An audit of Outcome of Liver Biopsy of Patients with Malignancy of Undefined Primary Origin in a Local Health Board

Liver biopsies are invasive procedures commonly employed to diagnose the primary malignancy in likely, liver metastases. If performed without intention to treat the malignancy, undergoing a liver biopsy can cause considerable and unnecessary distress to the patient.

This audit is worth carrying out because acute oncology services across the UK are identifying more patients who require early oncological input after presenting with metastatic disease. Performing a liver biopsy is a convenient yet invasive way to identify the primary malignancy if amenable liver metastases present, to enable targeted oncological treatment. However, patients may be subjected to a liver biopsy despite not being fit enough to receive subsequent oncological treatments. In these circumstances the procedure may be considered inappropriate to perform, incurring unnecessary distress to patients.

The standard: 

NICE guidelines for management of Metastatic Malignant Disease of Unknown Primary (2010) state that investigations to identify the primary site of origin should not take place if patients are unfit for treatment and any investigation performed should affect treatment decision. Therefore, all cases for consideration for liver biopsy's should be discussed in the Upper Gastrointestinal Multidisciplinary Team (UGI MDT) meeting before proceeding to procedure. The local UGI MDT agreed that a biopsy was unlikely to be clinically appropriate if death occurred within 42 days.

Target: 

- 100% of patients who undergo liver biopsy should have a life expectancy of greater than 42 days

- 100% of patients should be discussed in an appropriate MDT prior to liver biopsy

- 100% of patients should be referred to an oncology centre

- 80 - 100% of patients should receive oncological treatment after a liver biopsy

Indicators: 

- Percentage of patients with confirmed malignancy that died within 42 days of liver biopsy

- Percentage of patients who underwent liver biopsy discussed in MDT prior to or after procedure

- Percentage of patients who underwent liver biopsy that were referred to the local oncology centre

- Percentage of patients who underwent liver biopsy that received oncological treatment

Data items to be collected: 

- Malignancy type (to ensure current cancer diagnosis is evaluated)

- Date of liver biopsy

- Date of Death

- Date of MDT discussion

- Registration of patient with local cancer centre

- Oncological treatment received

Suggested number: 

All patients with confirmed malignancy who underwent liver biopsy within a 2 year period.

- Streamline all liver biopsy requests so that they are discussed in an MDT that has radiological, oncological and palliative care input prior to procedure

- Re-audit in 2 years

Personnel: Consultant Oncologist, Consultant Radiologist, Clinical Oncology SpR, Medical SHO, Medical Student, Audit Department

Data Collection Sources: Local electronic patient database

1. National Institute for Health and Clinical Excellence (2010) [Metastatic Malignant Disease of Unknown Primary Origin (CG104)]. London: National Institute for Health and Clinical Excellence

2. Royal College of Physicians and Royal College of Radiologists (Clinical Oncology) (2012), Cancer patients in crisis: responding to urgent needs. London: Royal College of Physicians

Dr Elin Evans