Smilow Shares CME Seminar: Sarcoma

Transcript

• 00:04Hello, everyone.
• 00:06I am Francis Lee. I'm
• 00:07a tumor surgeon, orthopedic oncology
• 00:10at the Yale School of
• 00:11Medicine. It's so much pleasure
• 00:14to meet you on Zoom,
• 00:16and I work with doctor
• 00:17Deshpande, doctor Olino, doctor Ladich.
• 00:20And,
• 00:21we have a very strong
• 00:23team for connective tissue oncology,
• 00:25meaning
• 00:26sarcomas in the muscles and
• 00:28bone.
• 00:29At the same time,
• 00:31we provide
• 00:32all the metastasis
• 00:34from lung, kidney, prostate,
• 00:36thyroid,
• 00:37melanoma
• 00:39to bone, including
• 00:41myeloma and the lymphoma.
• 00:44It has been very exciting
• 00:45year,
• 00:47over the past ten years.
• 00:48My my pain is And,
• 00:51this is what we do
• 00:52all the time. I cannot
• 00:53This patient had a breast
• 00:55cancer,
• 00:56and the pain is unbearable
• 00:58after radiation, chemo and the
• 01:00Prolia. Nothing worked. And you
• 01:03can see actually the femoral
• 01:04head seen through the pelvis.
• 01:07And these are the treatments
• 01:08we are doing now, twelve
• 01:10treatments.
• 01:11And most of them are
• 01:12open procedure,
• 01:14and we just stabilize the
• 01:16bone.
• 01:17So, but But from oncology
• 01:20perspective It it's
• 01:22I do not think this
• 01:23is really right treatment
• 01:25because we are not really
• 01:26addressing
• 01:27the radio or chemo resistant
• 01:29cancers.
• 01:32And this is what we
• 01:33have been doing
• 01:34until twenty sixteen
• 01:36nationwide,
• 01:37actually all over the world.
• 01:39We make a very big
• 01:40skin cut to expose
• 01:43the hip.
• 01:44This particular case is a
• 01:45thyroid
• 01:46papillary cancer
• 01:48destroying the bone.
• 01:50And then we replace the
• 01:51hip using very big implants.
• 01:54But after radiation,
• 01:56patient can get infected,
• 01:58and we cannot continue
• 02:01oncological care due to infection.
• 02:05I moved from Columbia University
• 02:07to Yale in two thousand
• 02:09sixteen,
• 02:10and I was very fortunate
• 02:12to meet doctor Ladich.
• 02:14And this is what I
• 02:15have been dreaming about over
• 02:17the past twenty years.
• 02:19And we
• 02:20have developed
• 02:22a minimally invasive procedure
• 02:25for all the skeletal metastases,
• 02:27just like for all percutaneous
• 02:30procedures for aneurysm
• 02:32and cardiac valve replacement surgery.
• 02:35Instead of making big incision,
• 02:38we are doing the same
• 02:39procedure
• 02:40through a very small tiny
• 02:42incision.
• 02:44Doctor Ladich, can you join
• 02:46or
• 02:47if you cannot join,
• 02:49I I am here, unfortunately.
• 02:51I had a solitary tooth,
• 02:52I can only join by
• 02:53audio, but I can hear
• 02:54you.
• 02:55Do you see any of
• 02:56my slides? Do you see
• 02:58Yes. I I see all
• 02:58of your slides. Correct. Can
• 03:00you add some, with statements?
• 03:02This is the movie you
• 03:03made.
• 03:06Yes. This movie, has a
• 03:08a long backstory, and I
• 03:09will,
• 03:10spare you, from some of
• 03:12the, jufier details because it
• 03:14might be in violation of
• 03:15some of our present day
• 03:16narratives.
• 03:18But,
• 03:19this shows,
• 03:20the the procedure that, doctor
• 03:22Lee, in fact, is out
• 03:23to AORIF,
• 03:24which is a a modification
• 03:27of another,
• 03:29well known,
• 03:30surgical acronym,
• 03:32where a stands for, ablation,
• 03:34o stands
• 03:36for osteoplasty,
• 03:37with a compliant balloon, typically.
• 03:40R is reinforcement,
• 03:42typically
• 03:43cement reinforcement and internal fixation.
• 03:45So as you can see
• 03:46from the animation, this is
• 03:48all done for continuously
• 03:49using a combination of fluoroscopy,
• 03:52and cone beam CT.
• 03:55We are also able to
• 03:56do these with conventional CT
• 03:59in some cases, and we're
• 04:00looking to actually
• 04:03make this even more precise,
• 04:05and,
• 04:07probably even less minimally invasive.
• 04:09That is actually even possible
• 04:10by using
• 04:11navigation and hopefully robotics someday.
• 04:15So the, the approach is
• 04:18that,
• 04:19using,
• 04:20horoscopic guidance,
• 04:22and basic anatomical landmarks, we
• 04:24make a tiny little incision
• 04:25just wide enough to be
• 04:26able to accommodate,
• 04:28one of our guide wires,
• 04:31and then advance it using
• 04:33multi plane velocities,
• 04:36into and through our lesion,
• 04:38target lesion. Typically, in this
• 04:40case, for example, in the
• 04:41acetabulum,
• 04:42we may place a few
• 04:43guide wires,
• 04:45depending on
• 04:46the size and location of
• 04:48the lesion and the need
• 04:50for stabilization.
• 04:51Once we have the guide
• 04:53wire in place, essentially,
• 04:55half the battle is,
• 04:57is, you know, is complete.
• 04:59Now we have our access,
• 05:02and then,
• 05:03over the guide wire, we
• 05:05placed
• 05:06a a cannulated screw that
• 05:08has an, open inner channel,
• 05:10obviously.
• 05:11And now through that channel,
• 05:13that's so we have a
• 05:14portal into the lesion.
