Insights From: Victor Villalobos, MD, PhD, University of Colorado School of Medicine; Saketh Guntupalli, MD, University of Colorado School of Medicine; Shreyaskumar R. Patel, MD, University of Texas MD Anderson Cancer Center; Anthony P. Conley, MD, University of Texas MD Anderson Cancer Center
Victor Villalobos, MD, PhD: Gynecologic sarcomas can be quite aggressive, but there is also a very broad range in how they behave. What is your approach to the tumor for sarcomas in the advanced or metastatic setting?
Saketh Guntupalli, MD: The first thing we want to do is make sure that we have outstanding imaging. Before we make a surgical decision, we try our best to get the surgical extent of disease. So, in a patient with metastatic disease, depending on how many sites of metastasis they have, we do believe that surgery for sarcomas is an incredibly important part of our armamentarium to treat these tumors. We would look to see, is this person going to be able to get surgically resected to almost no residual disease? A lot of the studies that have looked at this have looked at patients who are kind of reduced to R0 or minimal residual disease. That will just help the chemotherapy work better for the microscopic disease that we don’t see.
Victor Villalobos, MD, PhD: Yes, we’ve seen that with lung metastasectomies, as well.
Saketh Guntupalli, MD: Absolutely.
Victor Villalobos, MD, PhD: Even if there’s upwards of 8 to 10, you could take them out. They actually live longer...
Saketh Guntupalli, MD: Sure. So, we look at that. Then, we look at, is this patient going to tolerate a very big surgery? For example, if they have a metastatic uterine leiomyosarcoma, they’ve got an omental metastasis and, maybe, an isolated metastasis to the liver. If we can surgically debulk all of that, and it’s in a recurrent setting and they’ve had a long progression-free survival, that might be the patient to do surgery on. But we want to make sure that they’re healthy, have a good performance status, and will be able to tolerate a long surgery. We want to make sure that they’re going to be able to tolerate a large blood loss. Often, sarcoma surgery tends to be very bloody. So, we want to make sure that they’re going to be able to tolerate all of those things. We’re not doing them any services if they have a huge blood loss, end up in renal failure, end up in the intensive care unit, and can’t get chemotherapy which is, ultimately, what is going to help them. It’s very important to look at all of those factors when deciding if surgery is the right approach. For example, we had a case, about a year-and-a-half ago, of a sarcoma that looked quite adherent to the aorta. It was actually a retroperitoneal sarcoma, we think, extending from the uterus. We elected not to do surgery because we didn’t think that we could safely approach that patient.
Victor Villalobos, MD, PhD: You mentioned aggressiveness. I think that’s a multifactorial part of the equation, to some degree, aggressiveness. First off, how is a tumor behaving? That, in large part, takes the grade into account. So, the grade. And, looking under the microscope. How many cells are dividing? How much necrosis is there? How weird does it look compared to normal cells? I think that grade is kind of a double-edged sword. Some tumors can be very aggressive but, also, can be more responsive to chemotherapies. Whereas, if you have a moderately aggressive tumor, but it’s not responsive to any therapies, it makes our job a little bit more difficult.
Saketh Guntupalli, MD: Sure. Absolutely.
Victor Villalobos, MD, PhD: If I had a patient who was in really bad shape and had a very poor performance status, but, if that was caused by the tumor and it was likely to respond, I would be pretty aggressive with it, right?
Saketh Guntupalli, MD: Sure.
Victor Villalobos, MD, PhD: Now, it changes the equation if someone comes in that has a lot of different medical comorbidities and you’re not sure if they’d be able to tolerate therapy. In that situation, my approach is to talk to the patient about a balance. There’s a balance between toxicity and quality of life, versus tumor control and length of life. Every patient is different. Often, I will see patients who are already metastatic and are not surgical candidates. Surgery wouldn’t make sense for them, though we can get to that point if they have responses. That balance is different for every person. What is your discussion with patients about how aggressive you can be? And, what would do for them, based on what their values are and what their performance status is?
Saketh Guntupalli, MD: You bring up, probably, the most important point in this conversation. We have to be realistic with our patients. In a widely metastatic sarcoma, we are probably not going for cure in those patients. We’re going for extending quality of life and quantity, as well. We want to make sure that we’re not harming our patients. It’s important to really sit down with our patients, and discuss the pros and cons of a surgical approach. One thing that often comes up, in my discussions with patients, is the creation of an ostomy, a urostomy or a colostomy. There are some people that don’t want to have that.
Victor Villalobos, MD, PhD: It’s a quality of life issue.
Saketh Guntupalli, MD: It’s a quality of life issue, and that’s not for me or you to decide. It’s for the patient to decide. And so, we present all of those options and we say, “If we do this, and we’re able to get all of it out, you have a very mitotically active sarcoma. It will likely respond to chemotherapy, afterwards. This is something we think would benefit you, with these possible side effects, surgically.” That’s kind of that balance, exactly as you said, with talking about side effects and results of surgery versus how much quality we’re giving our patients.
Victor Villalobos, MD, PhD: I’m not sure if you see this as much as I do. Patients come and say, “What are my chances, doctor?” “What are my chances?” “What are the percentages?” The problem is, and what I tell them is, individuals are binary—0% or 100%. There’s no in-between. And so, we won’t know until we try. Often, if they’re really worried about the side effects of chemotherapy, I say, “Look, it’s important to see how you tolerate that.” I’ve seen people in their 80s that do great with chemotherapy and they have no problems. I also see people in their 30s that have a horrible time with that. But that comes up in the conversation quite a bit. It’s really important to be honest with your patients, so they can prepare and understand what the stakes are and what’s important to them. We can understand that.