Dr. Feigenberg is an Associate Professor/Director of Clinical Research, Department of Radiation Oncology; Dr. Campassi is an Assistant Professor, Department of Radiology; Dr. Sharma is an Assistant Professor, Department of Radiation Oncology, University of Maryland School of Medicine; Dr. Kesmodel is
an Assistant Professor of Surgery, Division of Surgical Oncology,
Department of Surgery, Department of Surgical Oncology; and Dr. Tkaczuk
is a Professor and Director of the Breast Evaluation and Treatment
Program, Department of Medical Oncology, University of Maryland School
of Medicine, Baltimore, MD. Dr. Yu is the Chief of Nuclear Medicine/PET, and Associate Professor of Diagnostic Imaging, Fox Chase Cancer Center, Philadelphia, PA.
multidisciplinary approach to cancer diagnosis and treatment is vital
to optimize care for the cancer patient. Multidisciplinary cancer
management requires coordination among many different specialities
involved in cancer care of an individual patient. Participants in this
care include physicians from diverse oncology specialties, including
surgical oncology, medical oncology, radiation oncology, pathology,
radiology, nuclear medicine, genetic counseling, and depending on the
tumor type, may also include various others from internal medicine and
palliative care. In addition to physicians, there are nurses, nurse
practitioners, physician assistants, and oncological nurse specialists
that are involved in care, including patient navigators, clinic and
research coordinators, and data managers as well as patient advocates
and social workers.
Benefits in care are multifactorial, arising
from improvements in communication between disciplines leading to more
efficient work-ups and decision making, which translates into improved
outcomes for patients. To appreciate this point, several investigators
have demonstrated that cancer care in a multidisciplinary setting is an
independent predictor of improved outcomes. For example, Birchall1
et al reported on patients with head and neck cancer in England before
and after a report by the Calman-Hine Expert Advisory Group on Cancer,2
recommending that designated cancer units and multidisciplinary care be
established. They observed that patients receiving treatment in such a
setting had an improved 2-year survival. Similarly, Junor3 et
al showed, in patients with ovarian cancer, that the multidisciplinary
setting was an independent predictor for improved 5-year survival (65%
versus 81%) compared to treatment outside this setting.
Patients with Hodgkin’s disease who were treated in a Surveillance,
Epidemiology and End Results Program region were found to have 1.5 times
higher cancer mortality as compared to patients treated at a
Centralized Cancer Center, independent of age or stage of disease,
suggesting that the process and quality of care was improved at the
Centralized Cancer Centers.4 These benefits are so convincing
that the Commission on Cancer and the American College of Surgeons both
require multidisciplinary conferences for the accreditation of health
centers delivering multidisciplinary cancer care.5-8
of the major benefits of multidisciplinary care is information sharing
between various physicians where literature that is unique to their
specialties and perspectives can be discussed, improving clinical care
overall. In addition, centralized review of the pertinent
patient-specific information, covering medical history, family history,
physical exam findings, imaging studies, pathology results, while all
cancer care specialists are present in the same conference room, is
invaluable to the management of cancer patients and helps with
immediate formulation of the recommendations for further management.
Data suggest that multidisciplinary clinics are not just valuable for
the participating physicians but also for their medical students,
residents, and fellows who learn the value of a collaborative
approach to management of complicated cases. The following cases
illustrate how a multidisciplinary approach improves care with an
emphasis on the impact of diagnostic radiology on cancer care.9
Case 1: Lung cancer
years ago, there was no published prospective literature on ablative
doses of radiation therapy for lung cancer (see below). Therefore, 2 of
the authors of the current manuscript, Drs. Feigenberg and Yu, developed
and opened a phase I dose escalation study10 testing this
novel technique, which had previously been successful in the management
of inoperable brain tumors. As part of this study, the use of
fluoro-deoxyglucose (FDG) positron emission tomography (PET)/computed
tomography (CT) was incorporated into the treatment paradigm for
patients with curable disease, with the specific purpose to use PET as a
potential early biomarker for treatment response similar to what others
had published in the setting of locally advanced disease.11 As is often the case in phase I studies, this patient’s situation created a clinical dilemma.
patient was a young woman with lung cancer. Her first follow-up CT scan
following trimodality therapy showed a new spiculated mass that was
biopsied and demonstrated a second primary nonsmall cell lung cancer.