• 05:16So through that channel, now
• 05:17we can perform an ablation,
• 05:19thermal ablation. Typically, we do
• 05:21radio frequency, but one can
• 05:22perform any type of an
• 05:24ablated
• 05:26procedure one would like.
• 05:29Some places, some centers use
• 05:30cryoablation.
• 05:32There can be some challenges
• 05:33with cryoablation and injection of
• 05:35cement because they can obviously
• 05:38cryo create a general size
• 05:40fall. It might be a
• 05:41little harder to inject cement.
• 05:42So we typically will use
• 05:43heat ablation.
• 05:45Once we are, done with,
• 05:47ablating,
• 05:48we remove our ablation probe,
• 05:51and
• 05:53typically place the, the compliance
• 05:55balloon. And by the way,
• 05:58we initially borrowed much of
• 06:00this tool kit from the,
• 06:02from, the protein block here,
• 06:04kyphoplasty
• 06:05set. So it's essentially much
• 06:06of the same tool. So
• 06:08with the balloon, we pushed
• 06:09away some of that scar
• 06:11to destroy super tissue
• 06:13to create a central cavity
• 06:15because, believe it or not,
• 06:16as I know,
• 06:18even with litig lesions, there's
• 06:19still it's not an empty
• 06:21space, obviously. It's not entirely
• 06:23a a hole in the
• 06:24bone. There's still some matrix
• 06:25there whether it's mucinous, sigma,
• 06:27something else. So once we
• 06:29have ablated, we push that
• 06:30tissue out of the way
• 06:31to create a a central
• 06:33pocket
• 06:34that'll allow us to now
• 06:35inject bone cement
• 06:37to help with reinforcement.
• 06:40And now that we once
• 06:41we have, cement deposited,
• 06:44we drill the crew through
• 06:46it into their final resting
• 06:47position. Now we also have
• 06:49access to,
• 06:50screws that have side holes
• 06:52along their lines. So now
• 06:53we can actually advance the
• 06:55screw into their,
• 06:56let's say, final,
• 06:58resting position
• 06:59before we inject cement.
• 07:01And once we inject cement,
• 07:02we,
• 07:04usually within about twenty minutes
• 07:06of the time when we
• 07:07mix up the cement.
• 07:09Within twenty minutes minutes, that
• 07:10cement is rock solid and
• 07:12the construct
• 07:13is stable.
• 07:14We come out,
• 07:16close the tiny little incisions,
• 07:18the features, staples, etcetera, put
• 07:20little bandages on, patient goes
• 07:22to recovery, and typically,
• 07:24most of the time, goes
• 07:26home the, the same night.
• 07:28So that's the, the long
• 07:29and short of the, the
• 07:30procedure. So I'll turn it
• 07:31over back to doctor Lima.
• 07:33Thank you so much. So
• 07:35this, technique was developed
• 07:37at Yale,
• 07:38and the patient's actually flying
• 07:40in.
• 07:41And, patients go somewhere the
• 07:42same day.
• 07:44So we are provide,
• 07:46really care. We are providing
• 07:48care for medical oncologist
• 07:50so that oncologist can give
• 07:52chemotherapy the next day without
• 07:55waiting two or three weeks.
• 07:57That used to be the
• 07:57case after open surgery.
• 08:00So we see patients in
• 08:02Trumbull, New Haven,
• 08:04and also Stanford,
• 08:05and we are well
• 08:07we'll be glad to assist
• 08:09to your medical oncology care.
• 08:13So this is another example,
• 08:14three year breast cancer patients.
• 08:18Patient couldn't walk. This is
• 08:19a de novo diagnosis of
• 08:20a stage four,
• 08:22and we did
• 08:24our,
• 08:25minimally invasive procedure.
• 08:27And she was able to
• 08:29emulate
• 08:30the next day,
• 08:32and she sustained,
• 08:33for four years.
• 08:36This is another case, same
• 08:38breast cancer patient.
• 08:40Patient is now five year
• 08:43out of the procedure.
• 08:45And nowadays,
• 08:47all of you made a
• 08:47miracle.
• 08:48Cancers are manageable disease,
• 08:51and we can facilitate
• 08:53your oncological
• 08:55care.
• 08:56Even though this is a
• 08:57So another patient with a
• 08:58renal cell cancer, you can
• 09:00see hypervascularity,
• 09:02and the patient can go
• 09:03home on the same day.
• 09:05Can you get out of
• 09:05the bed? This is the
• 09:07movie
• 09:07at the recovery rooms.
• 09:10So three or four hours
• 09:11later,
• 09:12the one hour procedure,
• 09:15the patient really worked with
• 09:17all of them.
• 09:19So the problem is my
• 09:20throat can And this can
• 09:21be also very powerful for
• 09:23multiple lesions.
• 09:24Patient had a bilateral as
• 09:26couple of fractures,
• 09:28right to femoral lesions, left
• 09:29to femoral neck fracture,
• 09:31everything in one stage, and
• 09:33the patient went home on
• 09:35the same day.
• 09:38Patient also had a very,
• 09:39radiation and the chemo refractory
• 09:42had just a cell phone
• 09:44with
• 09:45the spine and the left
• 09:46hip lesion.
• 09:47We were able to address
• 09:49both,
• 09:50spine and hip
• 09:52on the one anesthesia,
• 09:54and patient was able to
• 09:56ambulate right away.
• 10:00Another case of breast cancer
• 10:02after five years.
• 10:04The breast cancer relapsed,
• 10:06and, unfortunately,
• 10:07the bone bone quality became
• 10:09very poor.
• 10:11We did the reconstruction,
• 10:12and the patient is still
• 10:13alive.
• 10:16So in summary,
• 10:18we will be very happy
• 10:19to provide
• 10:21a minimally invasive procedure
• 10:23for your effective oncology care
• 10:26without interruption.
• 10:27And I thank you so
• 10:28much for listening, and I
• 10:30will stop here. And if
• 10:31there are any questions, doctor
• 10:33Latician,
• 10:33I can answer any questions.
