Multidisciplinary Team Decision Research Articles

Multidisciplinary Team Decisions in Management of Abdominal Aortic Aneurysm: A Service and Quality Evaluation

ObjectiveTo investigate whether decisions made by the multidisciplinary team (MDT) were implemented and review the MDT process to identify areas for improvement.MethodsThis was a retrospective service evaluation project. Consecutive cases of abdominal aortic aneurysm (AAA) from vascular surgery MDT meetings were reviewed. MDT outputs were extracted and compared with implemented clinical management obtained from the electronic health record (EHR) to determine concordance. Cases were re-reviewed to understand reasons why planned management was not implemented.ResultsFrom 42 MDT meetings, 106 patients were identified. Twenty four patients were discussed at two MDTs and four patients were discussed three times. Of the 106 patients, 91 (85.8%) were treated as planned, seven (6.6%) declined planned management and opted for conservative management, four (3.8%) patients died before treatment, and four (3.8%) had alternative management for individual reasons. Of the patients discussed multiple times, 15 (53.6%) needed review by a consultant anaesthetist or additional investigations.ConclusionThis service evaluation found a similar proportion of cases as in existing oncology literature where the MDT decision was not implemented. However, the natural history of AAA brings nuance to this finding. Facilitating patient preference is an important problem that will require future study. This evaluation resulted in local improvements to the MDT process for AAA.

Role of Dedicated Subspecialized Radiologists in Multidisciplinary Team Discussions on Lower Gastrointestinal Tract Cancers.

ObjectiveTo determine the impact of dedicated subspecialized radiologists in multidisciplinary team (MDT) discussions on the management of lower gastrointestinal (GI) tract malignancies.Materials and MethodsWe retrospectively analyzed the data of 244 patients (mean age ± standard deviation, 61.7 ± 11.9 years) referred to MDT discussions 249 times (i.e., 249 cases, as five patients were discussed twice for different issues) for lower GI tract malignancy including colorectal cancer, small bowel cancer, GI stromal tumor, and GI neuroendocrine tumor between April 2018 and June 2021 in a prospective database. Before the MDT discussions, dedicated GI radiologists reviewed all imaging studies again besides routine clinical reading. The referring clinician’s initial diagnosis, initial treatment plan, change in radiologic interpretation compared with the initial radiology report, and the MDT’s consensus recommendations for treatment were collected and compared. Factors associated with changes in treatment plans and the implementation of MDT decisions were analyzed.ResultsOf the 249 cases, radiologic interpretation was changed in 73 cases (29.3%) after a review by dedicated GI radiologists, with 78.1% (57/73) resulting in changes in the treatment plan. The treatment plan was changed in 92 cases (36.9%), and the rate of change in the treatment plan was significantly higher in cases with changes in radiologic interpretation than in those without (78.1% [57/73] vs. 19.9% [35/176], p < 0.001). Follow-up records of patients showed that 91.2% (227/249) of MDT recommendations for treatment were implemented. Multiple logistic regression analysis revealed that the nonsurgical approach (vs. surgical approach) decided through MDT discussion was a significant factor for patients being managed differently than the MDT recommendations (Odds ratio, 4.48; p = 0.017).ConclusionMDT discussion involving additional review of radiology examinations by dedicated GI radiologists resulted in a change in the treatment plan in 36.9% of cases. Changes in treatment plans were significantly associated with changes in radiologic interpretation.

Diffused coronary involvement in Takayasu arteritis with concomitant malignancy

Large vessel vasculitis (LVV) is composed of conditions in which inflammation of blood vessel walls affects mainly large arteries, such as the aorta and its main branches, and in some cases the coronary arteries. Coronary artery involvement in systemic vasculitis is associated with significant morbidity and mortality. We present a case of a young patient diagnosed with extensive coronary disease diagnosed as Takayasu arteritis, when whom a concomitant diagnosis of Hodgkin's lymphoma was made. The literature review revealed ten cases of malignancies associated with Takayasu arteritis. We discuss the complexity of the management of concurrent hematological malignancy with TAK and extensive coronary arteritis. This complicated and cross-disciplinary case also represents the pivotal importance of multi-disciplinary team decision in order to achieve the best clinical outcome of both disorders.

