P-P50 Analysis of the efficiency of the hepatobiliary multidisciplinary team meeting to identify quality improvement strategies

Background The multidisciplinary team meeting is the mainstay of management of patients with hepatopancreatobiliary (HPB) cancer and is considered the gold standard of care. Disadvantages of these meetings include large numbers of patients to be discussed covering multiple super-specialities over a short time span. This can lead to decision fatigue amongst clinicians. Logistical factors such as information technology and presence of clinicians with relevant expertise may also hamper the progress of the meeting. The aim of this study was to analyse the efficiency of our HPB MDT with a view to identifying multi-factorial quality improvement interventions. Methods 13 weeks of prospectively generated multidisciplinary team meeting outcomes were analysed from our departments weekly 150-minute long MDT meeting between 01/06/21 and 24/08/21. Patient demographics and pathology were noted. The number of overall discussions in each meeting were recorded. Number of patients in each sub-category (1. Regional pancreatic cancer service, 2. Hepatocellular carcinoma or liver adenoma, 3. pancreatic cystic neoplasms, 4. Gallbladder cancer and cholangiocarcinoma, 5. Pancreatic neuroendocrine tumours and 6. Other) were recorded. The number of patients without a recorded outcome was collated and reasons for no outcome being generated were categorised. Results 174/ 869 patients (20 %) did not receive an outcome from the meeting and were carried forward to the next week. Of the patients carried forward to the next week; 33/177 (18.6%) had no available histopathology following biopsies. Of these 33 patients, 23 did not have post-operative histopathology yet available for discussion. 82/177 (46 %) patients did not have the relevant investigations performed or available to move the discussion forward. These investigations were wide ranging and included radiological and endoscopic interventions. Of these, 19 patients (2 % over-all) had not had images sent across from a peripheral centre. 3 patients required both histology and radiology for further discussion. 59/869 (6%) of patients were not discussed due to time constraints. This equated to an average of 4 patients per meeting. Conclusions This study demonstrates the breadth and depth of a general HPB MDT. Strategies are required to simplify the MDT process to allow for time for discussion of the most complex patients, in particular those requiring surgery. Multifactorial reasons for a lack of MDT outcome at any single meeting have been found in this study. This signifies that a more robust triage process involving multiple specialities needs to be considered. Logistical factors also need to be in place allowing for transfer of relevant images from peripheral units. Histopathology reporting takes time and appropriate expectations for the availability of these results needs to be in place. The next step in this study is to identify and implement effective quality improvement strategies to improve outcome rates and allow more time for complex case discussions.

774 TEAM DYNAMICS AND CLINICIAN’S PERSONAL BELIEVES IN TREATMENT OPTIONS INFLUENCE MULTIDISCIPLINARY TREATMENT DECISION-MAKING DURING AN ONCOLOGIC UPPER GASTROINTESTINAL MULTIDISCIPLINARY TEAM-MEETING

The probability of undergoing treatment with curative intent according to the hospital of diagnosis has been shown to vary considerately for esophagogastric cancer affecting survival negatively. Little is known which factors attribute to this variation. The aim of this study is to investigate the possible differences in clinical decision-making (CDM) during the multidisciplinary team meeting (MDTM). Methods A mixed method study design consisting of quantitative and qualitative data was conducted in which thematic content analysis of the current sub-study focused on the 16 MDTM observations and transcripts of 30 semi-structured interviews with clinicians was performed. Interviews were transcribed ad verbatim and coded. Seven focus groups were held to enrich, further explore and validate the gathered data. Results Clinician’s personality traits including ambition and the intention to be innovative were mentioned as facilitators, whereas hierarchy was mentioned as a barrier in CDM. Physician’s believes in a certain treatment and previous experiences with treatment outcomes and team dynamics within the MDTM influenced CDM. A continuum was identified in which at one end hospitals tended to be more guideline and evidence minded and at the other end of the continuum hospitals tended to search for boundaries maximizing chances of curation. All hospitals took patient characteristics in consideration. Conclusion Mechanisms influencing decision-making consisted of following guidelines, using evidence-based medicine, searching for boundaries, and taking patient characteristics into consideration. Nevertheless, the extend in which hospitals involved these mechanisms in their CDM differed. Variation in team dynamics was observed and awareness should be created that these factors attribute to CDM during an MDTM.

Unusual case of malignant pleural mesothelioma

We present the case of a 65-year-old woman who presented with progressive dysphagia and was diagnosed with achalasia. She subsequently developed bilateral chylous pleural effusions, with no cause identified despite extensive investigations (including computed tomography (CT) scans, gastroscopy and medical thoracoscopy (MT)) and review at a dedicated pleural multidisciplinary team meeting.Despite optimal supportive management she deteriorated and was admitted to the intensive care unit, where she passed away due to sepsis and respiratory failure 10 months after initial presentation. A postmortem returned a diagnosis of epithelioid mesothelioma, encasing the carina, distal oesophagus and coeliac axis.Mesothelioma only very rarely presents with either chylous effusions or achalasia. Additionally while MT normally conveys excellent sensitivity for pleural malignancy, it was insufficient here. This case highlights how an unusually located mesothelioma can produce an unusual clinical picture. It also suggests a role for early video-assisted thoracoscopy to aid diagnosis.

Diagnostic interpretation of non-contrast qualitative MR imaging features for characterisation of uterine leiomyosarcoma

Objective: To assess the value of non-contrast MRI features for characterisation of uterine leiomyosarcoma (LMS) and differentiation from atypical benign leiomyomas Methods: This study included 57 atypical leiomyomas and 16 LMS which were referred preoperatively for management review to the specialist gynae-oncology multidisciplinary team meeting. Non-contrast MRIs were retrospectively reviewed by five independent readers (three senior, two junior) and a five-level Likert score (1-low/5-high) was assigned to each mass for likelihood of LMS. Evaluation of qualitative and quantitative MRI features was done using uni- and multi variable regression analysis. Inter reader reliability for the assessment of MRI features was calculated by using Cohen’s κ values. Results: In the univariate analysis, interruption of the endometrial interface and irregular tumour shape had the highest Odds ratios (OR) (64.00, p < 0.001 and 12.00, p = 0.002, respectively) for prediction of LMS. Likert score of the mass was significant in prediction (OR, 3.14; p < 0.001) with excellent reliability between readers (ICC 0.86; 95% CI, 0.76–0.92). The post-menopausal status, interruption of endometrial interface and thickened endometrial stripe were the most predictive independent variables in multivariable estimation of the risk of leiomyosarcoma with an accuracy of 0.88 (95%CI, 0.78–0.94). Conclusion: At any level of expertise as a radiologist reader, the loss of the normal endometrial stripe (either thickened or not seen) in a post-menopausal patient with a myometrial mass was highly likely to be LMS. Advances in knowledge: This study demonstrates the potential utility of non-contrast MRI features in characterisation of LMS over atypical leiomyomas and therefore influence on optimal management of these cases.