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Multidisciplinary Assessment of Soft Tissue Sarcomas

Panelists:Robin L. Jones, MD, MRCP, Royal Marsden Hospital; Shreyaskumar R. Patel, MD, University of Texas MD Anderson Cancer Center; R. Lor Randall, MD, FACS, Huntsman Cancer Institute; Jonathan C. Trent, MD, Sylvester Comprehensive Cancer Center; Brian A. Van Tine, MD, PhD, Siteman Cancer Center; Andrew J. Wagner, MD, PhD, Dana-Farber Cancer Institute
Published: Monday, Nov 09, 2015


Transcript:

Brian A. Van Tine, MD, PhD
: There are a lot of prognostic factors that we, as a community, have looked at over the last 30 years through large retrospective studies. I think it would be good to discuss what actually is prognostic in terms of outcomes.

R. Lor Randall, MD, FACS: I’d add that the AJCC is now coming out with its eighth edition, and that will be very informative. I won’t steal the thunder of that. Moving forward, we would encourage everyone to read it, of course. We know grade of tumor and size of tumor matter and that bigger is worse, higher grade is worse. But biology, as we’re resonating here, is really a driver.

When I give lectures to trainees in sarcoma, I always emphasize that I would much rather have a very large, deep-seated, well-differentiated liposarcoma than a little ulcerative epithelial sarcoma on my hands. The biology really does drive the behavior in many ways. Controlling for biology, however, smaller and lower grade is better.

Brian A. Van Tine, MD, PhD: One of the things that a number of us have already echoed is the importance of multidisciplinary care. The NCCN came out with a very nice statement which says that patients with sarcoma should be managed, but not necessarily treated, by a multidisciplinary panel who have heavy experience. The right recommendations could be altering for patients in terms of their outcomes, and it’s really important, right up front, to make sure that the right plan’s put in place.

I’d like to get everybody’s feelings about the need for multidisciplinary care and I think that the person who may drive a lot of this will be the surgeon. I’d like to pose my first question to you, Lor. What are the challenges involved in diagnosing and building a team for everybody with soft tissue sarcoma?

R. Lor Randall, MD, FACS: It is a challenge. While we always retrospectively say, “Gosh, I wish this person had been treated by us initially,” we also don’t want every little lipoma and lump and bump coming to a sarcoma center because then we would dilute our resources and compromise care. That in and of itself is a challenge. We would ideally like to screen everyone but we can’t. This is a very practical challenge.

Having said that, when referred to a center it really is very important that there is a seamless integration across disciplines. As a surgeon, I need to understand the biology, the medical oncology, the radiation therapeutics available, and the leading edge thought. I would say that the physicians that are involved in more the systemic management also need to understand the local control issues because we know that surgery and radiation therapy are backbones—no pun intended—for curing and managing sarcomas. So getting people together, having a common cause, and managing those patients is a full-time job really.

Robin L. Jones, MD, MRCP: I’d like to echo that. One modality can optimize the use of another. It’s important to have everybody together making decisions so that the pros and cons of each approach can be adequately addressed.

R. Lor Randall, MD, FACS: We really pride ourselves on our tumor board, making sure every discipline is there. And even if it’s a chondrosarcoma or a liposarcoma, where we know that surgery is going to be the exclusive treatment, we want everyone to weigh in because we know that there is going to be potential local relapse or systemic relapse. I think it engages everyone and gets everyone thinking.

Andrew J. Wagner, MD, PhD: It also provides the opportunity to look at new approaches and new treatments in a group setting, as one discipline might have a new study, say a new drug coming along that might be given neoadjuvantly or a randomized study of radiation therapy, for example, in part of the treatment of retroperitoneal sarcomas. Having that multidisciplinary approach is very important to keep each other informed, as well, about different approaches to treating the tumor.

Shreyaskumar R. Patel, MD: We can be each other’s conscience and keep each other in line. We can be the best physicians in making treatment decisions if we understand the abilities and limitations of our colleagues in other disciplines. It is absolutely of paramount importance that the group of physician specialties treating this disease have a forum to sit around a table and discuss these cases, outlining the plan of treatment at the very beginning and then carrying it out, rather than playing football where you keep punting from one person to another. That clearly does create some serious problems.

Andrew J. Wagner, MD, PhD: I’d add that these cases can be really complicated. We all know this. Also, it’s not just within our own centers that we discuss these things. It’s not unusual for us to send emails or call each other up and say, “What would you do with this?” because they are really challenging cases and it needs other minds involved too.

Robin L. Jones, MD, MRCP: The complexity, both in terms of heterogeneity, rarity, and the wide variety of anatomic primary sites just make it very, very challenging.

Andrew J. Wagner, MD, PhD: I feel like we’re scaring everyone away from treating these now.

Jonathan C. Trent, MD: One of the other advantages of a multidisciplinary conference, which we put all of our sarcoma patients through for discussion, is the timing. If you see a patient with a newly diagnosed Ewing’s sarcoma or rhabdomyosarcoma, you don’t want to get a consult from a medical oncologist and then a radiation therapist and then a surgeon, sequentially over 6 to 8 weeks. You want to present that patient as soon as they’re diagnosed with the entire multidisciplinary team, implement a treatment of action, and perhaps admit the patient to the hospital rapidly so that you can get the appropriate therapy initiated in a timely fashion. Some of these sarcomas, particularly the small cell sarcomas, can grow quite rapidly.

