Multidisciplinary Treatment Decision Research Articles

The awareness of radiologists for the presence of lateral lymph nodes in patients with locally advanced rectal cancer: a single-centre, retrospective cohort study

ObjectivesEnlarged lateral lymph nodes (LLNs) are associated with increased (lateral) local recurrence rates. Size and anatomical location should therefore always be reported by radiologists and discussed during multidisciplinary meetings. The objective was to investigate how often LLNs are mentioned in MRI reports in a tertiary referral centre.MethodsA single - centre, retrospective study of 202 patients treated for primary rectal cancer between 2012 and 2020, with at least a T2 tumour located within 12cm of the anorectal junction. The radiology reports were written by 30–40 consultant radiologists. MRI scans were independently re-assessed by an expert radiologist. The primary outcome was how often the presence or absence of LLNs was mentioned in the initial report.ResultsPrimary MRI reports explicitly mentioned the presence or absence of LLNs in 89 (44%) cases. Of the 43 reports with present LLNs, only one (1%) reported on all features such as size, location or malignant features. Expert review revealed 17 LLNs which were ≥ 7 mm (short-axis); two of these were not mentioned in the original reports. In 14/43 (33%) cases, LLNs were discussed during the primary multidisciplinary meeting, while 17/43 (40%) restaging MRI reports failed to report on the previously visible LLN. Reporting LLNs increased significantly with higher N-stage (p = .010) and over time (p = .042).ConclusionsThough improving with time, there is still limited consistency in reporting LLNs. Only 44% of primary MRI reports mentioned LLNs and relevant features of those LLNs were seldomly reported. Given the importance of this information for subsequent treatment; increased awareness, proper training and the use of templates are needed.Key Points• Comprehensive reporting of lateral lymph nodes in primary MRI reports was limited to less than 50%.• Lateral lymph nodes are not always discussed during primary multidisciplinary meetings or mentioned in restaging reports.• Improvements in the awareness and knowledge of lateral lymph nodes are needed to ensure adequate multidisciplinary treatment decisions.

Successful Secondary Endovascular Intervention in Pediatric Patients with Venous Thromboembolic Events.

In the past, pediatric patients with venous thromboembolic events (VTE) were treated with low-molecular-weight heparin (LMWH) which was successful in around 70% of the cases. However, anticoagulation alone might not restore patency in all patients, and advanced therapeutic options to prevent postthrombotic syndrome are needed. During recent years, endovascular interventions have become a treatment option for pediatric patients with persistent thrombotic occlusion, not only in life- or limb-threatening VTE. We evaluated 12 consecutive patients (11-17 years) with newly diagnosed VTE being treated at our department during the last 4 years (2017-2020). In case follow-up examination showed persistent venoocclusion under anticoagulation, patients received secondary interventional therapy like recanalization, percutaneous transluminal angioplasty with or without catheter-directed thrombolysis, and stenting. Patients with no clinical signs of venoocclusion or regredient thrombosis in imaging examination received anticoagulation alone. Six of 12 (50%) patients underwent catheter intervention. Median time from diagnosis to intervention was 4 months (0-12 months). Reintervention was necessary in one (8%) case and complete recanalization failed in one (8%) case. There were no major bleeding events or other major postinterventional complications, no acute or late local recurrence, and all patients reported clinical improvement after the procedure. If endovascular intervention is used in teenage patients with persistent symptomatic VTE, reduction of postthrombotic symptoms is possible, even if intervention is performed secondary to failure of anticoagulation. Multidisciplinary treatment decisions can be based on the clinical course and follow-up imaging.

