ONCAlert | Upfront Therapy for mRCC

Case 1: Considerations for Debulking Surgery

Targeted Oncology
Published Online:1:04 PM, Thu May 23, 2019


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Robert L. Coleman, MD: Now this patient, she’s young, right? She’s 44 years old.

Susana M. Campos, MD, MPH: She’s 44.

Robert L. Coleman, MD: And I’m just thinking, what goes through your mind when you see a 44-year-old who has a supposed ovarian cancer?

Susana M. Campos, MD, MPH: She’s very young and we haven’t any history in terms of extensive comorbid conditions, so that’s actually quite important. We really don’t have a family history to draw from on here, but you’re still going to be wondering, does she carry a BRCA mutation, whether it be a germline or a somatic mutation? So that’s quite important, certainly as these studies have evolved at this point in time. And given the fact that she has a liver lesion, she has a splenic mass, the question is, how is she best served? So this is really put in the hands of a multidisciplinary team, including our surgeons, our medical oncologists, and the like.

Robert L. Coleman, MD: Presuming this patient came and saw you first, probably by a referral from somebody who kind of did the reverse — they saw a patient with symptoms, got a CT [computed tomography] scan, and then referred for a pelvic exam, and then you saw that this is probably of GYN [gynecologic] origin — what is your natural process?

Susana M. Campos, MD, MPH: The natural process is always to work in conjunction with our gynecological surgical oncologists. At the end of the day, the opinion that’s rendered in terms of whether it be adjuvant, primary debulking surgery, or neoadjuvant therapy is really made by the medical oncologist, maybe sometimes radiation, or radiologists, as well as the medical oncologist.

Robert L. Coleman, MD: Dave?

David O’Malley, MD: This is a tough case. You know, she’s only 44 and we don’t know if she has resectable disease or not.

You can do a spleen. You can have a solitary liver lesion. You have peri-aortic lymph node. These may all be resectable. It’s dependent on what her peritoneal disease looks like. At The University of Texas MD Anderson Cancer Center, I know you are doing a lot of assessments by laparoscopy. We have a much more difficult time doing that at The Ohio State and the James Cancer Center, just because of the way our practices are set up. But in a 44-year-old, I really want to make sure that we find a reason not to operate on her. I think that is important. Now, saying that, this is going to be a big debulking.

Robert L. Coleman, MD: Right. I was going to say, Shannon, wasn’t that really kind of the whole point of doing the scope — to try to find the patients for whom you could get a complete resection in?

Shannon N. Westin, MD: Absolutely. We use a validated score and the whole goal of the score is to give you an idea of what your likelihood is of achieving no gross residual disease, which we know, based on multiple retrospective analyses of prospective data, is where you get the best bang for your buck, right? Those are the patients who live the longest. What we don’t know is, is it really the surgery that does it, or are we just picking those right patients and they just are going to do well no matter what we do? We haven’t answered that question, I don’t think.

David O’Malley, MD: That’s a great question. That’s a great point. I think Dr Neil Horowitz’s paper looking at some of the GOG [Gynecologic Oncology Group] data is probably one of the most underquoted papers, in regard to looking at the complexity of the surgery and the score with regard to their disease. And if you have both a high tumor volume and a high ….

Susana M. Campos, MD, MPH: Complexity of surgery.

David O’Malley, MD: Complexity of surgery, they don’t do as well. I know she’s 44, right?

Robert L. Coleman, MD: I often use that paper to justify the question you just asked, which was, is this biology versus just surgical ability? In that paper, the more aggressive the surgery, if you get that patient to the same disease volume they still do not as well as if they had not had the surgery at all.

Susana M. Campos, MD, MPH: A good point, also, is we’re told that she has a solitary liver lesion. We don’t know that it’s a solitary liver lesion.

Robert L. Coleman, MD: Right.

Susana M. Campos, MD, MPH: Oftentimes, this is just a CT scan. We’ve all known that CT scans can often underestimate what volume of disease is there. So that’s something to be mindful of.

Robert L. Coleman, MD: It’s a good point. So in this case, you send her to Dave, and Dave says, “I’m going to operate.” Are there other procedures that you would recommend that she have before you just release?