• 10:35Thank you.
• 10:39That's great,
• 10:40Francis.
• 10:42Really excellent
• 10:44demonstration of what you and,
• 10:46Igor can do. So thank
• 10:47you for
• 10:49sharing those.
• 10:50I
• 10:52don't see anything in the
• 10:54chat
• 10:55right now, but,
• 10:58if there are any, then
• 10:59I think Emily can,
• 11:02send them to you.
• 11:04But in the meantime, while
• 11:06people are thinking of questions,
• 11:08I'll just move on
• 11:10to,
• 11:12the the next part of
• 11:14the slide,
• 11:15of the talk.
• 11:17And if I can figure
• 11:19out how to share my
• 11:23slide.
• 11:30I
• 11:42apologize.
• 11:42Technology is not my best
• 11:44friend.
• 11:46Is that can you see
• 11:48the slides now?
• 11:52I can see that. Yes.
• 11:53Oh, great.
• 11:55So
• 11:56thank you, doctor Ladich and
• 11:58doctor Lee for starting this
• 12:00seminar, and
• 12:01I'm also very proud to
• 12:03be a part of such
• 12:05a great
• 12:06team that involves also doctor
• 12:08Alino as well, who should
• 12:10be hopefully joining us fairly
• 12:12soon.
• 12:14So we've heard about some
• 12:15of the newer surgical techniques
• 12:17from doctor Lee and doctor
• 12:19Laddich.
• 12:21I'll spend the rest of
• 12:22the time focusing
• 12:24on soft tissue and
• 12:27bone sarcomas.
• 12:29Now the WHO
• 12:30has classified
• 12:31soft tissue and bone
• 12:33tumors
• 12:35into four different categories. Many
• 12:37of you will be familiar
• 12:38with benign lesions such as
• 12:41lipomas
• 12:42and malignant lesions,
• 12:44which include sarcomas.
• 12:46But there are also two
• 12:48other categories,
• 12:50and these
• 12:51include intermediate grade tumors that
• 12:53are rarely metastasizing.
• 12:56And I put one example
• 12:58as a giant cell tumor
• 13:00and intermediate grade tumors
• 13:02that are locally aggressive.
• 13:05And these include
• 13:07something I'm gonna spend a
• 13:08little more time on, which
• 13:09is desmoid tumors.
• 13:13The management of soft tissue
• 13:15and bone tumors in general
• 13:18is similar to many of
• 13:19the malignancies
• 13:20that we see in oncology.
• 13:22So the main treatment
• 13:24historically has been surgery.
• 13:27But these days,
• 13:29as just like you heard
• 13:30from doctor Lee and doctor
• 13:31Ladich,
• 13:33other techniques have been used
• 13:34because surgery can be very
• 13:36morbid or it might delay
• 13:37other treatments.
• 13:39So various ablative techniques similar
• 13:42to what you've just seen
• 13:43have been tried
• 13:45as well
• 13:46as radiotherapy
• 13:48and medical management.
• 13:49So this includes chemotherapy,
• 13:52targeted therapy,
• 13:53and immunotherapy.
• 13:57So my first case is
• 13:58actually a case of a
• 13:59patient with a desmoid tumor.
• 14:01This is also
• 14:03known as
• 14:04a
• 14:05an aggressive fibromatosis.
• 14:07It goes by many different
• 14:08names.
• 14:10This is a thirty nine
• 14:11year old woman
• 14:13who, in September last year,
• 14:15noted
• 14:16a lump in the right
• 14:17axilla.
• 14:18The following month,
• 14:20she had an ultrasound which
• 14:22confirmed a mass and measured
• 14:24it at six point nine
• 14:25by three by five centimeters.
• 14:29This was confirmed on an
• 14:30MRI scan,
• 14:32which suggested it was a
• 14:33little bit larger, seven point
• 14:35nine by five point two
• 14:37by four point eight centimeters.
• 14:40And an ultrasound guided biopsy
• 14:43showed pathological
• 14:44features
• 14:45consistent with a desmoid tumor.
• 14:50So I don't know if,
• 14:51Igor, if you're still
• 14:53able to talk, but, I
• 14:55I don't know if you
• 14:56can take us through this
• 14:58MRI picture.
• 15:01Yes. I am I am
• 15:02I am here. Okay.
• 15:04So
• 15:05we see this, irregular. If
• 15:07if you were looking at
• 15:08an X-ray, I suppose one
• 15:10could almost call it a
• 15:11spiculated,
• 15:12lesion,
• 15:13which is fairly characteristic,
• 15:16appearance for a lot of
• 15:17these,
• 15:19desmoid
• 15:20and aggressive fibro motility.
• 15:22They're typically not very well
• 15:25circumscribed. They they tend to
• 15:26kind of invaginate
• 15:27themselves to all sorts of
• 15:29tissue planes, which is what
• 15:30sometimes makes them a challenge
• 15:32to, surgically respect for instance.
• 15:34It's it's not always easy
• 15:36to get very clean margins
• 15:38because they are,
• 15:39they're they're so easy regular,
• 15:42jagged almost. And,
• 15:44you can see this
• 15:46fairly
• 15:47typical appearance of it being
• 15:48very
• 15:49white,
• 15:50on, this
• 15:53sequence or contrast enhanced sequence.
• 15:54Either way, they they tend
• 15:56to really light up, quite
• 15:58obviously.
• 16:00And you can see them,
• 16:02the the prongs of the
• 16:04lesion kind of,
• 16:06sticking into various tissue planes
• 16:08in between muscles,
• 16:10and and and tendons and
• 16:12fat planes.
• 16:14So,
• 16:15this is precisely, like I
• 16:16said, what what causes them
• 16:18to be a
• 16:19a bit of a surgical
• 16:21dilemma, particularly in this area.