Importance of tumour volume and histology in trimodality treatment of patients with Stage IIIA non-small cell lung cancer-results from a retrospective analysis.

OBJECTIVESChemoradiotherapy (CRT) has been the backbone of guideline-recommended treatment for Stage IIIA non-small cell lung cancer (NSCLC). However, in selected operable patients with a resectable tumour, good results have been achieved with trimodality treatment (TT). The objective of this bi-institutional analysis of outcomes in patients treated for Stage IIIA NSCLC was to identify particular factors supporting the role of surgery after CRT.METHODSIn a 2-centre retrospective cohort study, patients with Stage III NSCLC (seventh edition TNM) were identified and those patients with Stage IIIA who were treated with CRT or TT between January 2007 and December 2013 were selected. Patient characteristics as well as tumour parameters were evaluated in relation to outcome and whether or not these variables were predictive for the influence of treatment (TT or CRT) on outcome [overall survival (OS) or progression-free survival (PFS)]. Estimation of treatment effect on PFS and OS was performed using propensity-weighted cox regression analysis based on inverse probability weighting.RESULTSFrom a database of 725 Stage III NSCLC patients, 257 Stage IIIA NSCLC patients, treated with curative intent, were analysed; 186 (72%) with cIIIA-N2 and 71 (28%) with cT3N1/cT4N0 disease. One hundred and ninety-six (76.3%) patients were treated by CRT alone (high-dose radiation with daily low-dose cisplatin) and 61 (23.7%) by TT. The unweighted data showed that TT resulted in better PFS and OS. After weighting for factors predictive of treatment assignment, patients with a large gross tumour volume (>120 cc) had better PFS when treated with TT, and patients with an adenocarcinoma treated with TT had better OS, regardless of tumour volume.CONCLUSIONSPatients with Stage IIIA NSCLC and large tumour volume, as well as patients with adenocarcinoma, who were selected for TT, had favourable outcome compared to patients receiving CRT. This information can be used to assist multidisciplinary team decision-making and for stratifying patients in studies comparing TT and definitive CRT.

EP.TU.533A rare clinical presentation of Goblet Cell Adenocarcinoma of the appendix: Recommendations for safe &amp; effective management

Abstract Background Goblet cell carcinoma (GCC) is a rare mixed neoplasm arising from the appendix, consisting of glandular and neuroendocrine tissue. It typically presents in adults with a mean age of 55-65 years old. Diagnosis is usually incidental via histopathological examination after 0.3% to 0.9% of all appendicectomies. Literature remains sparse on classification and prognosis of GCC, and cases documented in younger patients. Aims To highlight an interesting clinical presentation and intra- and post-operative management of GCC. To increase awareness for future practice when managing patients with GCC. Methods A 37 year-old male presented with left sided abdominal pain, constipation and fresh rectal bleeding. Computed Tomography demonstrated extensive SMV thrombus causing small bowel ischaemia. On the Intensive Care Unit, he underwent thrombolysis through a Transjugular Intrahepatic Porto-Systemic Shunt. A few days later, he developed bowel obstruction, necessitating a small bowel resection secondary to an ischaemic stricture. 9 months later, he presented with clinical signs of appendicitis. After an uneventful appendicectomy, he was diagnosed with GCC upon histopathological examination of the specimen. Results The patient made an uneventful post-operative recovery. A multidisciplinary team (MDT) decision was made to perform a completion right hemicolectomy, with histology confirming pT3N1M0 GCC. Adjuvant chemotherapy with 5-Fluorouracil was started. Conclusion This case highlights GCC with a preceding clinical course not yet published in the literature. It stresses the importance of the MDT in managing GCC. Although primarily diagnosed histologically, a clinical suspicion of GCC of the appendix is worth considering in pro-thrombotic patients.