Susana M. Campos, MD, MPH: You could always do a PET [positron emission tomography] scan, or an MRI [magnetic resonance imaging] of the liver if you’re really looking for more disease. You’re right. The splenic mass is a doable thing. It’s the liver lesion that I think turns me on a different scale. But I would do an MRI of the liver just to be sure that we’re not really dealing with more than multifocal disease.

David O’Malley, MD: And one thing we started doing in recurrent disease, not up front, is the MRI of the peritoneal cavity.

Robert L. Coleman, MD: Yes.

David O’Malley, MD: With proper protocols, you could really see the peritoneal disease. Because what’s probably going to define this is really the peritoneal...

Susana M. Campos, MD, MPH: Yes.

Robert L. Coleman, MD: I agree.

Shannon N. Westin, MD: There are a group of things that are really hard to assess. The mesentery is the other thing that I ....

Robert L. Coleman, MD: I was going to ask you about that. We recently undertook a study among our group and compared it against the radiologists to see who could do a better job of defining who these people are. What’s your sense of that?

Shannon N. Westin, MD: I think it’s a crapshoot based on who you see.

Robert L. Coleman, MD: Yes.

Shannon N. Westin, MD: There are going to be some people who are exceptional at reading the radiology, and some people who aren’t. We have an opportunity, as surgeons, because we can look at the radiology and then we can go in and operate on the patient and can really correlate. The question is, how often do you really do that in an organized manner?

David O’Malley, MD: I think that really is a testament to the minimally invasive evaluation in these patients.

Susana M. Campos, MD, MPH: Yes, I agree.

David O’Malley, MD: In having either a 2-step process or time set aside to do a combined procedure — combine the minimally invasive to conversion to maximally invasive.

Shannon N. Westin, MD: Right. We still struggle with that though because patients would like to have everything done at one time. But there is some benefit to doing a 2-step procedure, when you do the laparoscopy and then subsequently operate on the patient. And not the least of those is the ability to counsel the patient. If you’ve identified colon disease that’s going to require a potential colostomy, it’s really great to be able to tell a patient up front.

Robert L. Coleman, MD: We’ve had people who actually declare and want to go to neoadjuvant therapies specifically because they thought they were going to be ....

Shannon N. Westin, MD: Right. We have had patients for whom we thought, “This patient could be debulked.” But they absolutely said, “No way am I having a colostomy,” so they went to neoadjuvant.

Transcript edited for clarity.
 


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Robert L. Coleman, MD: Now this patient, she’s young, right? She’s 44 years old.

Susana M. Campos, MD, MPH: She’s 44.

Robert L. Coleman, MD: And I’m just thinking, what goes through your mind when you see a 44-year-old who has a supposed ovarian cancer?

Susana M. Campos, MD, MPH: She’s very young and we haven’t any history in terms of extensive comorbid conditions, so that’s actually quite important. We really don’t have a family history to draw from on here, but you’re still going to be wondering, does she carry a BRCA mutation, whether it be a germline or a somatic mutation? So that’s quite important, certainly as these studies have evolved at this point in time. And given the fact that she has a liver lesion, she has a splenic mass, the question is, how is she best served? So this is really put in the hands of a multidisciplinary team, including our surgeons, our medical oncologists, and the like.

Robert L. Coleman, MD: Presuming this patient came and saw you first, probably by a referral from somebody who kind of did the reverse — they saw a patient with symptoms, got a CT [computed tomography] scan, and then referred for a pelvic exam, and then you saw that this is probably of GYN [gynecologic] origin — what is your natural process?

Susana M. Campos, MD, MPH: The natural process is always to work in conjunction with our gynecological surgical oncologists. At the end of the day, the opinion that’s rendered in terms of whether it be adjuvant, primary debulking surgery, or neoadjuvant therapy is really made by the medical oncologist, maybe sometimes radiation, or radiologists, as well as the medical oncologist.

Robert L. Coleman, MD: Dave?

David O’Malley, MD: This is a tough case. You know, she’s only 44 and we don’t know if she has resectable disease or not.

You can do a spleen. You can have a solitary liver lesion. You have peri-aortic lymph node. These may all be resectable. It’s dependent on what her peritoneal disease looks like. At The University of Texas MD Anderson Cancer Center, I know you are doing a lot of assessments by laparoscopy. We have a much more difficult time doing that at The Ohio State and the James Cancer Center, just because of the way our practices are set up. But in a 44-year-old, I really want to make sure that we find a reason not to operate on her. I think that is important. Now, saying that, this is going to be a big debulking.

