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Multidisciplinary Approach to Resection in mCRC

Insights From: John L. Marshall, MD, MedStar Georgetown University Hospital; Tanios S. Bekaii-Saab, MD, Mayo Clinic
Published: Friday, Apr 05, 2019



Transcript: 

John L. Marshall, MD:
You and I spend our day mostly focused on managing patients with metastatic colon cancer, but a lot of our audience and folks watching don’t, I mean every now and then kind of thing. And it’s back to a drumbeat we had early on, of some metastatic colon cancer patients can be cured with a surgical approach. And we see it, right? You and I have patients that were cured, I’m pretty sure, not often enough. But I think about the role the oncologist plays in that decision making. And in our shops, we’re embedded in a multidisciplinary world. But if you think about a doctor whose office is over here, and the hospital is over here, and the radiologist, and they’re all in different places, the role of the oncologist in deciding to initiate these referrals, or this multidisciplinary approach, it’s still our game, right?

Tanios S. Bekaii-Saab, MD: Yes.

John L. Marshall, MD: We’re still calling the play.

Tanios S. Bekaii-Saab, MD: We have to.

John L. Marshall, MD: And what’s like the craziest thing you thought about? Where’s the bar? We all get the single liver MET [metastases], OK done. Maybe the single lung MET, we’d be consistent there. Less optimistic maybe about that patient. But you know, and then the multiple liver MET. Is peritoneal disease fair game? Are lymph nodes fair game now? What’s your stance on this?

Tanios S. Bekaii-Saab, MD: So my stance on this is essentially the same principle, for whatever reason, there’s a group of patients that tend to prefer actually to have the tumor sit in 1 spot and not go anywhere else. So we’ve radiated retroperitoneal lymph nodes when there were a couple of them and nothing else. However, there’s something called the test of time that’s important.

When we start wandering off away from the liver and the lungs, and maybe even the peritoneum, although I would say the peritoneum is in the latter bucket, you almost have to test the biology before you do anything. For those patients you essentially would give a short course of chemotherapy—2 to 3 months—and see how they behave. And then again repeat the PET [positron emission tomography] scan, PET CT [computed tomography], PET MRI [magnetic resonance imaging], and then go either with radiation if it’s not surgically possible.

Or, I just had a patient interestingly with an adrenal MET, nothing else. PET scan completely silent, adrenal MET. Treated him for about 6 to 8 months with chemotherapy then maintenance. Adrenal MET sitting there doing nothing. Gave radiation, the adrenal MET responded a little bit more, but it’s still relatively active. Nothing else.

Now 3-4 months no therapy except the radiation to this area. And this adrenal MET is shrinking a little bit. Sent to surgery, taken out, patient remains in remission. So we have to think outside the box.

John L. Marshall, MD: Is it only curative? You know the original thinking was that it would only be useful if you cured the patient, if you were actually pulling the last weed, versus getting us back to no evidence of disease and debulking.

Tanios S. Bekaii-Saab, MD: I don’t think it’s just curative. But I think you can achieve potential cure. I think it does change the course of the disease in many ways. I want to take it a step back.

You treat the patient, you have a couple of tumors in the liver and 1 in the lung, and those ones in the liver just disappear—chemotherapy sensitive. The 1 on the lung just shrinks a tiny bit. And then you put the patient off chemotherapy, their tumor is growing just a little bit. You know that this is a likely resistant clone. Go in, take it out.

John L. Marshall, MD: CyberKnife it.

Tanios S. Bekaii-Saab, MD: CyberKnife it, take it out. And what you’ve done essentially is gotten rid of the most malignant clone. That’s the principle of resection in gist for metastatic disease. Those that don’t respond, probably the same with immune therapy. I’ve had one patient actually with immune therapy. All the disease was responding except 1, and 1 kept on growing, and that’s the 1 ultimately we resected. And guess what? The patient ended up in a good strong remission. Because those are the resistant clones that perhaps with the chemotherapy we have today, we haven’t been able to address every 1 of those clones. So I think yes, there’s a role.

John L. Marshall, MD: To me this is the most fun. I love playing with interventional radiology, radiation, surgery, and we are increasingly aggressive. But not everybody has all of those tools around them. And so I think there’s value there, we agree on that. So in those folks who don’t feel like either their surgeons, or they don’t have all the bells and whistles for some of the toys that you need, this is an opportunity to let them off the disciplinary team.

Tanios S. Bekaii-Saab, MD: They have access to us, we’re pretty open in terms of helping. But it is a little bit tricky when you’re addressing some of these more complex questions in smaller community hospitals where the surgeon does an appendix or gallbladder and then has to deal with cancer surgery.


