Multidisciplinary Approach to the Management of Esophageal Malignancies

Inter-rater variability in multidisciplinary team meetings of oesophageal and gastro-oesophageal junction cancer on staging, resectability and treatment recommendation: national retrospective multicentre study

BACKGROUND

There are differences in oesophageal cancer care across Sweden. According to national guidelines, all patients should be offered equal care, planned and administrated by regional multidisciplinary team meetings. The aim of the study was to investigate differences between regional multidisciplinary team meetings in Sweden regarding clinical staging and treatment recommendations for oesophageal cancer patients.

METHODS

All six Swedish regional multidisciplinary teams were each invited to retrospectively include ten consecutive oesophageal cancer cases. After anonymization, radiological investigations were presented, along with the original case-specific medical history, anew at the participating regional multidisciplinary team meetings. Estimation of clinical tumour node metastasis (TNM) classification and treatment recommendation (curative, palliative or best supportive care) were compared between multidisciplinary team meetings as well as with original assessments.

RESULTS

Five multidisciplinary teams participated and contributed a total of 50 cases presented to each multidisciplinary team. In estimations of cT-stage, the multidisciplinary teams were in total agreement in only eight of 50 cases (16%). For cN-stage, total agreement was seen in 17 of 50 cases (34%) and for cM-stage there was agreement in 34 cases (68%). For cT-stage, the overall summarized κ value was 0.57. For N-stage and M-stage the κ values were 0.66 and 0.78 respectively. Differences in appraisal were not associated with usage of positron emission tomography-computed tomography. In 15 of 50 cases (30%) the multidisciplinary teams disagreed on curative or palliative treatment.

CONCLUSION

The study shows differences in assessment of clinical TNM classification and treatment recommendations made at regional multidisciplinary team meetings. Increased interrater agreement on clinical TNM classification and management plans are essential to achieve more equal care for oesophageal cancer patients in Sweden.

Improving Outcomes in the Advanced Gastrointestinal Stromal Tumors: The Role of the Multidisciplinary Team Discussion Intervention

Objectives: There is disagreement over the prognostic value of multidisciplinary team (MDT) discussion for advanced gastrointestinal stromal tumors (GISTs). This study examined how an MDT affected patients with advanced GISTs in terms of their overall survival (OS) and whether it may enhance their performance status (PS). Methods: A retrospective data analysis was conducted on patients with advanced GISTs between 2000 and 2022. Depending on whether they had received the MDT discussion intervention, the patients were split into two groups. The OS between the two groups was compared using the Kaplan–Meier method. A multivariate Cox regression analysis was used to analyze the prognostic variables for advanced GIST. Fisher’s test was used to investigate the relationship between an MDT and PS. Results: There were 122 patients with an MDT and 117 patients without an MDT in this study. In comparison to the non-MDT group, the MDT group showed a higher survival rate (5-year OS, 42.62% vs. 28.21%, p < 0.05). MDT was an independent prognostic factor for OS in univariate and multivariate Cox regression analyses (p < 0.05). Fisher’s test revealed that there were variations in PS between the two groups (p < 0.05). Conclusions: The effectiveness of an MDT in the treatment of advanced GIST was examined for the first time in this study. MDT discussion intervention is an effective measure for improving the outcomes of patients with advanced GISTs.

Efficacy of cell proliferation imaging with 4DST PET/CT for predicting the prognosis of patients with esophageal cancer: a comparison study with FDG PET/CT

PURPOSE

4'-[Methyl-11C] thiothymidine (4DST) incorporates into DNA directly and is a PET tracer used for cell proliferation imaging. The aim of this study was to evaluate the prediction of prognosis with pretreatment 4DST PET/CT compared to fluorodeoxyglucose (FDG) PET/CT in patients with esophageal cancer.

METHODS

In this prospective study, we analyzed 46 patients (68.2 ± 10.0 years old) with pathologically proven esophageal squamous cell cancer who underwent pretreatment 4DST and FDG PET/CT. The maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and total lesion proliferation (TLP) were measured for FDG and 4DST PET. The study endpoints were progression-free survival (PFS) and overall survival (OS). Patients' clinical backgrounds, including age, histological type, clinical stage, and surgical treatment, were adjusted using the Cox proportional-hazards model.

