Should a patient with potential liver malignancy be referred to gastroenterology?

Referral to Hepatobiliary Multidisciplinary Team for Potential Liver Malignancy

Patients with suspected liver malignancy should be promptly referred to a regional hepatobiliary multidisciplinary team (MDT) rather than gastroenterology alone, as this approach improves resection rates and survival outcomes. 1, 2

Rationale for Direct Hepatobiliary MDT Referral

• The British Society of Gastroenterology guidelines strongly recommend that patients with hepatocellular carcinoma (HCC) should be discussed in multidisciplinary team meetings which provide access to the full range of treatment options 1
• For colorectal liver metastases (CRLM), guidelines specifically state that patients should be referred to the regional hepatobiliary unit for discussion 1
• Population-based studies show that assessment by a liver MDT results in higher resection rates and improved survival for patients with liver metastases 2

Key Components of the Hepatobiliary MDT

The hepatobiliary MDT typically consists of:

• At least two specialist surgeons trained in liver resection surgery
• Oncologist
• Diagnostic and interventional radiologist with hepatobiliary expertise
• Hepatologist
• Histopathologist
• Clinical nurse specialist 1

Clinical Pathway Algorithm

1. Initial Detection of Liver Lesion

   • Contrast-enhanced CT or MRI should be performed for characterization
   • Avoid percutaneous biopsy without discussion with hepatobiliary unit 3

2. Direct Referral to Hepatobiliary MDT (not gastroenterology) when:

   • Radiological features suggest malignancy (HCC or metastatic disease)
   • Lesion is potentially resectable
   • Patient has underlying liver disease with suspicious lesion

3. MDT Assessment Will Include:

   • Review of imaging by specialized radiologists
   • Assessment of liver function and reserve
   • Evaluation of tumor characteristics and extent
   • Consideration of all treatment options (resection, transplant, ablation, systemic therapy)

Evidence Supporting Direct Hepatobiliary MDT Referral

• Studies show that 12.9% of patients with colorectal liver metastases who were not initially assessed by a liver MDT were later found to be potentially resectable 2
• Factors that inappropriately influence referral to liver MDT include advanced age, higher ASA score, and number of liver metastases 2
• For HCC, the MDT approach is strongly recommended despite the evidence being rated as "low quality" in guidelines, indicating the consensus on its importance 1

Common Pitfalls to Avoid

• Delayed referral: Waiting for gastroenterology assessment before hepatobiliary MDT referral can delay potentially curative treatment
• Inappropriate biopsy: Percutaneous biopsy without hepatobiliary consultation may cause tumor dissemination 3
• Incomplete imaging: CT liver without proper contrast enhancement has lower detection rates (68-91%) for hepatic metastases 1
• Underestimation of resectability: Non-specialized assessment may incorrectly deem lesions unresectable

Special Considerations

• For colorectal liver metastases, even patients with multiple or bilobar metastases may be candidates for resection if clear margins can be achieved 3
• For HCC, treatment options depend on tumor burden, underlying liver function, and performance status 1
• In non-cirrhotic patients with HCC, surgical resection is the preferred treatment 1

By referring directly to a hepatobiliary MDT rather than gastroenterology alone, patients with potential liver malignancies receive comprehensive evaluation by specialists with expertise in liver cancer management, leading to optimal treatment selection and improved outcomes.