671 Fetus-In-Fetu Found at Excision of An Antenatally Diagnosed Abdominal Mass: Multi-Disciplinary Approach

Abstract We present a case of antenatally detected abdominal mass and an alternative diagnostic course for suspected neonatal neuroblastoma as a result of investigative findings. A female infant presented antenatally with a left upper quadrant mass initially managed as a suspected neonatal neuroblastoma; further cross-sectional imaging suggested a wider differential including teratoma and aided surgical planning. The multi-disciplinary team (MDT) decision was for an early excision at 31 days and post-operative histology identified a diagnosis of fetus-in-fetu (FIF). We describe this case as a compliment to the current literature and an example of a necessary variation to recognised diagnostic and treatment pathways as a result of investigative findings.

Aspiration, risk and risk feeding: A critique of the royal college of physicians guidance on care of people with eating and drinking difficulties

The Royal College of Physicians has recently published guidance on supporting people with eating and drinking difficulties. Although much of the advice in the guidance is sensible and helpful, in this paper we argue that the recommendations regarding ‘risk feeding’ decisions are flawed. In particular, there is a failure to clearly identify the nature, frequency and severity of different risks. There is an undue emphasis on aspiration as a risk and as a potential cause of pneumonia, and the limited evidence base for many interventions to manage risk is not adequately acknowledged. There is an emphasis on multidisciplinary team decision making at the expense of individual professional responsibility. We conclude that this guidance regarding risk feeding supports an unduly defensive approach to oral intake and should not be adopted as a standard of medical practice.

Impact of Three Different Algorithms for the Screening of SSc-PAH and Comparison with the Decisions of a Multidisciplinary Team.

Background: to compare three existing screening algorithms of pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) with the results of a multidisciplinary team (MDT) meeting from a tertiary center. Methods: we conducted a monocentric longitudinal study from 2015 to 2018. All patients with SSc according to LeRoy’s classification were eligible. Patients were excluded in the case of missing data required by any of the three screening algorithms. The algorithms were applied for each patient at inclusion. Right heart catheterization (RHC) was performed based on the MDT decision. MDT members were all blinded from the results of the three algorithms regarding RHC recommendations. The RHC recommendations of each algorithm were compared with the MDT decision, and the impact on diagnosis and management was evaluated. Results: 117 SSc patients were consecutively included in the study, and 99 had follow-up data over the three-year duration of the study (10 deaths). Among the 117 patients, the MDT suggested RHC for 16 patients (14%), DETECT algorithm for 28 (24%), ASIG for 48 (41%) and ESC/ERS 2015 for 20 (17%). Among the 16 patients who had RHC, SSc-PAH was diagnosed in seven. Among patients with an initial recommendation of RHC based on at least one algorithm but not according to the MDT meeting, no SSc-PAH was diagnosed during the three-year follow-up. Results were unchanged when the new 2018 definition of PAH was applied instead of the previous definition. Conclusion: a MDT approach appears interesting for the screening of SSc-PAH, with a significant reduction of RHC performed in comparison with dedicated algorithms. The specific relevance of a MDT for the management and follow-up of patients with RHC recommended by existing algorithms but with no PAH warrants further studies.

Preoperative multidisciplinary team decisions for high-risk patients scheduled for noncardiac surgery-a retrospective observational study.