• 16:23Now I can't see on
• 16:24this one sequence exactly how
• 16:26close the brachial plexus is,
• 16:28but, you know, in the
• 16:29axilla, that
• 16:31that can always be a
• 16:32problem, from a management standpoint
• 16:35to try to peel away
• 16:36all these,
• 16:38prongs of the lesion away.
• 16:40But,
• 16:41Jen, this is pretty much
• 16:42the classical appearance of the
• 16:44lesion.
• 16:45Right. Thank you. And
• 16:47and, actually, it's exactly as
• 16:49you said. She
• 16:50first saw doctor Alino, and
• 16:52she pretty much
• 16:53said word for word what
• 16:55you said. Because of its
• 16:56location
• 16:57near the brachial plexus, it
• 16:59would have made surgery
• 17:01very challenging to try and
• 17:02get all of this tumor
• 17:04out.
• 17:05So desoid tumors are quite
• 17:07rare. They affect somewhere between
• 17:10three and six
• 17:11cases
• 17:12per million population
• 17:14every
• 17:16year. But
• 17:17and this, accounts for about
• 17:19fifteen hundred cases a year
• 17:21in this country.
• 17:23However, most patients do not
• 17:25die of their disease.
• 17:27So there are many, many
• 17:28more patients living with desmoid
• 17:30tumors,
• 17:31and this is why the
• 17:32prevalence is so much higher.
• 17:35The median age, it's a
• 17:37young person's disease, so we
• 17:40tend to see cancer in
• 17:42older populations. But desmoid tumors
• 17:44tend to have a median
• 17:45age of twenty to forty
• 17:47four, but it is quite
• 17:48variable. I have seen patients
• 17:50who are much older, and
• 17:51we've also seen desmoid tumors
• 17:53in children.
• 17:55Most desmoid tumors are sporadic,
• 17:58but there
• 17:59are some that are associated,
• 18:00as many of you will
• 18:02know,
• 18:03with the FAP gene or
• 18:04familial adenomatous
• 18:06polyposis gene.
• 18:10Desmoid tumors can occur anywhere
• 18:12in the body as shown
• 18:14on this particular slide.
• 18:16There is a slight
• 18:17increase in incidence in the
• 18:20intra abdominal or abdominal
• 18:22wall area,
• 18:24but their symptoms
• 18:25really depend on where the
• 18:27tumors are. As as, again,
• 18:29you can imagine if there's
• 18:30a big mass somewhere,
• 18:32it's gonna cause symptoms related
• 18:34to the size of the
• 18:35mass. So this can be
• 18:37trouble breathing if it's in
• 18:38the chest wall,
• 18:40abdominal distension if it's in
• 18:41the abdomen,
• 18:43and masses or restricted mobility
• 18:46if it's in the extremities.
• 18:49Over the last few decades,
• 18:51a lot of work has
• 18:52been done, however, into what
• 18:54causes
• 18:55desmoid tumors.
• 18:56And one of the first
• 18:57things that was realized is
• 18:59it seems to have
• 19:01an effect
• 19:02be more,
• 19:06prominent
• 19:07in patients who have hypereestrogenic
• 19:09states.
• 19:11And this can include recent
• 19:12pregnancies
• 19:14as well as women more
• 19:15than men.
• 19:17It actually led to one
• 19:19of the first
• 19:20medical treatments being tried
• 19:22as being tamoxifen,
• 19:24which is an estrogen receptor
• 19:26modifier
• 19:27that we use to treat
• 19:28breast cancer.
• 19:30It wasn't
• 19:31very successful, but we still
• 19:33very occasionally use that medication
• 19:35today.
• 19:37Similarly,
• 19:38some desmoid tumors occurred at
• 19:40the site of prior surgery
• 19:42or prior trauma, suggesting that
• 19:45it was that traumatic event
• 19:47that ended up causing the
• 19:49tumor.
• 19:52Most of us get our
• 19:53treatment guidelines from something called
• 19:55the NCCN,
• 19:56which is a national guideline
• 19:58for treating
• 19:59every cancer.
• 20:00And the treatment guidelines for
• 20:02Desmoid tumors have changed
• 20:04extensively
• 20:06over the last few decades.
• 20:09What we suggest these days
• 20:10is if you have a
• 20:12patient with a desmoid tumor,
• 20:14they should be
• 20:16evaluated by a multidisciplinary
• 20:18team such as the one
• 20:20we have here at Yale.
• 20:22This way we can decide
• 20:24whether we should go with
• 20:25the standard
• 20:27first line treatment, which is
• 20:29actually surveillance,
• 20:31or whether they need any
• 20:32of our other techniques that
• 20:34have been mentioned in this
• 20:35talk.
• 20:38So as usual for any
• 20:41medical condition, we need to
• 20:42do a good history and
• 20:44fit and physical.
• 20:45And this is really for
• 20:46patients who have just been
• 20:48diagnosed to see whether they
• 20:49need further workup
• 20:52for familial adenomatous
• 20:54polyposis.
• 20:55Because if they do have
• 20:57that condition, especially if they're
• 20:58very young,
• 21:00then they'll need much more
• 21:02intense screening for colorectal cancer
• 21:05as shown on this particular
• 21:07slide.
• 21:08Otherwise,
• 21:09we need to do surveillance
• 21:10imaging
• 21:11to see whether the tumors
• 21:13are staying the same,
• 21:15but whether they're growing, or
• 21:17whether they're even regressing.
• 21:22So because some of the
• 21:24tumors can regress, as shown
• 21:26on this particular slide, over
• 21:28a quarter, so twenty eight
• 21:29percent,
• 21:31that's why we tend to
• 21:32use surveillance
• 21:33as the first line of
• 21:34treatment.
• 21:36A further thirty percent will
• 21:37be stable. So if they're
• 21:38not bothering the patient, if
• 21:40it was, for instance, just
• 21:42picked up on another imaging
• 21:43technique,
• 21:45then we would still just
• 21:46do surveillance
• 21:47to just follow them
• 21:49and be ready to start
• 21:51treatment if needed.