822 HOW THE OPERATING SURGEON'S ASSESSMENT OF RADICALITY INFLUENCES SURVIVAL AFTER ESOPHAGEAL CANCER SURGERY

Abstract The operating surgeon’s assessment of surgical radicality following esophagectomy is reported to the Swedish National Registry for Esophageal and Gastric cancer(NREV). The variable provides means to identify risk factors for non-curative resections and study whether the surgeon’s assessment independently prognosticates survival. Methods All patients in NREV undergoing esophagectomy between 2006–2018 was grouped according to the surgeon’s assessment of radicality: Curative-, Borderline-curative- and Palliative resection. The cohort was followed until death, emigration or end of follow-up. Factors affecting group allocation was studied with multivariable logistic regression and survival with cox-regression and the Kaplan–Meier method. Results Of 1860 resected patients, esophagectomy was deemed curative in 1515(81%), borderline-curative in 179(10%), palliative in 63(3%) and missing in 103(6%). Median survival was 44.6, 20.0, 11.5 and 29.6 months respectively. Advanced stage (e.g., stage IVa), OR 7,37 (1,93–28,1 95%CI) and blood-loss >1000 mL, OR 1.90 (1,17-3,08), increased the risk of borderline-curative resection. Minimally invasive surgery and multidisciplinary treatment decision (MDT) decreased the risk of borderline-curative resection, OR 0.42 (0,23-0,77) and OR 0.41 (0,22-0,77). Adjusted for well-established prognostic factors, e.g. age, p-TNM and R1-resection, the surgeon’s assessment was an independent variable for survival; borderline-curative HR 1,38 (1,11-1,72), palliative HR 1,91 (1,38-2,63). Conclusion The surgeon’s operative assessment of radicality following esophagectomy appears to independently prognosticate survival. Advanced stage and large-volume intraoperative blood loss increases the risk while minimally invasive surgery and MDT decreases the risk for borderline-curative resection.

Liver-directed therapy for hepatocellular carcinoma.

The high mortality rate for hepatocellular carcinoma (HCC) relative to its prevalence underscores the need for curative-intent therapies. Multidisciplinary treatment decisions are required to craft optimal treatment strategies considering tumor size, location and underlying liver cirrhosis. Surgical resection of anatomically limited tumors with adequate hepatic reserve provides long-term survival in more than half of patients and remains a standard first-line therapy. Eligibility for resection among newly diagnosed patients is low and recurrences in the remaining cirrhotic liver are common. Transplantation offers a higher chance of cure. Long wait times for the limited door pool require neoadjuvant loco-regional therapies to maintain transplant eligibility. Image-guided therapies such as ablation and embolization have an established role as primary or neoadjuvant preparing patients for curative treatment. Percutaneous ablation in appropriately selected patients offers long-term survival similar to resection. New and evolving techniques such as stereotactic body radiotherapy (SBRT), radiation segmentectomy and lobectomy, and combination therapies employing both trans-arterial and ablative approaches show promise for curative-intent treatment but require further prospective data before they can be integrated into treatment algorithms. For palliativeintent therapy, conventional trans-arterial chemoembolization with lipiodol-based emulsions remains the only technique supported by clinical trials. Newer platforms such as drug-eluting embolics failed to improve survival over bland embolization in randomized trials and showed increased hepatobiliary toxicity. Transarterial radioembolization offers similar overall survival (OS) to transarterial chemoembolization (TACE) and non-inferiority to sorafenib in meta-analyses. The more favorable clinical toxicity profile makes it an appealing technique for patients willing to accept the longer time to response.

Axillary Nodal Evaluation in Breast Cancer: State of the Art.

Axillary lymph node (LN) metastasis is the most important predictor of overall recurrence and survival in patients with breast cancer, and accurate assessment of axillary LN involvement is an essential component in staging breast cancer. Axillary management in patients with breast cancer has become much less invasive and individualized with the introduction of sentinel LN biopsy (SLNB). Emerging evidence indicates that axillary LN dissection may be avoided in selected patients with node-positive as well as node-negative cancer. Thus, assessment of nodal disease burden to guide multidisciplinary treatment decision making is now considered to be a critical role of axillary imaging and can be achieved with axillary US, MRI, and US-guided biopsy. For the node-positive patients treated with neoadjuvant chemotherapy, restaging of the axilla with US and MRI and targeted axillary dissection in addition to SLNB is highly recommended to minimize the false-negative rate of SLNB. Efforts continue to develop prediction models that incorporate imaging features to predict nodal disease burden and to select proper candidates for SLNB. As methods of axillary nodal evaluation evolve, breast radiologists and surgeons must work closely to maximize the potential role of imaging and to provide the most optimized treatment for patients.

Systemic amyloidosis: moving into the spotlight.

Systemic amyloidosis is a rare but increasingly recognised disease that is heterogeneous in presentation. Early diagnosis, whilst imperative, remains challenging but can improve prognosis and limit organ dysfunction. An increased repertoire of diagnostic imaging and histological techniques are becoming mainstream and promise to aid early diagnosis. Better risk stratification, via biomarkers and cytogenetics, has improved multidisciplinary treatment decisions. The use of novel agents has improved treatment efficacy, which translates into survival benefit. Newer strategies targeting pre-deposited amyloidogenic protein are under investigation. The current paper reviews available data relating to the most recent advances in the field of systemic amyloidosis.