She had just recovered from a lobectomy and did not feel she could
undergo further surgery. She was offered a novel treatment using
stereotactic body radiotherapy (SBRT) on a phase I protocol as an
alternative to a 7-week course of conventionally fractionated
radiotherapy, which was the standard treatment at that time. She
tolerated the SBRT treatment uneventfully, feeling well with no
symptoms, and returned for her first post-therapy PET scan 3 months
later as per the study protocol. At that time, images were not available
in clinic, but the report was. The report read, “When compared to the
last study dated 6/7/04, there has been a marked interval increase in
the size of the previously noted left-upper lobe pulmonary nodule as
well as increased intensity of FDG uptake in the area. The nodule has
markedly increased in size and now extends out towards the pleural
surface. The previous maximum standard uptake value (SUV) of 4.4 has
increased to 6.7. This suggests that there has been no significant
response to radiation therapy with progression of tumor growth.”
this was a medically operable patient, it was vital to review her
images to determine further management. Her case was presented in
conference, and it became glaringly obvious that the imaging findings
were not as suspicious as the report indicated. Figure 1 demonstrates CT
lung windows and the corresponding FDG PET prior to and 3 months’
post-SBRT. Radiographic changes appeared as patchy consolidation with
some surrounding ground-glass opacities as opposed to a solid mass-like
Dr. Feigenberg discussed the “new” treatment technique
with his colleagues and demonstrated the differences in how the
radiation dose could be delivered using many unique nonopposing coplanar
and noncoplanar beams (Figure 2). This approach can cause a difference
in the appearance of radiation pneumonitis that will more precisely
conform to the tumor and will not have straight edges, typically seen
using 2 opposing beams as was the standard approach.
this factor, it was believed this abnormal PET finding was caused by an
asymptomatic pneumonitis. It was recommended that surveillance be
continued as opposed to any further intervention. Over time, the
radiographically abnormal region became linear and denser, stretching in
the direction of the radiation dose fall-off. This dense consolidation
has remained stable for 5 years (Figure 2). This initial interaction led
to several meaningful peer-reviewed presentations10, 12, 13
and publications describing the importance of pre-SBRT PET values,
post-SBRT PET values, and changes in PET values over the course of
therapy (Figure 3). These findings are critical as this novel
therapeutic radiation approach is currently challenging the paradigm of
surgery14 as standard of care for early stage lung cancer.
This was the first data to illuminate concern of false positive results
caused by radiation pneumonitis as well as the predictive value of a
drop of the maximum SUV of 50%, required to ensure long-term local
Patient case 2: Breast cancer
multidisciplinary (multiD) Breast Cancer (BC) conference is held weekly
before the multidisciplinary clinic and includes participants from all
specialties involved in management. All newly diagnosed BC cases are
presented, and pathology and imaging findings are discussed initially
followed by preliminary workup and treatment recommendations. Patients
are then seen on the same day in the multidisciplinary clinic held
immediately after the conference by the 3 primary cancer
specialists—surgical oncology, medical oncology, and radiation oncology.
The recommendations are then made same day; the benefit of seeing newly
diagnosed BC patients on the same day of the multiD conference is that
the team can rapidly implement recommendations for further work-up if
deemed necessary. In addition, the group can still consider the case or
review the medical history and clinical findings given mutual
accessibility at the same location. The additional benefit to the
patients is that they are seen by the 3 primary cancer specialists on
one day and do not have to make several trips to be reevaluated. Often
patients are not aware that the management of BC may require treatments
after surgery with radiation to the breast, hormonal therapy, and/or
chemotherapy. These basic concepts of management of early-stage BC can
also be introduced to the patients during their first visit to the
The following case demonstrates many interactions
between disciplines that are vital to patient care. A 40-year-old
woman, with no known risk factors for breast cancer, presented for a
baseline mammogram. This mammogram showed dense breasts with bilateral
scattered and grouped calcifications with an asymmetric distribution,
more numerous in the upper outer quadrant (Figure 5). The test was
interpreted as incomplete, requiring additional evaluation with
dedicated magnification views. When the patient returned for the
additional diagnostic work-up, the morphology of the left breast
calcifications was found to be suspicious, while the right breast
calcifications were categorized as probably benign (Figure 6). Of note
was that the breast thickness under mammographic compression was only
2.5 cm, usually a limiting factor to performing a needle biopsy under
stereotactic guidance. The radiologist informed the patient of the
results and need for biopsy. The patient was referred to the
multidisciplinary breast clinic for further evaluation and discussion of
Her case was presented to the
multidisciplinary panel (breast imaging, breast surgery, medical
oncology, radiation oncology, and breast pathology). Based on the
imaging findings, the options of stereotactic-guided core and excisional
biopsy were discussed. The patient elected to undergo a
stereotactic-guided approach with the pathology demonstrating extensive
atypical ductal hyperplasia. The case was discussed again in the
multidisciplinary conference. Due to the presence of extremely dense
breast tissue,15, 16 an independent risk factor for breast
cancer on mammogram, the patient’s young age, and the newly diagnosed
high-risk lesion, a breast MRI with gadolinium was recommended.
demonstrated a 1-cm highly suspicious spiculated mass at the 12 o’clock
position of the left breast and markedly asymmetric background
parenchymal enhancement of the left breast compared to the right.
