Imaging Pearls ❯ Pancreas ❯ Multidisciplinary Conference
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- “The unprecedented impact of the Sars-CoV-2 pandemic (COVID-19) has strained the healthcare system worldwide. The impact is even more profound on diseases requiring timely complex multidisciplinary care such as pancreatic cancer. Multidisciplinary care teams have been affected significantly in multiple ways as healthcare teams collectively acclimate to significant space limitations and shortages of personnel and supplies. As a result, many patients are now receiving suboptimal remote imaging for diagnosis, staging, and surgical planning for pancreatic cancer. In addition, the lack of face-to-face interactions between the physician and patient and between multidisciplinary teams has challenged patient safety, research investigations, and house staff education. In this study, we discuss how the COVID-19 pandemic has transformed our high-volume pancreatic multidisciplinary clinic, the unique challenges faced, as well as the potential benefits that have arisen out of this situation. We also reflect on its implications for the future during and beyond the pandemic as we anticipate a hybrid model that includes a component of virtual multidisciplinary clinics as a means to provide accessible world-class healthcare for patients who require complex oncologic management.”
The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience
Ammar A. Javed et al.
Current Problems in Diagnostic Radiology 51 (2022) 675 679 - “Precise imaging and accurate reporting lie at the heart of multidisciplinarycare for pancreatic cancer. The gold standard for assessment of these patients is a pancreas protocol computed tomography(PPCT). Guidelines for the techniques of performing and accurately by reporting a PPCT are well described.These have been developed tofacilitate the decision-making for the management of patients with pancreatic cancer. The scan permits focused visualization of the arterial and venous structures in relation to the primary tumor; which is imperative for accurate staging and surgical planning. Furthermore, three-dimensional (3D) reconstruction of the scans is routinely performed at our PMDC which can provide additional valuable information such as the degree of tumor-vessel relationship, aberrant anatomy through vascular mapping, and more sensitive assessment of occult metastatic disease. Given that our PMDC is commonly comprised of patients with borderline and locally advanced diseases having access to complete and accurate radiological information becomes exceedingly valuable.”
The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience
Ammar A. Javed et al.
Current Problems in Diagnostic Radiology 51 (2022) 675 679 - “Since its introduction, PMDC has offered trainees (residents, clinical fellows, and research postdoctoral fellows) an excellent platform for learning. Firstly, these trainees get an opportunity to practice focused history taking and physical exam, and case presentation to a multidisciplinary team. Secondly, observing the cross-discipline interaction expedites the learning process and instills the benefits of collaborative care. Often providers utilize patient cases to educate trainees on various facets of disease and patient management. Unfortunately, with new virtual meetings, we have noticed that the emphasis on training has decreased substantially. While not intentional, it seems likely that the in-person pre-COVID-19 PMDC provided a more conducive and stimulating environment. Lastly, with social distancing protocols in place, our pathologists find it difficult to accommodate students and trainees in the labs, which limits their training. While the effect of these changes on the field will not be immediate, it would certainly influence patient care in the long run, by effecting training of future healthcare providers. We recommend that faculty take this into account and potentially identify other avenues of teaching that could help overcome these deficiencies.”
The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience
Ammar A. Javed et al.
Current Problems in Diagnostic Radiology 51 (2022) 675 679 - “In conclusion, the pandemic has unquestionably changed the way we practice medicine, especially in the multidisciplinary setting. Physicians of all specialties have been impacted to various degrees. However, this collective experience has provided us with a learning opportunity to change and improve on how we do things and become more effective in making world-class healthcare accessible to a broader patient population. It has led us to identify potential shortcomings in the system such as the need for strict adherence to imaging protocols for PPCT. Even once this pandemic is behind us, new norms will persist that can improve how we provide patient care if we are mindful of the pitfalls and appreciate the potential benefits of adopting this new approach. We anticipate a certain hybrid model for multidisciplinary clinics as a means to provide accessible world-class healthcare for patients who require complex oncologic management for pancreatic cancer”
The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience
Ammar A. Javed et al.
Current Problems in Diagnostic Radiology 51 (2022) 675 679
- “While the pandemic has had momentous impact on our current practices, it has also provided us with an opportunity to learn, adapt, and improve. It has become clear that, although challenging, our PMDC can be delivered remotely and is no longer restricted by geographic constraints. Traditionally, patients who could not have had access to care at a high-volume center are now offered this opportunity without the financial and physical burden of travelling. However, this is limited by the licensing policies, with providers requiring expedite licensing in other states, to continue seeing these patients.”
The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience
Javad AA, Fishman EK, Lafaro K et al
Current Problems in Diagnostic Radiology (in press 2022) - “While not intentional, it seems likely that the in-person pre-COVID-19 PMDC provided a more conducive and stimulating environment. Lastly, with social distancing protocols in place, our pathologists find it difficult to accommodate students and trainees in the labs, which limits their training. While the effect of these changes on the field will not be immediate, it would certainly influence patient care in the long run, by effecting training of future healthcare providers. We recommend that faculty take this into account and potentially identify other avenues of teaching that could help overcome these deficiencies.”