Preoperative multidisciplinary team (MDT) meetings are recommended for patients at high risk for perioperative complications and mortality, although the underlying evidence is scarce. We aimed to investigate the effect of MDT decisions on patient management and patient outcome. We conducted a single-centre retrospective cohort study including all noncardiac surgical patients selected for discussion at preoperative MDT meetings from January 2017 to December 2019 (N = 120). We abstracted preoperative data, MDT decisions, and patient outcomes from the electronic health records for analysis. Of the 120 patients registered for an MDT meeting, 43% did not undergo their initially planned surgery. Only 27% of patients received perioperative management as planned before the MDT meeting. Most surgery cancellations were the MDT's decision (22%) or the patient's decision before or after the MDT discussion (10%). Postoperative complications occurred in 28% of operated patients, and postoperative mortality was 4% at 30 days and 10% at three months, most of which was attributable to postoperative complications. Non-operated patients had a 7% mortality rate at 30 days and 9% at three months. Alterations of perioperative management following MDT discussion were associated with fewer cases of extended length of hospital stay (> ten days). This study shows that preoperative MDT meetings for high-risk noncardiac surgical patients altered the management of most patients. Management alterations were associated with fewer hospital admissions of long duration. These results should be interpreted with appropriate caution given the methodological limitations inherent to this small study.

Machine-learning algorithm to predict multidisciplinary team treatment recommendations in the management of basal cell carcinoma

Basal cell carcinoma (BCC) is the most common human cancer. Facial BCCs most commonly occur on the nose and the management of these lesions is particularly complex, given the functional and complex implications of treatment. Multidisciplinary team (MDT) meetings are routinely held to integrate expertise from dermatologists, surgeons, oncologists, radiologists, pathologists and allied health professionals. The aim of this research was to develop a supervised machine-learning algorithm to predict MDT recommendations for nasal BCC to potentially reduce MDT caseload, provide automatic decision support and permit data audit in a health service context. The study population included all consecutive patients who were discussed at skin cancer-specialised MDT (SSMDT) with a diagnosis of nasal BCC between January 1, 2015 and December 31, 2015. We conducted analyses for gender, age, anatomical location, histological subtype, tumour size, tumour recurrence, anticoagulation, pacemaker, immunosuppressants and therapeutic modalities (Mohs surgery, conventional excision or radiotherapy). We used S-statistic computing language to develop a supervised machine-learning algorithm. We found that 37.5% of patients could be reliably predicted to be triaged to Mohs micrographic surgery (MMS), based on tumour location and age. Similarly, the choice of conventional treatment (surgical excision or radiotherapy) by the MDT could be reliably predicted based on the patient's age, tumour phenotype and lesion size. Accordingly, the algorithm reliably predicted the MDT decision outcome of 45.1% of nasal BCCs. Our study suggests that the machine-learning approach is a potentially useful tool for predicting MDT decisions for MMS vs conventional surgery or radiotherapy for a significant group of patients. We suggest that utilising this algorithm gives the MDT more time to consider more complex patients, where multiple factors, including recurrence, financial costs and cosmetic outcome, contribute to the final decision, but cannot be reliably predicted to determine that outcome. This approach has the potential to reduce the burden and improve the efficiency of the specialist skin MDT and, in turn, improve patient care, reduce waiting times and reduce the financial burden. Such an algorithm would need to be updated regularly to take into account any changes in patient referral patterns, treatment options or local clinical expertise. lPLAS_20-21_A08.

The positive yield of multidisciplinary team decisions in a high volume head and neck center after those made in its preferred partner: An example of enhanced quality of care

The positive yield of multidisciplinary team decisions in a high volume head and neck center after those made in its preferred partner: An example of enhanced quality of care

THE PRIMARY RESULTS OF THE EFFICACY OF UPFRONT HIGH‐DOSE CHEMOTHERAPY WITH AUTOLOGOUS STEM CELL TRANSPLANTATION FOR IV STAGE AND HIGH‐INTERMEDIATE/HIGH IPI RISK GROUPS DLBCL

