Karolinska University Hospital, January 2013-October 2018, were identified. Donors were classified according to the European Committee Guide to the quality and safety of organs for transplantation and potential recipients were evaluated by selection criteria, based on studies on the Norwegian Secondary Cancer study database. Out of 1,462 evaluated potential donors, 62 (2.7 pmp) donors were identified, corresponding to 6-18% of the utilized donor pool. Out of 1,008 included patients with CRLM, 25 (2.1 pmp) potential recipients were recognized. Eligibility for LT and left-sided colon cancer were favorable prognostic factors. Today's donor pool could increase with the use of extended criteria donors, which is sufficient and display an acceptable risk-benefit ratio for patients with unresectable CRLM. With current selection criteria a small subset of patients with unresectable CRLM are eligible recipients. This subset of patients has a better survival compared to patients ineligible for LT.

Clinically decisive (dis)agreement in multidisciplinary team assessment of esophageal squamous cell carcinoma; a prospective, national, multicenter study

Background Decisions regarding tumor staging, operability, resectability, and treatment strategy in patients with esophageal cancer are made at multidisciplinary team (MDT) conferences. We aimed to assess interobserver agreement from four national MDT conferences and whether this would have a clinical impact. Methods A total of 20 patients with esophageal cancer were included across all four upper gastrointestinal (GI) cancer centers. Fully anonymized patient data were distributed among the MDT conferences which decided on TNM category, resectability, operability, curability, and treatment strategy blinded to each other’s decisions. The interobserver agreement was expressed as both the raw observer agreement and with Krippendorff’s α values. Finally, a case-by-case evaluation was performed to determine if disagreement would have had a clinical impact. Results A total of 80 MDT evaluations were available for analysis. A moderate to near-perfect observer agreement of 79.2%, 55.8%, and 82.5% for TNM category was observed, respectively. Substantial agreement for resectability and moderate agreement for curability were found. However, an only fair agreement was observed for the operability category. The treatment strategies had a slight agreement which corresponded to disagreement having a clinical impact in 12 patients. Conclusions Esophageal cancer MDT conferences had an acceptable interobserver agreement on resectability and TM categories; however, the operability assessment had a high level of disagreement. Consequently, the agreement on treatment strategy was reduced with a potential clinical impact. In future MDT conferences, emphasis should be on prioritizing the relevant information being readily available (operability, T & M categories) to minimize the risk of disagreement in the assessments and treatment strategies, and thus, delayed or suboptimal treatment.

Diagnosing axial spondyloarthritis by multidiciplinary team conference at 3.5 years’ follow-up in a cohort of patients with disease features according to the ASAS criteria

Objectives During the past two decades, magnetic resonance imaging (MRI) has increasingly been used diagnostically in axial spondyloarthritis (axSpA), and in 2009 MRI was introduced in the Assessment of SpondyloArthritis Society (ASAS) classification criteria. In clinical practice, there is a risk of overdiagnosis if MRI findings are not related to clinical and biochemical findings. The aim of this study was to provide an estimate of the prevalence of axSpA in a cohort of clinical patients with low back pain and findings suggestive of axSpA according to ASAS through consensus diagnosis at a multi-disciplinary team (MDT) conference, and to describe the performance of the features included in the ASAS criteria. Method Consensus diagnoses of axSpA at MDT conferences were retrospectively established at 3.5 years’ follow-up in a cohort of 84 patients, initially referred with disease features according to the ASAS criteria. Patients were examined clinically regarding spondyloarthritis features, and biochemical tests and MRI of the sacroiliac joints and entire spine were performed at baseline and after a mean of 3.5 years. Results According to the MDT consensus, 25 patients (30%) of the total cohort had axSpA at follow-up; 40% of individuals who fulfilled the ASAS criteria at baseline had axSpA, and 37% at follow-up; 96% of axSpA patients according to the MDT consensus met the ASAS criteria at baseline and 92% at follow-up. Conclusion Approximately one-third of the included patients had axSpA when evaluated at the MDT conference. The ASAS criteria had low predictive value, but high sensitivity at both baseline and follow-up.

Conversion therapy in patients with colorectal liver metastases

BackgroundThe occurrence of colorectal liver metastases (CRLM) impairs prognosis, yet long-term survival can be achieved by enabling liver resection. This study aims to describe factors associated with conversion therapy leading to liver surgery and treatment outcome. MethodsA retrospective cohort study was conducted including all patients with CRLM discussed at multidisciplinary team conference at Karolinska University Hospital, Stockholm, Sweden, from 2013 to 2018. Factors associated with conversion therapy and outcome following conversion therapy were analysed with logistic regression and survival analyses. ResultsOut of 1023 patients with CRLM, 100 patients (10%) received conversion chemotherapy, out of whom 31 patients (31%) subsequently underwent liver resection. Patients in whom conversion chemotherapy resulted in liver resection were younger (median age 61 vs. 66 years, p = .024), less likely to have a KRAS/NRAS-mutated primary tumours (25% vs. 53%, p = .039) and more likely to have received anti-EGFR agents (32% vs. 4%, p = .001) than patients progressing during conversion chemotherapy. The median OS for patients treated with conversion chemotherapy leading to liver resection was 24 months, compared to 14 months for patients progressing during conversion chemotherapy, p < .001. The OS for patients progressing during conversion chemotherapy was similar to patients given palliative chemotherapy, approximately 13 months. ConclusionConversion therapy offers a survival benefit in selected patients. Despite treatment advances, the majority of patients undergoing conversion chemotherapy never become eligible for curative treatment.