a new platform for discussion of challenging desmoid tumor ... · 64 received systemic therapy (40%...
TRANSCRIPT
Aaron Weiss, DO
Associate Professor of Pediatrics
Tufts University School of Medicine
Pediatric Hematology-Oncology
Maine Children’s Cancer Program
A New Platform for
Discussion of Challenging
Desmoid Tumor Cases: DTRF
Virtual Tumor Board
Tumor Board Definition
Multidisciplinary treatment planning approach
for reviewing and discussing the medical
condition and treatment options of a patient
NCI Dictionary of Cancer Terms
Background
No standardized approach to upfront,
progressive or recurrent desmoid tumor
management
Opinions of “experts” frequently sought
Advice often given with limited information
regarding the case
Purpose
Creation of an established scientific forum for
discussion of complex desmoid tumor cases
Planning
Small working group discussions
Surgical oncology
Radiology
Pathology
Medical oncology
Pediatric oncology
Informatics
DTRF
Sponsorship
Desmoid Tumor Research Foundation
Administrative
Financial
Format
Regularly scheduled meetings
Quarterly
First Wednesday of the month
Web-based conference platform
GoToMeeting
Core of committed specialists
Personnel
Oncology (medical and pediatric)
Radiology
Surgical oncology (general and orthopedic)
Pathology
Radiation oncology
Access
Open to medical personnel (no patients)
Initially North America but more recent
international expansion
Process
Cases solicited ahead of meeting
Meeting announcements
Powerpoint presentation preferred
Presenting site responsible for providing their
own radiology/pathology personnel (if
applicable)
Security
HIPAA provisions
Removal of Protected Health Information
Name, date of birth, age, date of scans
Pre-presentation site instructions
Sample Cases
Sample Case #1
18 yo male with familial adenomatous
polyposis (FAP) syndrome
Maternal history of FAP
Underwent screening colonoscopy in 2014
Found numerous polyps removal of colon
Developed lower abdominal/back pain in
October 2015
Abdominal mass discovered
Needle biopsy performed
Sample Case #1
Sample Case #1
December 2015: started on sorafenib
Mild decrease in symptoms and tumor burden
October 2016: changed to tamoxifen/sulindac
Worsening pain and new concerns of bowel
encased within the tumor
Surgery being recommended
Would lead to permanent colostomy and patient
reluctant
Sample Case #1
Questions for the group:
Is surgery a reasonable option as a next
step?
What other, if any, neoadjuvant (presurgical)
or adjuvant (postsurgical) therapies should be
considered?
Is this patient eligible for any open clinical
trials?
Sample Case #2
• 17 year old male with two year history of
enlarging right shoulder/axillary mass
• 6 months of pain, decreased mobility, and
preferentially using non-dominant hand
• Active wake boarder, notes he tends to
have prolonged scars for years after
superficial trauma
Sample Case #2
• Past Medical History: scoliosis
• Family History: brother seizures, MGM
breast cancer in remission, MGGF colon
and prostate cancer, MGGA ovarian
cancer, MGGM breast and pancreatic
cancer
Examination
Biopsy
Systemic Therapy Literature Review
Methotrexate/Vinblastine
POG 9650
2 yr PFS 46%
CWS Ped Blood & Cancer
May 2018
90 children and adolescents
54 initial resection
64 received systemic therapy
(40% received MV)
SD 39% at 3 months and PR
53% at 6 months
21/35 secondary resection
following primary systemic
therapy
Reports with TKI
Agresta L, et al. Ped Blood
& Cancer June 2018
Pazopanib 6 patients (PR in
2/7 tumors and SD in 6/7
tumors)
Benech N, et al. NEJM
June 2017
Two adult female patients
with FAP and intra-abdominal
tumors
Multiple prior therapies
Sorafenib 600 mg daily plus
celecoxib 400 mg daily
90% and 50% reductions in
tumor volume
Sorafenib 400 mg1 Pazopanib 800mg2
Trial Design Randomized, placebo crossover
Randomized, MTX/VBL crossover
n 87 (37 p, 50 S) 72 (24 MV, 48 PZ)
n assessed 75 66
Ages 18-72 yr 18 -79 yr
Male: Female 27: 60 26: 46
Results S p PZ MV
PR 33% 21% 37% 25%
SD 45.7% 30%
PD 16% 69%
1 yr PFS 87% 43%
6 mo non-PD 86% 50%
1Gounder MM, et al. ASCO 20182Toulmonde M, et al. ASCO 2018
Tyrosine Kinase Inhibitor Literature Review
Sample Case #2
Questions for the group:
Systemic therapy options
Methotrexate/Vinblastine?
Would stable response at any timepoint lead to
consideration of tyrosine kinase inhibitor therapy?
Systemic therapy versus surgical
management or radiation
Beyond disease progression, any other
indications for local control? Considerations of
side effects?
Mission
Multidisciplinary
Resourceful
Inclusive
Collaborative
Challenges
Publicity
Time zone considerations for international
participants
Status
Meetings
December 6, 2017: 2 cases
February 7, 2018: 4 cases
May 2, 2018: 3 cases
August 1, 2018: 4 cases
Next: November 7, 2018
Acknowledgements
Aimee Crago (surgical
oncology)
Keila Torres (surgical
oncology)
Rob Lefkowitz (radiology)
Matt van de Rijn
(pathology)
Steve Attia (medical
oncology)
Robert Benjamin
(medical oncology)
Palma Dileo (medical
oncology)
Joe Earl and Tom
Ellingson (informatics)
Marlene, Jeanne and
Lynne (DTRF)
Interested in Have Your Case
Presented?
Aaron Weiss: [email protected]
or
Lynne Hernandez: [email protected]