Robin L. Jones, MD, MRCP: Yes, exactly. It’s a real time discussion and, as I say, the optimization of each modality in real time.
                                                                                                                                                                                                                                                                                                                 Transcript Edited for Clarity
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Transcript:

Brian A. Van Tine, MD, PhD
: There are a lot of prognostic factors that we, as a community, have looked at over the last 30 years through large retrospective studies. I think it would be good to discuss what actually is prognostic in terms of outcomes.

R. Lor Randall, MD, FACS: I’d add that the AJCC is now coming out with its eighth edition, and that will be very informative. I won’t steal the thunder of that. Moving forward, we would encourage everyone to read it, of course. We know grade of tumor and size of tumor matter and that bigger is worse, higher grade is worse. But biology, as we’re resonating here, is really a driver.

When I give lectures to trainees in sarcoma, I always emphasize that I would much rather have a very large, deep-seated, well-differentiated liposarcoma than a little ulcerative epithelial sarcoma on my hands. The biology really does drive the behavior in many ways. Controlling for biology, however, smaller and lower grade is better.

Brian A. Van Tine, MD, PhD: One of the things that a number of us have already echoed is the importance of multidisciplinary care. The NCCN came out with a very nice statement which says that patients with sarcoma should be managed, but not necessarily treated, by a multidisciplinary panel who have heavy experience. The right recommendations could be altering for patients in terms of their outcomes, and it’s really important, right up front, to make sure that the right plan’s put in place.

I’d like to get everybody’s feelings about the need for multidisciplinary care and I think that the person who may drive a lot of this will be the surgeon. I’d like to pose my first question to you, Lor. What are the challenges involved in diagnosing and building a team for everybody with soft tissue sarcoma?

R. Lor Randall, MD, FACS: It is a challenge. While we always retrospectively say, “Gosh, I wish this person had been treated by us initially,” we also don’t want every little lipoma and lump and bump coming to a sarcoma center because then we would dilute our resources and compromise care. That in and of itself is a challenge. We would ideally like to screen everyone but we can’t. This is a very practical challenge.

Having said that, when referred to a center it really is very important that there is a seamless integration across disciplines. As a surgeon, I need to understand the biology, the medical oncology, the radiation therapeutics available, and the leading edge thought. I would say that the physicians that are involved in more the systemic management also need to understand the local control issues because we know that surgery and radiation therapy are backbones—no pun intended—for curing and managing sarcomas. So getting people together, having a common cause, and managing those patients is a full-time job really.

Robin L. Jones, MD, MRCP: I’d like to echo that. One modality can optimize the use of another. It’s important to have everybody together making decisions so that the pros and cons of each approach can be adequately addressed.

R. Lor Randall, MD, FACS: We really pride ourselves on our tumor board, making sure every discipline is there. And even if it’s a chondrosarcoma or a liposarcoma, where we know that surgery is going to be the exclusive treatment, we want everyone to weigh in because we know that there is going to be potential local relapse or systemic relapse. I think it engages everyone and gets everyone thinking.

Andrew J. Wagner, MD, PhD: It also provides the opportunity to look at new approaches and new treatments in a group setting, as one discipline might have a new study, say a new drug coming along that might be given neoadjuvantly or a randomized study of radiation therapy, for example, in part of the treatment of retroperitoneal sarcomas. Having that multidisciplinary approach is very important to keep each other informed, as well, about different approaches to treating the tumor.

Shreyaskumar R. Patel, MD: We can be each other’s conscience and keep each other in line. We can be the best physicians in making treatment decisions if we understand the abilities and limitations of our colleagues in other disciplines. It is absolutely of paramount importance that the group of physician specialties treating this disease have a forum to sit around a table and discuss these cases, outlining the plan of treatment at the very beginning and then carrying it out, rather than playing football where you keep punting from one person to another. That clearly does create some serious problems.

Andrew J. Wagner, MD, PhD: I’d add that these cases can be really complicated. We all know this. Also, it’s not just within our own centers that we discuss these things. It’s not unusual for us to send emails or call each other up and say, “What would you do with this?” because they are really challenging cases and it needs other minds involved too.

Robin L. Jones, MD, MRCP: The complexity, both in terms of heterogeneity, rarity, and the wide variety of anatomic primary sites just make it very, very challenging.

Andrew J. Wagner, MD, PhD: I feel like we’re scaring everyone away from treating these now.

Jonathan C. Trent, MD: One of the other advantages of a multidisciplinary conference, which we put all of our sarcoma patients through for discussion, is the timing. If you see a patient with a newly diagnosed Ewing’s sarcoma or rhabdomyosarcoma, you don’t want to get a consult from a medical oncologist and then a radiation therapist and then a surgeon, sequentially over 6 to 8 weeks. You want to present that patient as soon as they’re diagnosed with the entire multidisciplinary team, implement a treatment of action, and perhaps admit the patient to the hospital rapidly so that you can get the appropriate therapy initiated in a timely fashion. Some of these sarcomas, particularly the small cell sarcomas, can grow quite rapidly.

Robin L. Jones, MD, MRCP: Yes, exactly. It’s a real time discussion and, as I say, the optimization of each modality in real time.
                                                                                                                                                                                                                                                                                                                 Transcript Edited for Clarity
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