Curative-Intent Therapies in Localized Hepatocellular Carcinoma.

The high mortality rate for hepatocellular carcinoma (HCC) relative to its prevalence underscores the need for curative-intent therapies. Image-guided therapies such as ablation and embolization have an established role as primary or neoadjuvants preparing patients for curative treatment. For HCC < 3 cm, percutaneous thermal ablation provides oncologic outcomes similar to surgical resection and is now a recommended first-line therapy in the EASL guidelines. Both ablation and embolization are recommended as bridging therapies for HCC patients awaiting liver transplantation. T3 HCC can be downstaged by embolization to T2, allowing liver transplantation with similar outcomes to patients transplanted within Milan criteria. New and evolving techniques such as SBRT, radiation segmentectomy and lobectomy, and combination therapies show promise but require further prospective data before they can be integrated into treatment algorithms. Combinations of embolic, ablative, and extirpative therapies can increase access to curative-intent treatment of HCC. Multidisciplinary treatment decisions are required to craft optimal treatment strategies considering tumor size, location, and underlying liver cirrhosis.

Diagnosis and management of head and neck cancers in a high-incidence area in France: A population-based study.

Head and neck cancers have a very poor prognosis and are common in France. They are subject to various recommendations for early detection and management, but there is no detailed data in the French general population to fuel the public health debate on it.A high-resolution population-based study about cancer management was conducted, using cancers registries in the north-west of France, on 1729 tumors diagnosed between 2008 and 2010.The tumors were diagnosed late (70.3% stage III–IV), mainly after the onset of symptoms (93.2%). After adjustment, advanced stages were more frequent in patients with hypopharyngeal [adjusted odds ratio (ORa): 4.68; 95% confidence interval [CI] 3.11–7.05] and oropharyngeal tumors (ORa: 2.84; 95% CI 2.02–3.99) compared with oral cavity ones. They were also more frequent in patients with moderate (ORa 1.68; 95% CI 1.12–2.52) or severe comorbidities (ORa 1.86; 95% CI: 1.23–2.80). A multidisciplinary meeting (MM) had taken place in 96.9% of cases. The assessment included a panendoscopy in 80.3% of cases, a cervical computerized tomography (CT) scan in 89.3% and a chest CT scan in 87.3%. The vast majority of patients (90.7%) had received treatment, with surgery in 48.7% of cases and/or radiotherapy in 76.9%.Despite the recommendations for early detection, diagnoses are often made late, even for tumors that can be detected by a direct visual and tactile examination of the oral cavity. However, the major risk of advanced stage concerns deep tumors and the most weakened subjects. Otherwise, diagnostic assessment is broadly consistent with the recommendations, and multidisciplinary treatment decisions are widespread.

Paranoidism and memory deficits: An epidemiological study

BackgroundThe Green et al. Paranoid Thought Scales (GPTS) was developed to fulfill a need for a tool that was adapted to the current dimensional definition of paranoia, capable to assess dimensions of preoccupation, conviction, and distress, valid and reliable for the assessment of both clinical and healthy populations, and precise enough to detect subtle clinical change. It has recently been validated for the Spanish population (S-GPTS) with very good psychometric properties. Numerous studies suggest that patients with severe psychiatric disorders have impaired sustained attention and memory. A wide spectrum of executive deficits have also been described (goal-oriented tasks, recognizing priority patterns, planning, etc.) Very few studies have attempted to identify whether these same relationships between neuropsychological deficits and psychotic symptoms also occur in general population.MethodsThis is a cross-sectional study. We undertook a multistage sampling using different standard stratification levels and out of the 5496 eligible participants finally approached, 4507 (83.7%) agreed to take part in the study, completed the interview and were finally included in the study (n = 4507).ResultsIndividuals with high cut off S-GPTS scores showed lower scores in working memory subtest verbal statistically significant(P &gt; .05). While no significant difference was found among for immediate verbal learning subtest and high S-GPTS scores (P &gt; .05654).DiscussionThis information can improve the clinician's understanding of patient's cognitive strength and weaknesses, put patients’ cognitive abilities into perspective for their diagnosis, and facilitate multidisciplinary treatment decisions as we improve our ability to distinguish clinical cases from non-clinical population.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Contrast-Enhanced Ultrasound Guided Biopsy of Undetermined Abdominal Lesions: A Multidisciplinary Decision Making Approach