• 21:53About forty two percent, however,
• 21:55will have progressive disease and
• 21:57probably
• 21:58symptomatic disease.
• 22:00For those patients in the
• 22:01past, we used to do
• 22:03surgery. But as doctor Ladich
• 22:05mentioned,
• 22:06this can often be a
• 22:07very morbid procedure
• 22:09where patients
• 22:11will need a very, very
• 22:12big operation to remove a
• 22:14relatively
• 22:15small tumor.
• 22:18Over the past few years,
• 22:20doctor Ladich and doctor Lee
• 22:22have really
• 22:23pioneered the use of interventional
• 22:26techniques. And I know
• 22:29I've shared quite a few
• 22:30patients with doctor Lavich.
• 22:33And the ablative techniques
• 22:36for desmoid tumors,
• 22:38I would say,
• 22:39are they similar to what
• 22:41you just described on the
• 22:42first few slides, or are
• 22:44there any big differences
• 22:47from how you would treat
• 22:48a desmoid tumor as a
• 22:51It's it's all thermal ablation.
• 22:53However,
• 22:54like I mentioned or unlike
• 22:55in, the acetababulum,
• 22:57especially if we're looking to
• 22:59put in cement, I prefer
• 23:00to use
• 23:02e double h
• 23:07Okay. Sorry. You were cutting
• 23:09out a little bit there.
• 23:14Maybe we can come back
• 23:16to you
• 23:17when you're in a better
• 23:18area.
• 23:21But, otherwise, we do have
• 23:22new medical therapists, and the
• 23:24medical therapist
• 23:26sorry. Go ahead, Igor. Can
• 23:27you hear us? It? I
• 23:28can hear you better. Said,
• 23:29is the line choppy?
• 23:31Got it. I'm sorry. So,
• 23:32typically,
• 23:33with desmoids, we use cryoablation
• 23:36rather than a a heat
• 23:38ablation.
• 23:39And that is primarily
• 23:41because on CT, which is
• 23:43what we use for guidance,
• 23:45we can use we can
• 23:46see our ablation zones very
• 23:48nicely.
• 23:49We see these, so called
• 23:51ice balls
• 23:52almost perfectly delineating,
• 23:54the, the margins of the
• 23:56tumor. Whereas with heat ablation,
• 23:58typically, let's say, with
• 24:00sarcomas, we would use
• 24:02microwave ablation
• 24:04for larger lesions. You do
• 24:06not see that margin
• 24:07on imaging at least immediately.
• 24:10You can anticipate it, but
• 24:11you don't know exactly where
• 24:12it is. Where where with
• 24:13cryo, you can see exactly
• 24:15the margin of the ice
• 24:16fall. So that's one of
• 24:18the advantages and that's the
• 24:20preferred modality for Desmos.
• 24:23That's great. And then I
• 24:24know you mentioned the brachial
• 24:26plexus was a concern for
• 24:28surgery. So how would you
• 24:30get around that with doing
• 24:32ablation, or would you
• 24:33refer them to me for
• 24:34medical therapy?
• 24:37So our preferred option would
• 24:38be, obviously, do no harm
• 24:40or do least harm first.
• 24:42So one would certainly start
• 24:43with,
• 24:44systemic therapy first, see how
• 24:46the patient responds.
• 24:51The pathology, obviously, will be
• 24:53for the treatment,
• 24:56plays out.
• 24:58If an ablation is still
• 25:00needed, one can still do
• 25:01stage the treatment to maybe
• 25:03manage,
• 25:04let's say, ninety percent of
• 25:05the lesion if we can't
• 25:06get the the entirety of
• 25:08it.
• 25:09But in many cases, we
• 25:10can do some of these,
• 25:12advanced,
• 25:13ablations using,
• 25:15neuro monitoring at the same
• 25:17time so we can tell
• 25:18in real time if we
• 25:19are causing any damage,
• 25:22to the plexus and and
• 25:23just gonna back off. But
• 25:25our preference will be to
• 25:26go with systemic treatment first
• 25:28to see if that perhaps,
• 25:31manages to a strength delusion
• 25:33or at least keep it
• 25:34at bay.
• 25:36Great. Thank you.
• 25:38And that brings us into
• 25:39the medical therapist. So there
• 25:42have been a few advances
• 25:43in the last few decades,
• 25:46and they have moved earlier
• 25:47in the treatment. So I
• 25:49would say now we tend
• 25:50to get most of our
• 25:51referrals
• 25:53from orthopedic surgeons who have
• 25:55seen these desmoid tumors.
• 25:57They know that there's medications
• 25:59available, and they'll send them
• 26:01for surveillance
• 26:03and possible,
• 26:04medical treatment to me before
• 26:07they attempt any surgery.
• 26:10And we used to use
• 26:11radiation a lot
• 26:13for
• 26:14desmoid tumors. I would have
• 26:15to say,
• 26:16I don't think I've seen
• 26:18radiation being used for desmoid
• 26:20tumors
• 26:21in the last five years.
• 26:23It just has fallen out
• 26:24of favor. And the main
• 26:26reason for that is,
• 26:27as I mentioned
• 26:29earlier,
• 26:30these patients don't tend to
• 26:32die of their disease. This
• 26:34can be a very morbid
• 26:35disease. They can have a
• 26:36lot of pain,
• 26:37but they live for as
• 26:38long as if they didn't
• 26:40have the desmoid tumor,
• 26:42which means if you're giving
• 26:43radiation
• 26:44or even doing a lot
• 26:45of CAT scans, you're exposing
• 26:47the patient
• 26:49to potentially
• 26:50a treatment
• 26:52that may result in a
• 26:53second malignancy. And that's the
• 26:55last thing we want to
• 26:56do
• 26:57is to take someone who
• 26:58has a an intermediate
• 26:59tumor
• 27:01and then give them a
• 27:02more malignant tumor. And so
• 27:04we have to be careful
• 27:05with our imaging techniques. We
• 27:07tend to use MRIs or
• 27:08ultrasounds
• 27:09to follow these patients rather
• 27:11than CAT scans,
• 27:12and we save radiation
• 27:14for patients who really have
• 27:16failed everything else.
