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Local Control in Metastatic Soft Tissue Sarcoma

Panelists:William D. Tap, MD, Memorial Sloan Kettering Cancer Center; Mark Agulnik, MD, Feinberg School of Medicine;George D. Demetri, MD, Dana-Farber Cancer Center;Martee L. Hensley, MD, Memorial Sloan Kettering Cancer Center; Shreyaskumar Patel, MD, The University of Texas MD Anderson Cancer Center;Damon Reed, MD, Moffitt Cancer Center
Published: Thursday, Aug 18, 2016


Transcript:

William D. Tap, MD:
Mark, why don’t you segue into that a little bit, about local control in patients with metastatic disease, or are there treatment options for patients? I agree totally with Shreyas, that any time you can make someone disease-free. And sometimes we go to tremendous extents to do that, right? Is that an option that you often look for?

Mark Agulnik, MD: We’ve all said this, or we’re all alluding to this: you walk in, and you’re extremely, realistically optimistic. I don’t think we’re being naïve about it. You’re realistically optimistic. And if you’re not aggressive from the beginning, if you give up at the beginning, then the patient needs to change physicians. I really do think that there is a role for that. If you have localized disease, you need to be aggressive with it. You need to use radiation if it’s appropriate, you need to use surgery if it’s appropriate, and you need to use adjuvant chemotherapy if you feel it’s appropriate. And you have the data to support it.

When we start to look at metastatic disease, if you really have oligometastatic disease, you really are looking to cure someone. And so, once again, you’re not going to bypass the use of radiation to the primary, necessarily, if you just have two lung lesions. Because then, in the end, you’re going to end up with no disease. You’ve resected the lung lesions, you’ve resected the primary, and then you have a local recurrence. What did you achieve? And so, I do think you have to take everything in a context, and you do have to treat every individual patient as an individual and give them the best shot. I really think that if you’re going to be their advocate, you really are fighting for them to have the longest survival and the best outcomes.

William D. Tap, MD: I love sitting here on the panel because I can see the passion and the fire. So, we can make a difference, right?

George D. Demetri, MD: I wanted to follow up on this. Because I think one thing about soft tissue sarcomas is that we break rules of standard conventional solid tumor oncology. Metastatic disease in the carcinoma world very rarely gets a lot of surgery. And yet, many of our dedifferentiated liposarcoma patients who may have a 2-year disease-free interval and then have a single site of recurrence, yes, they’re metastatic; it’s recurrent. But surgery is still very valuable to that patient. And then maybe we’ll do systemic therapy and surgery, but it’s a very different way of thinking about many of the subtypes of sarcomas than we would if we were other carcinoma metastatic treaters. So, I think that’s important. And the role that our multidisciplinary colleagues play in our thought processes is always very interesting. We all have multidisciplinary clinics where the radiation oncologists, and the surgical oncologists, often will have as much to offer the patient, even in the metastatic setting, as our drugs will. And so, the clever interdigitation of the modalities is really, really important to patients.

Damon Reed, MD: I find the word “work” is a good trigger for a good conversation about prognosis or about chances of response and all those things. So, whenever someone uses the word “work,” I just say, “What does the word ‘work’ mean to you?” And if it means 100% of the time the tumor melts away, then no, chemotherapy does not work in soft tissue sarcomas. But if it means that it gives you more of a chance, that’s better. And if they understand that the chance is 2 out of 10, then that is even better. Because then, we’re going that extra sentence. I still have yet to meet the patient who thinks they’re in the 8; they’re all in the 2 or the 10. But that’s fine. I share that optimism up front and frequently scan to make sure that I’m not wrong if it’s a tumor I can’t look at, at bedside.

Transcript Edited for Clarity
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Transcript:

William D. Tap, MD:
Mark, why don’t you segue into that a little bit, about local control in patients with metastatic disease, or are there treatment options for patients? I agree totally with Shreyas, that any time you can make someone disease-free. And sometimes we go to tremendous extents to do that, right? Is that an option that you often look for?

Mark Agulnik, MD: We’ve all said this, or we’re all alluding to this: you walk in, and you’re extremely, realistically optimistic. I don’t think we’re being naïve about it. You’re realistically optimistic. And if you’re not aggressive from the beginning, if you give up at the beginning, then the patient needs to change physicians. I really do think that there is a role for that. If you have localized disease, you need to be aggressive with it. You need to use radiation if it’s appropriate, you need to use surgery if it’s appropriate, and you need to use adjuvant chemotherapy if you feel it’s appropriate. And you have the data to support it.

When we start to look at metastatic disease, if you really have oligometastatic disease, you really are looking to cure someone. And so, once again, you’re not going to bypass the use of radiation to the primary, necessarily, if you just have two lung lesions. Because then, in the end, you’re going to end up with no disease. You’ve resected the lung lesions, you’ve resected the primary, and then you have a local recurrence. What did you achieve? And so, I do think you have to take everything in a context, and you do have to treat every individual patient as an individual and give them the best shot. I really think that if you’re going to be their advocate, you really are fighting for them to have the longest survival and the best outcomes.

William D. Tap, MD: I love sitting here on the panel because I can see the passion and the fire. So, we can make a difference, right?

George D. Demetri, MD: I wanted to follow up on this. Because I think one thing about soft tissue sarcomas is that we break rules of standard conventional solid tumor oncology. Metastatic disease in the carcinoma world very rarely gets a lot of surgery. And yet, many of our dedifferentiated liposarcoma patients who may have a 2-year disease-free interval and then have a single site of recurrence, yes, they’re metastatic; it’s recurrent. But surgery is still very valuable to that patient. And then maybe we’ll do systemic therapy and surgery, but it’s a very different way of thinking about many of the subtypes of sarcomas than we would if we were other carcinoma metastatic treaters. So, I think that’s important. And the role that our multidisciplinary colleagues play in our thought processes is always very interesting. We all have multidisciplinary clinics where the radiation oncologists, and the surgical oncologists, often will have as much to offer the patient, even in the metastatic setting, as our drugs will. And so, the clever interdigitation of the modalities is really, really important to patients.

Damon Reed, MD: I find the word “work” is a good trigger for a good conversation about prognosis or about chances of response and all those things. So, whenever someone uses the word “work,” I just say, “What does the word ‘work’ mean to you?” And if it means 100% of the time the tumor melts away, then no, chemotherapy does not work in soft tissue sarcomas. But if it means that it gives you more of a chance, that’s better. And if they understand that the chance is 2 out of 10, then that is even better. Because then, we’re going that extra sentence. I still have yet to meet the patient who thinks they’re in the 8; they’re all in the 2 or the 10. But that’s fine. I share that optimism up front and frequently scan to make sure that I’m not wrong if it’s a tumor I can’t look at, at bedside.

Transcript Edited for Clarity
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