Introduction: Approximately 30% of patients(pts) with IPI ≥2 diffuse large B-cell lymphoma (DLBCL) have relapsed after the frontline regimens. High-dose chemotherapy (HDCT) with autologous hematopoietic stem cell transplantation (auto-HSCT) in the first remission can be an effective option to decrease the relapse rate in these patients. Methods: 108 pts, which fit the following criteria: DLBCL NOS, age 18-65, stage IV, IPI ≥2, treated by x6 CHOP/EPOCH/H-CVAD + R in frontline from 01.01.2010 to 31.12.2019 at NMRC of Oncology named after N.N.Petrov of MoH of Russia were retrospectively analyzed. If patients achieved a complete response (CR) or partial response (PR) after frontline, they enrolled into upfront HDCT with auto-HSCT group (Group 1, n = 38) or follow-up group (Group 2, n = 70) based on multidisciplinary team (MDT) decision. More than one extranodal involvement (extra) had 78.9% (30/38) pts in Group 1 and 75.7% (53/70) pts in Group 2. MYC and BCL-2 coexpression were analyzed in 84% (32/38) pts samples in Group 1 and 65.7% (46/70) in Group 2 and were present (DEL) in 46.8% (15/32) pts samples in Group 1 and 28.2% (13/46) in Group 2. A Fisher's exact test (Fisher's) with a two-tailed p-value was used to determine the difference in relapse rate between Group 1 and Group 2. A McNemar test (McNemar) with Yates correction (Yates) was used to determine the difference in responses in Group 1 after upfront HDCT with auto-HSCT. Results: CR after induction was achieved in 61% (23/38) pts in Group 1. After HDCT with auto-HSCT, the CR rate increased to 97% (37/38) and continues for a median of 30 (7-56) months in 87% (33/38) pts. It demonstrates the statistically significant difference – McNemar = 11.27 (p ≤ 0.001) and with Yates = 10.42 (p = 0.002). Early relapses (ER) were diagnosed in 6% (2/38) pts, late relapses (LR) in 6% (2/38) pts. HDCT associated mortality (infection) has occurred in 3% (1/38) pts. Group 2 pts achieved CR in 81% (57/70) cases. CR continues for median 38 (8-73) months in 67% (47/70) pts. Group 2 pts have 14% (14/70) ER and 6% (4/70) LR. No treatment-related deaths occurred. ER rate was higher in Group 2 (p = 0.048). In Group 2 pts with ˃1 extra experienced more ER (Group 1 – 3.3% (1/30), Group 2 – 20.8% (11/53), p = 0.048). DEL was significant in terms of both ER (Group 1 – 6.6% (1/15), Group 2 – 38.4% (6/13), p = 0.029) and all relapses (AR) (Group 1 – 6.6% (1/15), Group 2 – 53.8% (7/13), p = 0.011). The ER rate in Group 2 was significantly higher if the combination of ˃1 extra and DEL were present (Group 1 – 9.1% (1/11), Group 2 – 60% (6/10), p = 0.0237). Conclusions: 1. CR rate significantly increased in DLBCL NOS pts with stage IV, IPI ≥2 treated by upfront HDCT with auto-HSCT. 2. ER rate significantly decreases in DLBCL NOS with stage IV, IPI ≥2 after upfront HDCT with auto-HSCT pts if ˃1 extranodal site, DEL, and combination of these factors are present; AR rate decreases if pts only have DEL. EA – previously submitted to EHA 2021. Keywords: Aggressive B-cell non-Hodgkin lymphoma, Stem Cell Transplant No conflicts of interests pertinent to the abstract.

The Next Step Toward Patient-Centeredness in Multidisciplinary Cancer Team Meetings: An Interview Study with Professionals.