• 27:21So one of the medical
• 27:23treatments that
• 27:25we have
• 27:28seen over the past few
• 27:29years
• 27:30is something called nirogacastat
• 27:34or
• 27:35OXIVIO.
• 27:36And I can say it
• 27:37because I've had
• 27:38five years of practice saying
• 27:40it, but like most of
• 27:41our oncology medicines, they don't
• 27:43exactly roll off the tongue.
• 27:45But this is a medication
• 27:47that's called a gamma secretase
• 27:49inhibitor,
• 27:50and then it inhibits
• 27:52some of the genetic
• 27:54changes that occur in desmoid
• 27:56tumors, either
• 27:58related to the FAP gene
• 28:00or the beta catenin gene.
• 28:02That's one of the other
• 28:03genes that can be mutated
• 28:05in this disease.
• 28:08So
• 28:09when this new medication
• 28:11was developed
• 28:12and they realized it had
• 28:14a lot of activity in
• 28:15the very early trials,
• 28:17they decided to test it
• 28:19in what we call a
• 28:20phase three trial. So this
• 28:21is a trial
• 28:22where a new medication
• 28:24is tested
• 28:26against the standard of care.
• 28:27Now the standard of care
• 28:29for desmoid tumors is actually
• 28:31surveillance.
• 28:33So it was tested in
• 28:34this study against placebo.
• 28:37They had to have
• 28:38they patients had to have
• 28:40a desmoid tumor that was
• 28:41histologically
• 28:42confirmed.
• 28:43They had to be progressing
• 28:45after
• 28:46one line of therapy
• 28:49or refractory
• 28:51to more than one line
• 28:52of therapy
• 28:53and had and if they
• 28:55would have felt that if
• 28:56continued
• 28:57progression,
• 28:58they would have an immediate
• 28:59significant,
• 29:02they wouldn't have an immediate
• 29:03significant risk,
• 29:06if they had to wait
• 29:07if they were on the
• 29:08placebo arm.
• 29:10They did need biopsy
• 29:12to confirm the disease so
• 29:14that everyone had the same
• 29:15disease going into the trial,
• 29:17and they had to have
• 29:18what we call a good
• 29:19performance status, which means
• 29:21they were able to do
• 29:23all of their activities
• 29:25without being in bed most
• 29:26of the day or in
• 29:27hospital or anything like that.
• 29:31They also had to have
• 29:32adequate
• 29:33organ and bone marrow function.
• 29:36These medications, remember, had only
• 29:38been tested on a few
• 29:39patients before
• 29:41being tested in this big
• 29:42clinical trial, so we didn't
• 29:44know how it would affect
• 29:46patients in terms of side
• 29:48effects
• 29:48or in terms of some
• 29:50of their blood tests.
• 29:52The primary endpoint was progression
• 29:54free survival. How long did
• 29:56it keep the disease
• 29:57as it was or even
• 29:59keep it at a smaller
• 30:01size?
• 30:02And the secondary
• 30:03response rates included objective response,
• 30:06so how small
• 30:08could it make the cancer
• 30:09get or the tumor get,
• 30:11and also patient reported outcomes.
• 30:14So if they had a
• 30:14lot of pain to start
• 30:16off with,
• 30:17did this medication make them
• 30:19feel overall better despite any
• 30:21side effects?
• 30:23So patients were randomly assigned
• 30:26to receive this medication, nirogacastat,
• 30:29a hundred and fifty milligrams
• 30:31twice a day
• 30:32or a placebo, a similar
• 30:35appearing placebo
• 30:36twice a day.
• 30:37If they did well on
• 30:38the medication, they were able
• 30:40to continue it.
• 30:41If they got the placebo
• 30:43but progressed,
• 30:45they were able to cross
• 30:46over to get this new
• 30:47medication.
• 30:49All patients had their tumors
• 30:52measured using a standard radiological
• 30:55technique called recist,
• 30:58and they had patient reported
• 31:00outcomes very accurately measured
• 31:03as well as looking at
• 31:05the safety of the medication.
• 31:09In this study, as you
• 31:11can see, the majority of
• 31:13patients had
• 31:14disease that was outside the
• 31:16abdomen, unlike that particular
• 31:19slide that I've mentioned before
• 31:21for the general population.
• 31:25Patients either had
• 31:27single
• 31:28sites of disease or they
• 31:29were multifocal
• 31:31disease.
• 31:32The size of these tumors
• 31:34was quite large. So in
• 31:35the treatment arm, it was
• 31:37nine point one centimeters.
• 31:40And in the placebo arm,
• 31:41it was eleven centimeters.
• 31:44A minority of patients, less
• 31:46than twenty percent, had familial
• 31:48adenomatous polyposis.
• 31:51And these were the genes
• 31:52that were mutated.
• 31:54And you can see here
• 31:56the APC gene
• 31:58and the beta catenin gene.
• 32:00Some patients had no
• 32:02identified mutations.
• 32:05Many patients had already had
• 32:07quite a few treatments in
• 32:09some cases
• 32:10up to fourteen lines of
• 32:12prior treatment.
• 32:14And these are some of
• 32:15the treatments that they received.
• 32:19A vast,
• 32:21well, a a significant minority,
• 32:23I should say, of patients
• 32:25had significant pain
• 32:27at the time of enrollment
• 32:28in this particular trial.