RESULTS

In the follow-up period (median 18.8 (interquartile range: 10.1-29.0) months), 26 and 19 patients showed disease progression and cancer-related death, respectively. After adjusting for clinical variables, only the 4DST parameters (SUVmax (p = 0.001) and TLP (p = 0.022)) were statistically significant for predicting PFS. FDG MTV (p = 0.031), 4DST SUVmax (p = 0.022), and TLP (p = 0.023) were statistically significant for predicting OS. Of the PET parameters, 4DST SUVmax yielded the highest adjusted hazard ratio for both PFS (4.88, 95% confidence intervals (CI): 1.83-12.97) and OS (4.19, 95% CI: 1.23-14.20).

CONCLUSION

Higher accumulation of 4DST in the primary tumor may lead to shorter OS and PFS. 4DST PET/CT is useful for predicting prognosis and may outperform FDG PET/CT.

Contribution of FDG-PET/CT to the management of esophageal cancer patients at multidisciplinary tumor board conferences

Background

A multidisciplinary team approach to the management of esophageal cancer patients leads to better clinical decisions.

Purpose

The contribution of CT, endoscopic and laparoscopic ultrasound to clinical staging and treatment selection by multidisciplinary tumor boards (MTB) in patients with esophageal cancer is well documented. However, there is a paucity of data addressing the role that FDG-PET/CT (PET/CT) plays to inform the clinical decision-making process at MTB conferences. The aim of this study was to assess the impact and contribution of PET/CT to clinical management decisions and to the plan of care for esophageal cancer patients at the MTB conferences held at our institution.

Materials and methods

This IRB approved study included all the cases discussed in the esophageal MTB meetings over a year period. The information contributed by PET/CT to MTB decision making was grouped into four categories. Category I, no additional information provided for clinical management; category II, equivocal and misguiding information; category III, complementary information to other imaging modalities, and category IV, information that directly changed clinical management. The overall impact on management was assessed retrospectively from prospectively discussed clinical histories, imaging, histopathology, and the official minutes of the MTB conferences.

Results

79 patients (61 males and 18 females; median age, 61 years, range, 33–86) with esophageal cancer (53 adenocarcinomas and 26 squamous cell carcinomas) were included. The contribution of PET/CT-derived information was as follows: category I in 50 patients (63%); category II in 3 patients (4%); category III in 8 patients (10%), and category IV information in 18 patients (23%). Forty-five patients (57%) had systemic disease, and in 5 (11%) of these, metastatic disease was only detected by PET/CT. In addition, PET/CT detected previously unknown recurrence in 4 (9%) of 43 patients. In summary, PET/CT provided clinically useful information to guide management in 26 of 79 esophageal cancer patients (33%) discussed at the MTB.

Conclusion

The study showed that PET/CT provided additional information and changed clinical management in 1 out of 3 (33%) esophageal cancer cases discussed at MTB conferences. These results support the inclusion whenever available, of FDG-PET/CT imaging information to augment and improve the patient management decision process in MTB conferences.

Less is More: The Impact of Multidisciplinary Thyroid Conference on the Treatment of Well-Differentiated Thyroid Carcinoma

BACKGROUND

In 2006, a multidisciplinary thyroid conference (MDTC) was implemented to better plan management of thyroid cancer patients at our institution. This study assessed the clinical impact of a MDTC on radioactive iodine (RAI) treatment patterns.

METHODS

A prospective database (2003-2014) collected patient and tumor characteristics, RAI doses, and tumor recurrences. Patients treated with total thyroidectomy for differentiated thyroid carcinoma ≥1 cm were stratified based on American Thyroid Association (ATA) risk classification. RAI regimens were compared before initiation of MDTC (2003-2005, n = 88), after establishment of MDTC (2007-2009, n = 95), and after the release of 2009 ATA guidelines (2011-2014, n = 181). RAI doses were defined as low (≤75 mCi), intermediate (76-150 mCi), and high (>150 mCi).

RESULTS

There was a significant decrease in the number of patients who received high-dose RAI after implementation of MDTC compared to before initiation of MDTC in the intermediate and high-risk patient groups (p = 0.04 and p < 0.01) without an associated increase in tumor recurrence (11 vs. 7%, p = 0.74). On multivariable analysis, presentation of a patient at MDTC was a negative predictor for receiving high-dose RAI (p = 0.002). As might be expected, there was also a significant decrease in use of RAI after the 2009 ATA guidelines were issued compared to after implementation of MDTC (p < 0.01).

CONCLUSION

In conjunction with implementation of a thyroid malignancy multidisciplinary conference, we observed significantly decreased postoperative dosing of RAI without increased tumor recurrence. The 2009 ATA guidelines were associated with a further decrease in RAI administration. Treatment for patients with thyroid carcinoma is optimized by a multidisciplinary approach.