BackgroundPatient-centeredness is essential in complex oncological multidisciplinary team decision-making. Improvement seems to be needed, while there is a lack of knowledge about health care providers’ needs for improvement.ObjectiveTo explore multidisciplinary team members’ perspectives on the need to improve patient-centeredness in complex decision-making, and subsequently the strategies to enhance it.MethodsThis was a qualitative descriptive interview study. The participants were twenty-four professionals who attended multidisciplinary cancer team meetings weekly. The setting was five multidisciplinary teams (gastrointestinal, gynecological, urological, head and neck, and hematological cancer) in a Dutch academic hospital. Data were collected by semi-structured interviews and were analyzed with a combination of inductive and deductive content analysis.ResultsThe participants voiced the need for additional information (patient-centered information, patients’s needs and preferences, individualized medical information) during the multidisciplinary team meeting, to be more patient-centered in the decision-making conversation with the patient following the meeting, and for more information following the meeting to support patient-centeredness. The strategies, which mostly originated from the needs, were categorized as organization, decision-making, and communication. The most prominent strategies were those aimed at collecting and using patient-centered information, and to facilitate the decision-making conversation with the patient following the multidisciplinary team meeting.ConclusionOur findings highlighted the need to improve patient-centeredness in oncological multidisciplinary teams and provided a comprehensive overview of strategies for improvement, supported by multidisciplinary team members. These strategies emphasize involvement of patients throughout the continuous process of decision-making for patients with cancer. These strategies may be implemented in other oncological multidisciplinary teams, taking in mind the local needs. Future research may help to prioritize the strategies and to determine and evaluate the effect on endpoints, like patient or professional satisfaction, shared decision-making, and on the decision that was made.

Is staging breast magnetic resonance imaging prompted upgrade to mastectomy appropriate?

Breast magnetic resonance imaging (MRI) use for surgical staging is increasing, though remains controversial. We aimed to evaluate the accuracy of MRI in surgical decision-making to determine if mastectomy prompted by MRI was appropriate. A single-centre observational study in Perth, Western Australia, with the inclusion of all preoperative and postoperative studies (e.g. involved margins after breast-conserving surgery) undergoing staging breast MRI from 1 January 2015 to 26 August 2019. A standard protocol using gadolinium contrast was used. The reference standard was postoperative histopathology or, for studies without additional surgery after MRI following breast-conserving surgery, the next and subsequent annual screening episodes. By reviewing the final histopathology, the medical case notes and multidisciplinary team decision process, we evaluated whether the reported MRI disease extent was accurate in prompting an appropriate upgrade to mastectomy. Outcomes are reported with descriptive statistics. Of 130 cancers staged with MRI; seven were excluded as information was incomplete, 104 were performed preoperatively and 19 postoperatively. The majority (60%) staged lobular carcinoma (invasive 59%, in situ 1%) compared to ductal carcinoma (invasive 31%, in situ 8%). For preoperative MRI, half (54% - 56/104) underwent subsequent mastectomy. Of these, MRI prompted mastectomy in 45% (25/56), all appropriate for disease extent. In the postoperative staging group, two mastectomies were performed, one planned before imaging, the other prompted when MRI diagnosed residual disease and confirmed on histopathology. No false-negative staging MRI was identified. In our cohort, MRI prompted an upgrade to mastectomy in 21% (26/123), appropriate for cancer extent.

Exploring Physicians' Views, Perceptions and Experiences about Broad-Spectrum Antimicrobial Prescribing in a Tertiary Care Hospital Riyadh, Saudi Arabia: A Qualitative Approach.

Antimicrobial resistance (AMR) is a global public health threat associated with increased mortality, morbidity and costs. Inappropriate antimicrobial prescribing, particularly of broad-spectrums antimicrobials (BSAs), is considered a major factor behind growing AMR. The aim of this study was to explore physician perception and views about BSAs and factors that impact upon their BSAs prescribing decisions. Qualitative semistructured telephone interviews over an eleven-week period were conducted with physicians in a single tertiary care hospital in Riyadh, Saudi Arabia. Purposeful and snowball sampling techniques were adopted as sampling strategy. All interviews were audio recorded, transcribed verbatim, uploaded to NVivo® software and analysed following thematic analysis approach. Four major themes emerged: views on BSAs, factors influencing BSA prescribing and antimicrobial stewardship: practices and barriers and recommendations to improve appropriate BSA prescribing. Recommendations for the future include improving clinical knowledge, feedback on prescribing, multidisciplinary team decision-making and local guideline implementation. Identification of views and determinants of BSA prescribing can guide the design of a multifaceted intervention to support physicians and policymakers to improve antimicrobial prescribing practices.

