Cancer Treatment Today » Sarcoma

Sutent for Extraskeletal myxoid chondrosarcoma

M Levin, MD — Fri, 21 Dec 2012 15:59:18 +0000

Extraskeletal myxoid chondrosarcoma (EMC) is arare sarcoma thatgrows slowly but is hard to cure. It tends to spread and come back locally. The 2009 review by Drilon highlighted ineffectiveness of chemotherapy and emphasized an agressive approach to local control. In other words, the best chance to cure this disease is before it spreads. Radiotion is sometimes helpful but chemotherapy appears ineffective. There are , however, two case reports showing excellent responses to chemotherapy. Two patients are published to have responded well to Sutent. On the other hand, the one patient with EMC in a study of multiple non-GIST sarcomas had no response to sunitinib. The problem with basing therapy decisions on case reports is that there is a bias to publish only the positive cases; in this context, the single negative case is highly significant. Clearly more investigation is warranted before suntinib is used routinely for this admittedly rare cancer.

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Desmoid tumors – Nexavar

M Levin, MD — Mon, 17 Dec 2012 16:34:11 +0000

Desmoid tumorsdo not generally metastsize but can cause pain by locally invading nearby structures and damage nearby organs. Several new drugs are being research, among them Nexavar (sorafenib). Establihsing a dose in children has been difficulat. A recent study of sorafenib in children with neurofabromatosis was not able to establish the minmally tolerated dose. A series from Sloan Kettering used sorafenib as first and later line therapy. Sixteen of 22 (∼70%) patients reported significant improvement of symptoms. At a median of 6 months (2-29) of treatment, the 6/24 (25%) patients had partial response (PR), 17/24 (70%) with stable disease, and 1 with progression and death. NCCN lists sorafenib on p. SARC-E.

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Votrient (pazopanib) for Gastrointenstinal Stromal Tumors (GIST)

M Levin, MD — Thu, 29 Nov 2012 16:04:31 +0000

Pazopanib(Votrient) is a new drug that is approved for kidney cancer and acts in ways that may be effective in GIST. These are important pathways for GIST tumors and several trials are avaluating this drug in GIST, including: Efficacy of Pazopanib in Gastrointestinal Stromal Tumors (GIST), NCT Number: NCT01323400, Pazopanib in Imatinib Refractory or Intolerant Gastrointestinal Stromal Tumors (GIST) NCT Number: NCT01391611 and Pazopanib in Advanced Gastrointestinal Stromal Tumors Refractory to Imatinib and Sunitinib NCT Number: NCT01524848. There is also the PAZOPANIB IN ADVANCED GASTROINTESTINAL STROMAL TUMORS REFRACTORY TO IMATINIB AND SUNITINIB: A Non-comparative Phase II Multicenter Study by the Scandinavian Sarcoma Group.

Several studies showed activity in other sarcomas, and the FDA approved it for soft tissue sarcomas in April of 2012, but thus far there has not been a supportive study in GIST and currently there are no guidelines that support this drug for GIST.

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Chemotherapy after removal of soft tissue sarcoma (STS)

M Levin, MD — Mon, 03 Sep 2012 23:01:24 +0000

Adjuvant chemotherapy is a term for chemo that is given after tumor resection. The goal is to eradicate disease that may have been left behind or had already spread. A meta-analysis of published trials published in 1997 reported an improvement in local control and progression free survival after adjuvant chemotherapy; however, although there was a trend towards an overall survival benefit (how long the patients lived) this was not statistically significant. That there is some benefit has been supported by two more recent overviews but data from the EORTC 62931, the largest trial of adjuvant chemotherapy for STS, has failed to demonstrate any benefit from chemotherapy in local control, progression free survival or overall survival in patients treated with adjuvant chemotherapy. European Society of Medical Oncology(ESMO) in 2009 wrote: “Therefore, adjuvant chemotherapy is not standard treatment in adult-type soft tissue sarcomas, and can be proposed as an option to the high-risk individual patient (having a G2–3, deep, >5 cm tumor) for shared decision-making in conditions of uncertainty [II, C]. The histological type may be considered in the decision-making, since some types are felt to be more chemosensitive, whereas others are less so.” NCCN on p. MS-8 reviews all this evidence and appears to accept adjuvant chemotherapy as an option, on p. EXTRASARC-3, but with a footnote that explains that “there is limited and conficting data…”.

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Tamoxifen, Endometrium and Hysterectomy

M Levin, MD — Tue, 19 Jun 2012 14:12:27 +0000

Tamoxifen has different effects on different tissues. Whereas it blocks estrogen in the breast, it has pro- estrogenic effects on bone and in the uterus. Working as an estrogen-like substance, it can cause dysfunctional uterine bleeding and endometrial thickening and very rarely, superficial, easily treatable, endometrial cancer and sarcoma. In a review of all NSABP breast cancer treatment trials, the rate of sarcoma in women treated with tamoxifen was 17 per 100,000 patient years versus none in the placebo group. Similarly, in a separate trial of high-risk women without breast cancer taking tamoxifen as part of a breast cancer prevention trial with a median follow-up of 6.9 years, there were four in the tamoxifen group versus none in the placebo group, translating into a very low risk. This is compared with the incidence of one to two per 100,000 patient years in the general population.

Some women develop endometrial thickening when taking tamoxifen. The significance of endometrial thickening is not clear. At one time, women were regularly subjected to regular screening, ultrasound and even intra-uterine biopsies. Experience had not borne out such an approach. Beyond a routine gynecologic examination eliciting any history of abnormal bleeding, it has been recommended that screening studies and procedures for detecting endometrial pathology in women taking tamoxifen should be left to the discretion of the individual gynecologist. Routine ultrasound screening is not recommended because of significant incidents of false-positive endovaginal ultrasound screening tests. Of course, any abnormal uterine bleeding should be completely evaluated.

There are no guidelines to recommend hysterectomy routinely for patients of tamoxifen. One guideline that has taken up this issue is this Society of Gynecologic Oncology pf Canada and it recommends: “In asymptomatic women on tamoxifen, a routine ultrasound for endometrial thickening should not be performed.” It does not recommend routine hysterectomy.

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