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Multidisciplinary Assessment is Critical for Soft Tissue Sarcoma

Panelists: William D. Tap, MD, Memorial Sloan Kettering Cancer Center; Kristen Ganjoo, MD, Stanford University Medical Center; Richard Riedel, MD, Duke Cancer Institute; Jonathan Trent, MD, PhD, Sylvester Comprehensive Cancer Center; Victor Villalobos, MD, PhD, University of Colorado
Published: Thursday, Jul 12, 2018



Transcript: 

William D. Tap, MD: How important is it to discuss the sarcomas with your colleagues at your institutions?

Jonathan C. Trent, MD, PhD: I think it’s critical. This is a multidisciplinary disease, so every new patient at Sylvester Comprehensive Cancer Center is discussed at our multidisciplinary tumor board where we have not only a medical oncologist like us, but we also have our pathologists, radiologists, and surgeons there. At times, everybody can even help make the diagnosis. We’ve all run into these extraskeletal osteosarcomas and entities that you really have to understand. The pathologist and the radiologist have to get together to make the diagnosis, so I think it’s really key. I’d be interested to hear what the others on the panel say about multidisciplinary conferences.

Richard F. Riedel, MD: I would just add that it’s not only critical to talk with your colleagues at your own institutions, but also elsewhere. Even with their specific histology, being at a sarcoma center—we’re all at sarcoma centers—there are a few cases a year of something I’ve still never seen. And so, reaching out to each of you and other colleagues to get their impression and experience, I think is important. To John’s point, we also have a multidisciplinary board with orthopedic oncologists, radiologists, pathologists, PT, medical oncology, and radiation oncology, because it’s critical to do this right the first chance we get.

Victor M. Villalobos, MD, PhD: That can be complicated. In Denver, we also have a multidisciplinary clinic, but getting all of the surgeons in the right place together is complicated as well. You need to have your orthopedic oncologist, your thoracic surgeons, your GI [gastrointestinal] surgical oncologists, and plastic surgeons involved. It’s essentially quite a big team. With more people in the room, you have hundreds of years of experience between people who have seen these tumors. It really makes care optimal to these patients. I think seeing a sarcoma center is so incredibly important as it’s not just one person you’re seeing who has expertise. You’re really seeing a whole team that can help optimize care.

William D. Tap, MD: I think that’s one of the important messages we can get out to our community oncology colleagues. We’re really there to work with them, but that initial diagnosis and initial management of the patient is critical, even approaching the initial biopsy. Sometimes you have to consider the biopsy within the resection that will be planned. And so, this multidisciplinary approach is critical. What do you think about when you first see a sarcoma patient? How do you approach that? How do you put it in the context of what this patient will go through? What are some of the things that you think about when you’re going to approach the patient to start with?

Victor M. Villalobos, MD, PhD: First, is it curable and how do we get to that point?

William D. Tap, MD: What does curable mean to you? What patients are curable? What patients are a little bit more challenging to cure?

Victor M. Villalobos, MD, PhD: I think a big question is resectability. Most things are potentially resectable, but you’re always trying to balance quality of life and morbidity, meaning the toxicity of a resection. You can always take off a leg, but you don’t want to do that. Limb salvage is incredibly important, and that involves multiple layers of care: radiation therapy, a good surgeon who actually knows how to perform surgeries appropriately to maximize outcomes and optimize the ability to use a limb, and consideration of chemotherapies or systemic therapies to really improve overall outcomes. I think it’s nuanced. Staging criteria in sarcoma are not that helpful, frankly, because it’s almost like saying you have a single set of staging criteria for all carcinomas. You can’t apply everything to that particular criteria, so we use stage III as a large tumor that’s high grade, and that’s a baseline. But it requires a lot more nuance than that.

William D. Tap, MD: Yes.