Multidisciplinary team meetings for patients with complex extremity defects: a retrospective analysis of treatment recommendations and prognostic factors for non-implementation

BackgroundThis study aimed to assess a multidisciplinary team (MDT) meeting approach for the management of patients with complex extremity defects, analyze treatment recommendations, and evaluate factors influencing non-implementation.MethodsAll patients introduced to an MDT meeting for complex extremity defects from 2015 to 2017 were included in a retrospective cohort study. Patients’ characteristics and defect causes were evaluated. Treatment recommendations (TR) of MDT meetings and subsequent implementation were reviewed (cohort with implementation of TR versus cohort with non-implementation of TR), and factors associated with non-adherence to recommendations were statistically analyzed using logistic regression.ResultsFifty-one patients (41 male) with a mean age of 54 years were presented in 27 MDT meetings. Most of the patients (70%) suffered from reconstructive challenging or combined bone- and soft tissue defects, primarily located at the lower extremity (88%). Large skeletal defects, chronic osteomyelitis, and multi-fragmented fractures were present in 65% of cases. Forty-five percent of the patients suffered from peripheral vascular disease, necessitating surgical optimization. Of the 51 MDT decisions, 40 were implemented (78%; (32/40) limb salvage versus 22%; (8/40) limb amputation). Limb salvage was successfully achieved in 91% (29/32) of the cases. Failed limb salvages were due to flap failure (33%; 1/3), recurring periprosthetic joint infections (66%; 2/3) and concomitant reconstructive failure. Patients who underwent limb amputation, as recommended, showed proper stump healing and regained mobility with a prosthesis. Overall the MDT treatment plan was effective in 92.5% (37/40) of the patients, who adhered to the MDT treatment recommendation. In eleven patients (22%; 11/51), the MDT treatment was not implemented. MDT decisions were less likely to be implemented, if amputation was recommended (p = 0.029).ConclusionsMDT meetings represent a valid tool to formulate individualized treatment plans, avoiding limb amputation in most patients with severe extremity defects. Recommendation for limb amputation is less likely to be implemented than plans for limb salvage.Trial registration: Retrospectively registered

Therapeutic results and prognostic factors of stage III NSCLC: a population-based study in Tunisia.

Prognostic factors are crucial to guide patient's selection through therapeutic decisions and outcome prediction. To investigate prognostic factors associated with improved survival in stage III non-small cell lung cancer. We retrospectively reviewed clinical data of 88stage III non-small cell lung cancer patients treated between 2010-2017. Multidisciplinary evaluation prior to therapy onset was mandatory. Univariate analyses and multivariate logistic regression were performed to identify factors associated with survival. Median follow-up was 28months, 56% of patients experienced recurrence. Median overall survival (OS) was 19months. On univariable analysis, improved OS correlated with younger age (p=0.011), better performance score (ECOG PS<2) (p<0.01), absence of weight loss (p=0.019) and smaller tumor size (≤7cm) (p=0.005). OS was improved in patients receiving therapy planned by multidisciplinary meeting compared with those who did not (p<0.01), in those with resected tumors (p=0.001), responding to therapy (neoadjuvant chemotherapy (p=0.034) and concurrent chemoradiation (p=0.001), as well as those with lower neutrophil-lymphocyte ratio (p=0.026) and lower platelet-lymphocyte ratio (p=0.003). Postoperative adjuvant therapy increased OS (64vs 24, p=0.025). Longer recurrence-free interval, locoregional failure and better perfomance status at recurrence were good prognostic factors for OS. Multivariate analysis showed that only upfront surgery followed by adjuvant therapy (hazard ratio (HR)=0.61; 95% confidence interval (CI) 0.38-0.96; p=0.034), adherence to multidisciplinary team decision (HR=0.26; 95% CI 0.15-0.47; p<0.01) and tumor size>7 cm (HR=2.31; 95% CI 1.29-4.13; p=0.005) were independent prognostic factors affecting OS. Optimal therapeutic strategy and adherence to the decision provided by the multidisciplinary evaluation of patients played an important role in stage III non-small cell lung cancer outcome.