To investigate the value of contrast-enhanced ultrasound (CEUS) guided biopsy of undetermined abdominal lesions in multidisciplinary treatment (MDT) decision making approach. Between Jan 2012 and Dec 2015, 60 consecutive patients (male 37, female 23, mean age, 51.3 years ± 14.6) who presented with undetermined abdominal lesions were included. CEUS was performed with injection of 2.4ml SonoVue® (Bracco, Italy). Core needle (16 Gauge) percutaneous biopsies were performed under real-time CEUS guidance in all lesions. The displayment of internal necrotic or active areas, major vessels inner or surrounding lesions were recorded and compared with conventional ultrasound (US) guidance group (n = 75). All CEUS findings and clinical data were evaluated in MDT. Comparing to the conventional US guidance, CEUS enabled the delimitation of more (88.3 % vs 41.3 %) and larger (14.1 ± 10.7 mm vs 32.3 ± 18.5 mm) non-enhanced necrotic areas during different phases of CEUS. More inner (20.0 % vs 6.7 %) and surrounding (18.3 % vs 2.7 %) major vessels were visualized and avoided during biopsies. CEUS-guided biopsy increased the diagnostic accuracy from 93.3 % to 98.3 %, with correct diagnosis in 57 of 60 lesions (95.0 %). The therapeutic plan was influenced by CEUS guided biopsies findings in the majority of patients (98.3 %). Percutaneous CEUS guided biopsy is an efficient, minimally invasive, accurate and safe method in the diagnosis of undetermined abdominal lesions. The combination of CEUS guided biopsy and MDT decision making approach is useful in the diagnostic work-up and therapeutic management.

Seeing the Trees For the Forest: Rectal Cancer Intratumoral Heterogeneity.

Multidisciplinary treatment decisions in rectal cancer management are based on myriad tumor and patient characteristics. Although well-established guidelines direct protocols for radiation, chemotherapy, and surgery, rectal cancer care is not an exact science. Following guidelines based on clinical

Patients' preferences and trade-offs for the treatment of early stage hepatocellular carcinoma

BackgroundRadio frequency ablation (RFA) and hepatic resection (HR) provide similar survival for early stage hepatocellular carcinoma (ES-HCC). Although RFA has a higher recurrence rate, HR is associated with an increased risk of complications and death. When multiple treatments are available, patients should be enabled to direct their preferred therapy. Yet there is lack of knowledge on patients' preferences for the treatment of ES-HCC. The objective of this study was to assess treatment preferences between HR and RFA for ES-HCC. MethodsA cohort of 75 cirrhotic adults was educated about the natural history of HCC, treatment options, and the risks and the benefits of HR and RFA. Probability trade-off interviews were used to elicit participants' preferences between the two treatments and strength of their decisions. ResultsRFA was preferred by 70% of participants (P = 0.001) who identified the risk of perioperative morbidity and mortality of HR as the main reasons for their decision. Participants changed their minds if HR could provide better 5 (≥15%) and 3-y disease-free survival (≥10%) when compared with RFA. Their preference also changed when RFA had a median ≥8% risk for complications, ≥5% for mortality, ≥8% for nonradical therapy, and ≥5% for tumor seeding. ConclusionsInformed cirrhotic patients prefer RFA for the treatment of ES-HCC. Participants who preferred RFA were more concerned about the risks of perioperative morbidity and mortality of HR than long-term cancer outcomes. Patients' values and attitudes toward risks and benefits for the treatment of ES-HCC should be explicitly elicited and included in multidisciplinary treatment decisions.