• 32:31We were one of the
• 32:31sites for this trial, and
• 32:33it was very exciting
• 32:34being on a medication that
• 32:37could be given to a
• 32:38disease that previously had no
• 32:41FDA approved treatment.
• 32:43And you can see that
• 32:44there was a significant
• 32:45difference in progression free survival
• 32:48on this particular graph.
• 32:50There's a wide separation of
• 32:52the curves between placebo
• 32:54and the study medication.
• 32:58And this is a a
• 32:59graph that we use a
• 33:00lot in oncology called a
• 33:01waterfall
• 33:03plot. Basically, where you see
• 33:04the zero line,
• 33:06that's the size of the
• 33:07tumor of each individual patient.
• 33:09Each bar is an individual
• 33:11patient.
• 33:12Anything that's going above the
• 33:14line means the tumors are
• 33:15growing,
• 33:16and anything below the line
• 33:18means the tumors are responding
• 33:20to treatment.
• 33:21And you can see on
• 33:23this first graph,
• 33:24the majority of patients, the
• 33:26tumors are getting smaller.
• 33:28And this dotted line is
• 33:30a thirty percent smaller line,
• 33:32and that's
• 33:33our arbitrary definition of a
• 33:35partial response.
• 33:37So
• 33:38over forty almost forty percent
• 33:40of patients had at least
• 33:42a partial response,
• 33:44and some of them even
• 33:45had a complete response. That's
• 33:46where when we do a
• 33:48follow-up scan, there's no evidence
• 33:50of disease on that scan.
• 33:52So this was really exciting
• 33:55stuff for a desmoid tumor.
• 33:58For the placebo group,
• 34:00again, some patients will have
• 34:02regression of disease without any
• 34:04treatment, and you can see
• 34:05that here.
• 34:07And others had progression of
• 34:08disease. And as I said,
• 34:09they were allowed to cross
• 34:11over
• 34:12and join the neurogastat
• 34:14group.
• 34:17So the nonmalignant
• 34:20soft tissues tumors,
• 34:22which desmoid tumor is one
• 34:24of them, they can either
• 34:25be totally benign,
• 34:27like lipomas,
• 34:30or intermediate
• 34:31tumors,
• 34:32such as desmoid and giant
• 34:34cell tumors.
• 34:36Usually, survival is not affected
• 34:40by these particular types of
• 34:42tumors, so you have to
• 34:43be very careful about the
• 34:44treatments you give.
• 34:46You don't want to give
• 34:47chemotherapies
• 34:48or radiation
• 34:49necessarily,
• 34:50which might have a risk
• 34:52of secondary
• 34:53complications
• 34:54down the line as these
• 34:55patients can live for many
• 34:57years.
• 34:58Similarly, when you're doing surveillance,
• 35:00you should opt
• 35:02for imaging techniques such as
• 35:04ultrasound or MRI
• 35:06rather than
• 35:08CT scans.
• 35:09But there are newer medications,
• 35:11one of which I've mentioned,
• 35:13Oxivio or Niragakastat,
• 35:16and newer techniques available
• 35:18for more advanced symptomatic
• 35:21cases.
• 35:27So that's the benign and
• 35:29intermediate
• 35:30grade.
• 35:31And I'm going to finally
• 35:33use the last part of
• 35:34the talk
• 35:35to go over
• 35:37sarcomas, which are malignant
• 35:39tumors.
• 35:40Sarcomas can be divided into
• 35:42two groups. They're either bone
• 35:44sarcomas,
• 35:46which you've seen some pictures
• 35:48on
• 35:49doctor Lee's slides,
• 35:52or soft tissue sarcomas.
• 35:54And soft tissue sarcomas are
• 35:56the vast majority, so eighty
• 35:58percent of all sarcomas.
• 36:01There are over fifty subtypes
• 36:04of sarcomas,
• 36:06and this is why it's
• 36:07often very difficult for physicians,
• 36:10even for
• 36:11our oncology fellows, to
• 36:13to really learn about these
• 36:15disease just because there's so
• 36:16many of them,
• 36:18and they're quite rare. So
• 36:20we see about seventeen thousand
• 36:23new sarcomas a year in
• 36:25the whole country,
• 36:26whereas we see three hundred
• 36:28thousand new breast cancers a
• 36:29year. So it's
• 36:31unless you're dealing with these
• 36:33patients every day like the
• 36:35four of us do,
• 36:36then it's hard to really
• 36:38understand
• 36:39the nuances of diagnosis and
• 36:41treatment.
• 36:43Once again, though, for sarcomas,
• 36:46surgery is the mainstay
• 36:48of treatment.
• 36:50It can be augmented
• 36:52with the use of radiation
• 36:53for soft tissue sarcomas
• 36:55and chemotherapy
• 36:57for bone sarcomas.
• 36:59Bone sarcomas tend not to
• 37:00be sensitive
• 37:02to radiation.
• 37:04There is a role for
• 37:05chemotherapy
• 37:06also after surgery in very
• 37:08large high grade
• 37:10sarcomas.
• 37:11So
• 37:12it's something we should think
• 37:14about for the more aggressive
• 37:15lesions.
• 37:17And for metastatic cases
• 37:19and some large tumors,
• 37:21we would think about giving
• 37:23targeted therapy
• 37:25or immunotherapy.
• 37:29So I'm gonna,
• 37:31continue with another slide. Hopefully,
• 37:33doctor Alino will
• 37:35be able to join
• 37:38with,
• 37:39some comments. This was a
• 37:41patient, again, I shared with
• 37:42her.
• 37:43This is a sixty nine
• 37:45year old man
• 37:47who, back in August last
• 37:49year, presented
• 37:51to his primary physician
• 37:53with a two week history
• 37:55of bilateral lower extremity edema
• 37:58on the right
• 37:59as opposed to the left.
• 38:03But at the same time,
• 38:04he had an ultrasound. The
• 38:06primary physician quite rightly
• 38:08was worried about a DBT,
• 38:11But the ultrasound didn't show
• 38:13a DVT.