Overlapping Phenotype of Cardiomyopathy in a Patient with Double Mutation: A Case Report

Hypertrophic cardiomyopathy and left ventricular noncompaction commonly occur as separate disorders with distinct clinical and pathoanatomical features. However, these cardiomyopathies may have a similar genetic origin with mutations encoding sarcomeric proteins. The described case report demonstrates an example in which phenotypic expression of both diseases occurred in the same patient, who has two different alterations; one of them is a likely pathogenic variant in the MYL3 gene (MIM#160790) and the second variant in the MYH6 gene (MIM#160710) of unknown significance so far. To better understand associations between specific genetic variants and phenotypical expression of these genetic alterations and to stratify patient risk and decide on the most appropriate treatment, a comprehensive multimodality imaging approach and experienced multidisciplinary cardiomyopathy team decisions are warranted. In the clinical routine, awareness of the existence of complex cardiomyopathy phenotypes should be paid more attention during echocardiographic examination and should encourage a broader use of cardiovascular magnetic resonance.

Medical and Nonmedical Information during Multidisciplinary Team Meetings in Cancer Care

Background: Multidisciplinary team (MDT) meetings provide treatment recommendations based on available information and collective decision-making in teams with complementary professions, disciplines and skills. We aimed to map ancillary medical and nonmedical patient information during case presentations and case discussions in MDT meetings in cancer care. Methods: Through a nonparticipant, observational approach, we mapped verbal information on medical, nonmedical and patient-related characteristics and classified these based on content. Data were collected from 336 case discussions in three MDTs for neuro-oncology, sarcoma and hepato-biliary cancer. Results: Information on physical status was presented in 48.2% of the case discussions, psychological status in 8.9% and comorbidity in 48.5% of the cases. Nonmedical factors, such as family relations, occupation, country of origin and abode were referred to in 3.6–7.7% of the cases, and patient preferences were reported in 4.2%. Conclusions: Provision of information on comorbidities in half of the cases and on patient characteristics and treatment preferences in <10% of case discussions suggest a need to define data elements and develop reporting standards to support robust MDT decision-making.

Inverted aortic bioprosthetic for mitral valve replacement with Ross procedure: case report

BackgroundA 34-year-old gentleman presented with Staphylococcus salivarius infective endocarditis 13 years after aortic homograft and mitral valve repair for degenerative bicuspid aortic valve associated with rheumatic heart disease. The homograft had calcified, and the mitral repair had deteriorated with severe regurgitation. Multidisciplinary team decision to restore best quality of life was for re-do Ross procedure with bi-leaflet preserving mitral valve replacement with an inverted RESILIA aortic valve as the patient was fundamentally against lifelong anti-coagulation.Case presentationThe aortic homograft was excised, and coronary arteries dissected out followed by harvesting of the pulmonary autograft. The mitral valve was accessed via a trans-septal approach. On examination, there was a restricted and thickened posterior mitral valve leaflet. An inverted 27-mm INSPIRIS RESILIA aortic bio-prosthesis was placed with mitral cusps preserved. The pulmonary autograft was implanted in an intra-annular position, and a 26-mm pulmonary homograft was used to replace the pulmonary valve. Echocardiogram at 4 weeks revealed preserved LV function and well-functioning prosthetic, autograft and homograft.ConclusionAn inverted RESILIA valve, with its anti-structural valve deterioration properties, can be used in the mitral position with preservation of the mitral cusps to avoid anti-coagulation with the hope of reducing need for re-operation in line with patient wishes.