Connections Are Clearly More Complex

CME articles on palliative medicine are to be welcomed, since they are very important. In the article of Bausewein and Simon (1), the sections regarding drug treatment of palliative symptoms are appropriate and reflect the current state of knowledge. Unfortunately, the authors did not stringently adhere to their stated objective of restricting the recommendations to patients with refractory dyspnea (for example, in the title, in the defined learning objectives on page 564, and in the algorithm on page 567). It is not stated clearly enough that the cited evidence is from studies that explicitly included only patients in whom tumor specific treatments (chemotherapy, radiotherapy, or surgery) was no longer indicated or not sufficiently effective. From an oncological perspective, this limitation likely leads to considerable deficits, particularly regarding the care for patients in a palliative setting. The systematic evaluation of possible causes of dyspnea and cough is a crucial step towards the best possible treatment in the palliative setting. tThis is, for example, stated in the current US guidelines on palliative medicine published by the National Comprehensive Cancer Network (2). A plain chest x-ray (as suggested by Bausewein and Simon) will, for example, not be sufficient to detect pulmonary embolism, which is quite common in cancer patients, or malignant pericardial effusion. Another important issue not covered by this article is the administration of local treatments such as radiotherapy. Radiotherapy is well recognized as a very effective local treatment generally associated with only minor adverse effects in the treatment of tumor or metastasis related dyspnea, cough, or hemoptysis. Furthermore, the aspect of communication with the patients was not appropriately mentioned. As described in the Canadian guidelines on the relief of dyspnea, preventive treatment of dyspnea should be initiated before a patient displays symptoms, This can be achieved by using structured education programs for patients and by discussing effective, symptom oriented treatment measures that can be applied when the malignant disease is progressing (3). The process of multidisciplinary treatment decision making is mandatory in order to provide the most appropriate treatment approach for each individual cancer patient being in a palliative situation .Such a process requires a great expertise (4), which has been emphasized by the authors of this CME article. However, the authors have not mentioned important disciplines that can contribute very effectively to the relief of dyspnea in palliative cancer patients. The S3 guideline on palliative medicine that is currently under development will likely provide a more comprehensive perspective.

Nomogram to predict sentinel lymph node involvement in patients with clinically node-negative breast cancer receiving neoadjuvant chemotherapy.

150 Background: Sentinel lymph node biopsy (SLNB) has been shown to be an accurate predictor of axillary lymph node involvement in breast cancer patients treated with neoadjuvant chemotherapy (NAC). A predictive model of SLN positivity in clinically node negative patients who completed NAC can assist in preoperative multidisciplinary treatment decision making, such as planning for postmastectomy radiation therapy and breast reconstruction. Methods: We reviewed our prospective database to identifyclinically node negative patients with invasive breast cancer who underwent NAC and SLNB from 1998-2011. Clincopathologic factors including age, tumor location, histology, nuclear grade, tumor size, decrease in tumor size with therapy, multifocality, nodal appearance on preoperative ultrasound, hormone receptor status, and lymphovascular invasion (LVI) were analyzed. A nomogram to predict SLN metastasis was developed using multivariate logistic regression analysis. Results: A total of 836 patients were treated with NAC followed by SLNB. Of these, 160 patients (19.1%) had a positive SLN. All factors were significant predictors of SLN positivity on univariate analysis except tumor location and nodal appearance on preoperative ultrasound. Multivariate analysis showed that young age, invasive lobular histology, tumor size, multifocality, and LVI were independent positive predictors of SLN positivity whereas high grade, response to chemotherapy, and triple negative hormone receptor status were negative predictors. Favorable histologies were strongly associated with a lower rate of SLN positivity but were excluded from the nomogram due to small numbers of patients (N=14). Discrimination of the nomogram to correctly predict SLN positivity was measured using the area under the receiver operating characteristic curve (AUC). The unadjusted AUC was 75.9, while the internally validated 2000 bootstrap sample-adjusted AUC was 74.2. Conclusions: Neoadjuvant chemotherapy is known to decrease the incidence of positive nodes in breast cancer patients. Use of our nomogram preoperatively can assist in decisions regarding multidisciplinary treatment planning.

Impact of neoadjuvant chemotherapy on wound complications after breast surgery

Use of neoadjuvant chemotherapy for breast cancer is increasing. The objective was to examine risk of postoperative wound complications in patients receiving neoadjuvant chemotherapy for breast cancer. Patients undergoing breast surgery from 2005 to 2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were included if preoperative diagnosis suggested malignancy and an axillary procedure was performed. We performed a stepwise multivariable regression analysis of predictors of postoperative wound complications, overall and stratified by type of breast surgery. Our primary variable of interest was receipt of neoadjuvant chemotherapy. Of 44,533 patients, 4.5% received neoadjuvant chemotherapy. Wound complications were infrequent with or without neoadjuvant chemotherapy (3.4% vs. 3.1%; P = .4). Smoking, functional dependence, obesity, diabetes, hypertension, and mastectomy were associated with wound complications. No association with neoadjuvant chemotherapy was seen (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.78-1.32); however, a trend was observed toward increased complications in neoadjuvant patients undergoing mastectomy with immediate reconstruction (OR, 1.58; 95% CI, 0.98-2.58). Postoperative wound complications after breast surgery are infrequent and not associated with neoadjuvant chemotherapy. Given the trend toward increased complications in patients undergoing mastectomy with immediate reconstruction, however, neoadjuvant chemotherapy should be among the many factors considered when making multidisciplinary treatment decisions.