The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience
Javad AA, Fishman EK, Lafaro K et al
Current Problems in Diagnostic Radiology (in press 2022) - "Third, in person conversations between providers and patients deliberating the pros and cons of current management options, provides a conducive atmosphere to generate important research questions worth investigating. On that note, in the past, the multidisciplinary meeting provided an excellent medium for identification of these questions leading to clinical studies and trials that have changed patient care for pancreatic cancer over the last decade. This was always considered to be a big advantage of our traditional PMDC. However, with the current changes, we feel that this aspect of our PMDC is suffering significantly. Lastly, our institution is one the premier centers for translational research on pancreatic cancer, the group having attracted significant funding in form of active direct support and endowments to date.The translational research has indeed been impacted by the COVID-19 pandemic. Initially our labs had to be shut down completely followed by reopening at limited capacity (tissue acquisition decreased with the reduction in surgical volumes).”
The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience
Javad AA, Fishman EK, Lafaro K et al
Current Problems in Diagnostic Radiology (in press 2022) - "While the pandemic has had momentous impact on our current practices, it has also provided us with an opportunity to learn, adapt, and improve. It has become clear that, although challenging, our PMDC can be delivered remotely and is no longer restricted by geographic constraints. Traditionally, patients who could not have had access to care at a high-volume center are now offered this opportunity without the financial and physical burden of travelling. However, this is limited by the licensing policies, with providers requiring expedite licensing in other states, to continue seeing these patients. In addition, providers who are travelling or provide care at multiple hospitals can now participate in PMDC remotely. Furthermore, in terms of research, remote consenting for research might result in fluent patient consenting and saving time and effort of the research staff which can then be dedicated towards other research activities. This will require us to readapt and modify current practices, however, could prove useful in the future.”
The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience
Javad AA, Fishman EK, Lafaro K et al
Current Problems in Diagnostic Radiology (in press 2022)
- Purpose: With the rise in popularity of structured reports in radiology, we sought to evaluate whether free-text CT reports on pancreatic ductal adenocarcinoma (PDAC) staging at our institute met published guidelines and assess feedback of pancreatic surgeons comparing free-text and structured report styles with the same information content.
Conclusion: Our results indicate that free-text reports may not include key descriptors for staging PDAC. Surgeons rated structured reports that presented the same information as free-text reports but in a template format superior for guiding clinical management, convenience of use, and overall report quality.
Structured CT reporting of pancreatic ductal adenocarcinoma: impact on completeness of information and interdisciplinary communication for surgical planning
Rubab F. Malik · Alina Hasanain · Kelly J. Lafaro · Jin He · Amol K. Narang · Elliot K. Fishman · Atif Zaheer
Abdominal Radiology (2022) 47:704–714 - “Structured reports in radiology offer many benefits, including improved completeness, interpretation, and quality of reports, and facilitate efficient, accurate, and consistent communications between radiologists and other physicians involved in the patient care, particularly when using dis- ease-specific templates, such as the PDAC staging template developed by Al-Hawary et al. used in our study. However, the use of structured reporting is limited by factors such as radiologists’ resistance to change from free-text prose-reporting styles, perceived changes in productivity, and potentially non-optimal use in disease settings involving multiple complex abnormalities.”
Structured CT reporting of pancreatic ductal adenocarcinoma: impact on completeness of information and interdisciplinary communication for surgical planning
Rubab F. Malik · Alina Hasanain · Kelly J. Lafaro · Jin He · Amol K. Narang · Elliot K. Fishman · Atif Zaheer
Abdominal Radiology (2022) 47:704–714 - "We conclude that structured reporting of PDAC provides a thorough evaluation of the disease that forces the radiologists to assess and include in their report important tumor descriptors, especially some of the more subtle ones, such as variant arterial anatomy and peritoneal and omental carcinomatosis. This may help the referring physician guide important treatment decisions, such as the use of neoadjuvant therapy and surgical planning. Furthermore, structured reporting leads to a higher level of satisfaction among the surgeons and helps enhance interdisciplinary communication compared to free-text format reporting.”
Structured CT reporting of pancreatic ductal adenocarcinoma: impact on completeness of information and interdisciplinary communication for surgical planning
Rubab F. Malik · Alina Hasanain · Kelly J. Lafaro · Jin He · Amol K. Narang · Elliot K. Fishman · Atif Zaheer
Abdominal Radiology (2022) 47:704–714
- “Our results indicate that free-text reports may not include key descriptors for staging PDAC. Surgeons rated structured reports that presented the same information as free-text reports but in a template format superior for guiding clinical management, convenience of use, and overall report quality.”