Additionally, a nonspecific 1-cm left axillary node was also noted on
MRI (Figure 7). The breast MRI was interpreted as suspicious. An
ultrasound of the breast and the axilla confirmed the presence of 2
breast tissue abnormalities at 12 o’clock, believed to be highly
suspicious for malignancy (Figure 8). The axillary node had a
nonspecific appearance on ultrasound. The patient underwent biopsy of
both masses and an ultrasound-guided fine-needle aspiration of the left
axillary node. The larger 9-mm mass was an invasive ductal carcinoma,
the smaller 8-mm mass was ductal carcinoma in situ, and the lymph node
was positive for metastasis.
The patient was brought back to the
multidisciplinary conference for a third time, where it was determined
that the patient was not a good candidate for breast conservation due to
the small size of her breast and a challenge for follow up due to
diffuse calcifications and multifocal disease. Further discussion of the
literature ensued regarding the possible need for radiotherapy and the
role of a lymph node dissection.17, 18 Delayed breast reconstruction19, 20
was recommended to decrease the risks of loss of the implant due to
encapsulation as compared to patients who undergo immediate
reconstruction. Lastly, the role of axillary dissection was discussed.
The recently conducted MRI evaluated the role of axillary dissection
following positive sentinel lymph node biopsy17. The data
were convincing that outcomes are not compromised by withholding
dissection, although patients received radiotherapy to the whole breast,
which indirectly also treats the majority of the axilla. 21, 22
In this case, since the patient was not going to receive radiotherapy
following her mastectomy, an axillary dissection was recommended.
Patient case 3: Hepatocellular carcinoma
case illustrates another example of how multiple disciplines were able
to work together to convert an “incurable patient” to a “potentially
curable patient.” Orthotopic liver transplant (OLT)23 is the
only realistic curative treatment for patients with chronic hepatitis
who are found to have hepatocellular carcinoma (HCC).
2010, a 56-year-old man was diagnosed with HCC in the setting of chronic
hepatitis C infection. At an outside institution, the patient was
thought to have a solitary 4-cm ill-defined posterior lesion in the left
lobe of the liver amenable to OLT. His alpha fetoprotein (AFP) level at
presentation was 1500 ng/ml. While a transplant evaluation was being
pursued, chemoembolization was performed twice in order to downstage the
patient, producing a drop in AFP level to117 ng/ml, but the level rose
to 566 ng/ml within 3 weeks. After transfer to the authors’ institution,
MRI with contrast demonstrated a cirrhotic liver with multifocal
enhancing masses in hepatic segment IV consistent with persistent HCC.
In addition, there was a suggestion of tumor invasion and thrombosis of
the left portal vein excluding him from OLT. Due to his overall
excellent performance status, his case was discussed at the
multidisciplinary hepatobiliary tumor board and “spirited” discussions
among the present medical, surgical, radiation oncologists,
interventional and diagnostic radiologists ensued. Due to the size of
the lesion, all single-modality therapies were thought to have poor
local control potential so a combination therapy was considered as the
best method to potentially eradicate the large residual tumor. This
approach entailed targeting the tumor through a combination of
irreversible electroporation (IRE)22, 23 performed by interventional radiology, followed by SBRT24, 25 performed by radiation oncology. The rationale for this approach was to get a direct tumoricidal effect through IRE24, 25
initially, and to then cover the core and periphery (including the
portal vein component) of the ablated region with high-dose SBRT.26, 27
The patient underwent CT-guided IRE on 3/22/2011 and tolerated his
treatment well. Subsequently, the patient underwent 4-dimensional
simulation (to account for tumor movement with the respiratory cycle)
and a 5-fraction treatment of 6 Gy each was delivered to a large portion
of the left lobe. The total dose of 30 Gy was administered over a 9-day
period ending on 4/20/11, also tolerated well by the patient. A
repeat MRI on 5/16/2011 demonstrated interval atrophy of the left lobe
(Figure 9) with no residual enhancement and consistent with tumor
regression/resolution. AFP levels (measured in ng/ml) continued to drop
to 390.8 on 5/2/11, 44.7 on 5/26/11, 6.6 on 6/22/11, and 4.8 on 8/8/11
Restaging PET and bone scans along with subsequent
MRI studies continued to demonstrate no further abnormal activity
compatible with disease recurrence. The patient was again presented to
the multidisciplinary hepatobiliary tumor board in September. Given the
dramatic decline in AFP levels without evidence of recurrent or
metastatic HCC, the patient was reconsidered for OLT and was
subsequently placed back on the active transplant list.
- Birchall M, Bailey D King P. Effect of process standards on
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- Davis S, Dahlberg S, Myers MH, et al. Hodgkin’s disease in the
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- Cohen RJ, Sharma N K, Yu JQ, et al. A phase I radiation dose
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- Hicks R J, Kalff V, MacManus MP, et al. The utility of (18)F-FDG PET
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- Husain ZA, Sharma NK, Hanlon AL, et al. Low pretreatment PET SUV
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- Christante D, Pommier SJ, Diggs BS, et al. Using complications
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