Kristen N. Ganjoo, MD: I think one of the important things is the sequencing of chemotherapy, radiation, and surgery. That’s where the tumor board comes in. Should we use chemotherapy first before surgery? Should we use radiation and chemotherapy or should we go ahead with surgery and then use adjuvant chemotherapy? I think that’s really important. That’s what the sarcoma tumor board allows us to do with all of the players in the room.

Transcript Edited for Clarity 

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Transcript: 

William D. Tap, MD: How important is it to discuss the sarcomas with your colleagues at your institutions?

Jonathan C. Trent, MD, PhD: I think it’s critical. This is a multidisciplinary disease, so every new patient at Sylvester Comprehensive Cancer Center is discussed at our multidisciplinary tumor board where we have not only a medical oncologist like us, but we also have our pathologists, radiologists, and surgeons there. At times, everybody can even help make the diagnosis. We’ve all run into these extraskeletal osteosarcomas and entities that you really have to understand. The pathologist and the radiologist have to get together to make the diagnosis, so I think it’s really key. I’d be interested to hear what the others on the panel say about multidisciplinary conferences.

Richard F. Riedel, MD: I would just add that it’s not only critical to talk with your colleagues at your own institutions, but also elsewhere. Even with their specific histology, being at a sarcoma center—we’re all at sarcoma centers—there are a few cases a year of something I’ve still never seen. And so, reaching out to each of you and other colleagues to get their impression and experience, I think is important. To John’s point, we also have a multidisciplinary board with orthopedic oncologists, radiologists, pathologists, PT, medical oncology, and radiation oncology, because it’s critical to do this right the first chance we get.

Victor M. Villalobos, MD, PhD: That can be complicated. In Denver, we also have a multidisciplinary clinic, but getting all of the surgeons in the right place together is complicated as well. You need to have your orthopedic oncologist, your thoracic surgeons, your GI [gastrointestinal] surgical oncologists, and plastic surgeons involved. It’s essentially quite a big team. With more people in the room, you have hundreds of years of experience between people who have seen these tumors. It really makes care optimal to these patients. I think seeing a sarcoma center is so incredibly important as it’s not just one person you’re seeing who has expertise. You’re really seeing a whole team that can help optimize care.

William D. Tap, MD: I think that’s one of the important messages we can get out to our community oncology colleagues. We’re really there to work with them, but that initial diagnosis and initial management of the patient is critical, even approaching the initial biopsy. Sometimes you have to consider the biopsy within the resection that will be planned. And so, this multidisciplinary approach is critical. What do you think about when you first see a sarcoma patient? How do you approach that? How do you put it in the context of what this patient will go through? What are some of the things that you think about when you’re going to approach the patient to start with?

Victor M. Villalobos, MD, PhD: First, is it curable and how do we get to that point?

William D. Tap, MD: What does curable mean to you? What patients are curable? What patients are a little bit more challenging to cure?

Victor M. Villalobos, MD, PhD: I think a big question is resectability. Most things are potentially resectable, but you’re always trying to balance quality of life and morbidity, meaning the toxicity of a resection. You can always take off a leg, but you don’t want to do that. Limb salvage is incredibly important, and that involves multiple layers of care: radiation therapy, a good surgeon who actually knows how to perform surgeries appropriately to maximize outcomes and optimize the ability to use a limb, and consideration of chemotherapies or systemic therapies to really improve overall outcomes. I think it’s nuanced. Staging criteria in sarcoma are not that helpful, frankly, because it’s almost like saying you have a single set of staging criteria for all carcinomas. You can’t apply everything to that particular criteria, so we use stage III as a large tumor that’s high grade, and that’s a baseline. But it requires a lot more nuance than that.

William D. Tap, MD: Yes.

Kristen N. Ganjoo, MD: I think one of the important things is the sequencing of chemotherapy, radiation, and surgery. That’s where the tumor board comes in. Should we use chemotherapy first before surgery? Should we use radiation and chemotherapy or should we go ahead with surgery and then use adjuvant chemotherapy? I think that’s really important. That’s what the sarcoma tumor board allows us to do with all of the players in the room.

Transcript Edited for Clarity 
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