Transcript Edited for Clarity
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Transcript: 

John L. Marshall, MD:
You and I spend our day mostly focused on managing patients with metastatic colon cancer, but a lot of our audience and folks watching don’t, I mean every now and then kind of thing. And it’s back to a drumbeat we had early on, of some metastatic colon cancer patients can be cured with a surgical approach. And we see it, right? You and I have patients that were cured, I’m pretty sure, not often enough. But I think about the role the oncologist plays in that decision making. And in our shops, we’re embedded in a multidisciplinary world. But if you think about a doctor whose office is over here, and the hospital is over here, and the radiologist, and they’re all in different places, the role of the oncologist in deciding to initiate these referrals, or this multidisciplinary approach, it’s still our game, right?

Tanios S. Bekaii-Saab, MD: Yes.

John L. Marshall, MD: We’re still calling the play.

Tanios S. Bekaii-Saab, MD: We have to.

John L. Marshall, MD: And what’s like the craziest thing you thought about? Where’s the bar? We all get the single liver MET [metastases], OK done. Maybe the single lung MET, we’d be consistent there. Less optimistic maybe about that patient. But you know, and then the multiple liver MET. Is peritoneal disease fair game? Are lymph nodes fair game now? What’s your stance on this?

Tanios S. Bekaii-Saab, MD: So my stance on this is essentially the same principle, for whatever reason, there’s a group of patients that tend to prefer actually to have the tumor sit in 1 spot and not go anywhere else. So we’ve radiated retroperitoneal lymph nodes when there were a couple of them and nothing else. However, there’s something called the test of time that’s important.

When we start wandering off away from the liver and the lungs, and maybe even the peritoneum, although I would say the peritoneum is in the latter bucket, you almost have to test the biology before you do anything. For those patients you essentially would give a short course of chemotherapy—2 to 3 months—and see how they behave. And then again repeat the PET [positron emission tomography] scan, PET CT [computed tomography], PET MRI [magnetic resonance imaging], and then go either with radiation if it’s not surgically possible.

Or, I just had a patient interestingly with an adrenal MET, nothing else. PET scan completely silent, adrenal MET. Treated him for about 6 to 8 months with chemotherapy then maintenance. Adrenal MET sitting there doing nothing. Gave radiation, the adrenal MET responded a little bit more, but it’s still relatively active. Nothing else.

Now 3-4 months no therapy except the radiation to this area. And this adrenal MET is shrinking a little bit. Sent to surgery, taken out, patient remains in remission. So we have to think outside the box.

John L. Marshall, MD: Is it only curative? You know the original thinking was that it would only be useful if you cured the patient, if you were actually pulling the last weed, versus getting us back to no evidence of disease and debulking.

Tanios S. Bekaii-Saab, MD: I don’t think it’s just curative. But I think you can achieve potential cure. I think it does change the course of the disease in many ways. I want to take it a step back.

You treat the patient, you have a couple of tumors in the liver and 1 in the lung, and those ones in the liver just disappear—chemotherapy sensitive. The 1 on the lung just shrinks a tiny bit. And then you put the patient off chemotherapy, their tumor is growing just a little bit. You know that this is a likely resistant clone. Go in, take it out.

John L. Marshall, MD: CyberKnife it.

Tanios S. Bekaii-Saab, MD: CyberKnife it, take it out. And what you’ve done essentially is gotten rid of the most malignant clone. That’s the principle of resection in gist for metastatic disease. Those that don’t respond, probably the same with immune therapy. I’ve had one patient actually with immune therapy. All the disease was responding except 1, and 1 kept on growing, and that’s the 1 ultimately we resected. And guess what? The patient ended up in a good strong remission. Because those are the resistant clones that perhaps with the chemotherapy we have today, we haven’t been able to address every 1 of those clones. So I think yes, there’s a role.

John L. Marshall, MD: To me this is the most fun. I love playing with interventional radiology, radiation, surgery, and we are increasingly aggressive. But not everybody has all of those tools around them. And so I think there’s value there, we agree on that. So in those folks who don’t feel like either their surgeons, or they don’t have all the bells and whistles for some of the toys that you need, this is an opportunity to let them off the disciplinary team.

Tanios S. Bekaii-Saab, MD: They have access to us, we’re pretty open in terms of helping. But it is a little bit tricky when you’re addressing some of these more complex questions in smaller community hospitals where the surgeon does an appendix or gallbladder and then has to deal with cancer surgery.


Transcript Edited for Clarity
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