Robert L. Coleman, MD: Right. I was going to say, Shannon, wasn’t that really kind of the whole point of doing the scope — to try to find the patients for whom you could get a complete resection in?

Shannon N. Westin, MD: Absolutely. We use a validated score and the whole goal of the score is to give you an idea of what your likelihood is of achieving no gross residual disease, which we know, based on multiple retrospective analyses of prospective data, is where you get the best bang for your buck, right? Those are the patients who live the longest. What we don’t know is, is it really the surgery that does it, or are we just picking those right patients and they just are going to do well no matter what we do? We haven’t answered that question, I don’t think.

David O’Malley, MD: That’s a great question. That’s a great point. I think Dr Neil Horowitz’s paper looking at some of the GOG [Gynecologic Oncology Group] data is probably one of the most underquoted papers, in regard to looking at the complexity of the surgery and the score with regard to their disease. And if you have both a high tumor volume and a high ….

Susana M. Campos, MD, MPH: Complexity of surgery.

David O’Malley, MD: Complexity of surgery, they don’t do as well. I know she’s 44, right?

Robert L. Coleman, MD: I often use that paper to justify the question you just asked, which was, is this biology versus just surgical ability? In that paper, the more aggressive the surgery, if you get that patient to the same disease volume they still do not as well as if they had not had the surgery at all.

Susana M. Campos, MD, MPH: A good point, also, is we’re told that she has a solitary liver lesion. We don’t know that it’s a solitary liver lesion.

Robert L. Coleman, MD: Right.

Susana M. Campos, MD, MPH: Oftentimes, this is just a CT scan. We’ve all known that CT scans can often underestimate what volume of disease is there. So that’s something to be mindful of.

Robert L. Coleman, MD: It’s a good point. So in this case, you send her to Dave, and Dave says, “I’m going to operate.” Are there other procedures that you would recommend that she have before you just release?

Susana M. Campos, MD, MPH: You could always do a PET [positron emission tomography] scan, or an MRI [magnetic resonance imaging] of the liver if you’re really looking for more disease. You’re right. The splenic mass is a doable thing. It’s the liver lesion that I think turns me on a different scale. But I would do an MRI of the liver just to be sure that we’re not really dealing with more than multifocal disease.

David O’Malley, MD: And one thing we started doing in recurrent disease, not up front, is the MRI of the peritoneal cavity.

Robert L. Coleman, MD: Yes.

David O’Malley, MD: With proper protocols, you could really see the peritoneal disease. Because what’s probably going to define this is really the peritoneal...

Susana M. Campos, MD, MPH: Yes.

Robert L. Coleman, MD: I agree.

Shannon N. Westin, MD: There are a group of things that are really hard to assess. The mesentery is the other thing that I ....

Robert L. Coleman, MD: I was going to ask you about that. We recently undertook a study among our group and compared it against the radiologists to see who could do a better job of defining who these people are. What’s your sense of that?

Shannon N. Westin, MD: I think it’s a crapshoot based on who you see.

Robert L. Coleman, MD: Yes.

Shannon N. Westin, MD: There are going to be some people who are exceptional at reading the radiology, and some people who aren’t. We have an opportunity, as surgeons, because we can look at the radiology and then we can go in and operate on the patient and can really correlate. The question is, how often do you really do that in an organized manner?

David O’Malley, MD: I think that really is a testament to the minimally invasive evaluation in these patients.

Susana M. Campos, MD, MPH: Yes, I agree.

David O’Malley, MD: In having either a 2-step process or time set aside to do a combined procedure — combine the minimally invasive to conversion to maximally invasive.

Shannon N. Westin, MD: Right. We still struggle with that though because patients would like to have everything done at one time. But there is some benefit to doing a 2-step procedure, when you do the laparoscopy and then subsequently operate on the patient. And not the least of those is the ability to counsel the patient. If you’ve identified colon disease that’s going to require a potential colostomy, it’s really great to be able to tell a patient up front.

Robert L. Coleman, MD: We’ve had people who actually declare and want to go to neoadjuvant therapies specifically because they thought they were going to be ....

Shannon N. Westin, MD: Right. We have had patients for whom we thought, “This patient could be debulked.” But they absolutely said, “No way am I having a colostomy,” so they went to neoadjuvant.

Transcript edited for clarity.
 
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