Structured CT reporting of pancreatic ductal adenocarcinoma: impact on completeness of information and interdisciplinary communication for surgical planning
Rubab F. Malik, Alina Hasanain, Kelly J. Lafaro, Jin He, Amol K. Narang, Elliot K. Fishman, Atif Zaheer
Abdominal Radiology https://doi.org/10.1007/s00261-021-03353-9 - “We conclude that structured reporting of PDAC provides a thorough evaluation of the disease that forces the radiologists to assess and include in their report important tumor descriptors, especially some of the more subtle ones, such as variant arterial anatomy and peritoneal and omental carcinomatosis. This may help the referring physician guide important treatment decisions, such as the use of neoadjuvant therapy and surgical planning. Furthermore, structured reporting leads to a higher level of satisfaction among the surgeons and helps enhance interdisciplinary communication compared to free-text format reporting.”
Structured CT reporting of pancreatic ductal adenocarcinoma: impact on completeness of information and interdisciplinary communication for surgical planning
Rubab F. Malik, Alina Hasanain, Kelly J. Lafaro, Jin He, Amol K. Narang, Elliot K. Fishman, Atif Zaheer
Abdominal Radiology https://doi.org/10.1007/s00261-021-03353-9
- “Recent improvements in multimodality care have substantially improved overall survival, local control, and metastasis-free survival for patients who have localized tumors that are amenable to surgical resection. The widening gap in prognosis between patients with resectable and unresectable or metastatic disease reinforces the importance of detecting pancreatic cancer sooner to improve outcomes. Furthermore, the developing use of therapies that target tumor-specific molecular vulnerabilities may offer improved disease control for patients with advanced disease.”
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626. - “Although most patients are symptomatic at presentation, symptoms of PDAC are often nonspecific,leading to a median delay between presentation and diagnosis of >2 months. The most commonly reported symptoms are fatigue (86%), weight loss (85%), anorexia (83%), jaundice (56%), nausea (51%), abdominal pain (79%), diarrhea (44%), pruritis (32%), and steatorrhea (25%). Clinical signs of PDAC, including jaundice (55%), hepatomegaly (29%), cachexia (13%), epigastric mass (9%), or ascites (5%), are much less common.”
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626. - “Approximately 10% of patients with PDAC harbor a pathogenic germline mutation in a cancer-predisposing gene, of which BRCA2 and ATM are the 2 most common candidates, followed by BRCA1, PALB2, CDKN2A/p16, and LKB1/STK11; the mismatch repair genes (hMLH1, hMSH2, and hPMS6); and other rarer variants (Table 1). Of note, only one-half of patients with a deleterious germline mu- tation report an overt family history of PDAC, in light of which the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) recently updated their guidelines to recommend universal germline mutation testing for all patients diagnosed with PDAC (instead of only those with a suspicious family history).”
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626. 
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626.
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626.- “Approximately 10% of patients with PDAC harbor a pathogenic germline mutation in a cancer-predisposing gene, of which BRCA2 and ATM are the 2 most common candidates, followed by BRCA1, PALB2, CDKN2A/p16, and LKB1/STK11; the mismatch repair genes (hMLH1, hMSH2, and hPMS6); and other rarer variants (Table 1). Of note, only one-half of patients with a deleterious germline mu- tation report an overt family history of PDAC, in light of which the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) recently updated their guidelines to recommend universal germline mutation testing for all patients diagnosed with PDAC (instead of only those with a suspicious family history).”
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626. - “Serum CA 19-9 levels are closely related to tumor size, and the degree of elevation in CA 19-9 is associated with prognosis.87 In a study of patients with apparently localized disease, values >130 units/mL predicted occult, unresectable disease and were prognos-tic for survival among >1500 patients with resectable cancers.90,91 Although patients with apparently localized PDAC and high levels of CA 19-9 are commonly recommended for staging laparoscopy and neoadjuvant therapy, ASCO guidelines do not specify a cutoff value of CA 19-9 to be used in this manner.92 Because elevations in serum CA 19-9 can be induced by either tumor production or cholestasis, CA 19-9 should be remeasured after stent placement in patients with biliary obstruction to estimate true tumor burden, accounting for its 4-day to 8-day half-life.”
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626. - “A failure in CA 19-9 normalization after surgery is associ- ated with poor survival and is thought to represent occult metastatic disease. Similarly, declining CA 19-9 during systemic therapy correlates with improved patient survival, although it is unclear what magnitude of decline is most prognostic. Rises in CA 19-9 after a nadir can represent treatment failure and often precede imaging evidence of re- current or progressive cancer.99 Serum CA 19-9 changes are not considered to be a substitute for imaging evidence of treatment response or recurrence. In some tumors, additional cancer-specific biomarkers. "
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626. - "The reported accuracy in determining tumor resectability ranges from 73% to 87% for CT and from 70% to 79% for MRI.103 CT offers superior spatial resolution and is less sus- ceptible to respiratory motion artifacts than MRI, which is essential in demonstrating the critical relationship between the tumor and adjacent vasculature. The accuracy of PDAC detection and staging critically depends on the appropriate imaging protocol, postprocessing technique, and experience of radiologists.”
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626. 
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626.
Multidisciplinary Standards of Care and Recent Progress in Pancreatic Ductal Adenocarcinoma
Aaron J. Grossberg, Linda C. Chu, Christopher R. Deig, Elliot K. Fishman, et al.
CA Cancer J Clin. 2020 Jul 19. doi: 10.3322/caac.21626.