• 38:14But
• 38:15very astutely,
• 38:17the primary care physician followed
• 38:19this up with a CAT
• 38:20scan of the abdomen and
• 38:21pelvis.
• 38:22And this showed a very
• 38:24large mass. You can see
• 38:25it's seventeen by three
• 38:27seventeen point three by nineteen
• 38:29point one
• 38:30by twenty three centimeters,
• 38:33retroperitoneal,
• 38:34so in the abdomen,
• 38:36with extremely
• 38:37heterogeneous
• 38:38internal components. Now this is
• 38:40a sign
• 38:41of a very
• 38:43rapidly growing tumor when it
• 38:45doesn't look the same all
• 38:46the way through.
• 38:47Sometimes we'll see these sarcomas
• 38:50that
• 38:51patients present to us with
• 38:53a huge tumor, but when
• 38:54you ask them, they'll say,
• 38:55oh, yes. I've had this
• 38:56mass. It's It's been growing
• 38:58a little bit over the
• 38:59past twenty years, and it
• 39:00actually
• 39:01is a much more low
• 39:02grade, often a liposarcoma.
• 39:07In his case, however, he
• 39:08had obstruction of the right
• 39:10ureter
• 39:11with right hydronephrosis,
• 39:14and an ultrasound guided biopsy
• 39:17of the retroperitoneal
• 39:19mass was
• 39:20performed.
• 39:22The pathology
• 39:23was initially read
• 39:26as undifferentiated
• 39:27sarcoma,
• 39:28but now we have better
• 39:29techniques in pathology to
• 39:32actually place it in one
• 39:33of those individual fifty categories.
• 39:37And if they have this
• 39:38gene called MDM two
• 39:41with certain other features,
• 39:43then we call it a
• 39:44dedifferentiated
• 39:45liposarcoma.
• 39:49So this is some of
• 39:50his,
• 39:52imaging.
• 39:53And, again, I don't see
• 39:54Kelly on the line, so
• 39:56I will do my best
• 39:58in my nonradiology
• 40:02technique to to say, well,
• 40:04this is pretty obvious. This
• 40:06is a very large mass,
• 40:08and this is what they
• 40:09mean by
• 40:10the heterogeneous
• 40:11appearance in the abdomen.
• 40:14So areas that are lighter
• 40:16and areas that are darker.
• 40:17These darker areas
• 40:19probably represent necrosis.
• 40:21And if you see a
• 40:22lot of necrosis
• 40:23on a sarcoma specimen,
• 40:26then that immediately pushes its
• 40:28grade up. We use
• 40:30necrosis, mitosis,
• 40:31and the type of sarcoma
• 40:33to determine the grade of
• 40:35the lesion.
• 40:36And when staging cancers,
• 40:38many of you will have
• 40:39heard of the TNM staging
• 40:42system, where t is the
• 40:43size of the tumor and
• 40:44n is nodes, m is
• 40:46metastasis.
• 40:48But sarcomas have a fourth
• 40:50component, which is the grade.
• 40:52And it's so important
• 40:54that a tumor that's very
• 40:55small
• 40:57yet has a very high
• 40:59grade can be a stage
• 41:00three.
• 41:01Whereas if this was a
• 41:02low grade tumor, it would
• 41:04actually still only be a
• 41:05stage one.
• 41:06So that's how important grade
• 41:08is
• 41:09because it has such a
• 41:11key effect
• 41:12on the prognosis.
• 41:15So he underwent
• 41:17resection of the retroperitoneal
• 41:19tumor on block
• 41:21with the right adrenal band,
• 41:23the kidney,
• 41:24the IVC,
• 41:26the common iliac artery and
• 41:28vein, and reconstruction
• 41:30with vascular surgery.
• 41:31It was a huge operation.
• 41:33I'm so glad
• 41:34doctor Alino was there to
• 41:36do it because she's used
• 41:37to doing these big operations.
• 41:39He needed thirty one units
• 41:41of packed red blood cells,
• 41:43nineteen units of FFP,
• 41:46three units of cryo, and
• 41:47two
• 41:48packs of platelets.
• 41:50And it involved three different
• 41:52surgical teams.
• 41:54And luckily, he did so
• 41:56well that he had an
• 41:57uneventful
• 41:58recovery.
• 41:59He was able to get
• 42:00home for the holidays,
• 42:02but unfortunately
• 42:03ended up with recurrent disease,
• 42:05including lung and retroperitoneal
• 42:08metastases.
• 42:09And I'm currently treating him
• 42:11for the metastatic disease.
• 42:14He technically
• 42:15would have been eligible for
• 42:17one of our clinical trials,
• 42:19however,
• 42:20and this is the schema
• 42:21for the trial. Basically,
• 42:23what we know with these
• 42:24very large
• 42:26retroperitoneal
• 42:27sarcomas
• 42:28is that
• 42:29surgery is a good treatment
• 42:31for them when they're very
• 42:32small, but the larger they
• 42:34get,
• 42:35the more likely they are
• 42:36to come back.
• 42:38So,
• 42:39historically,
• 42:40adding
• 42:41chemotherapy
• 42:42or radiation to these tumors
• 42:45has not made much of
• 42:46a difference in terms of
• 42:48survival.
• 42:49In fact,
• 42:50radiation was tested in a
• 42:51very similar trial called the
• 42:53STRAS
• 42:54one
• 42:55trial, where just like here,
• 42:56patients were randomized to either
• 42:58get surgery alone
• 43:00or radiation
• 43:01followed by surgery.
• 43:03And this was a negative
• 43:04trial, the previous trial, the
• 43:06STRAS one trial.
• 43:08It ended up saying that
• 43:09radiation did not improve survival.
• 43:12In fact,
• 43:13in some cases,
• 43:15it was even detrimental
• 43:17to get radiation plus surgery.
• 43:19There were a couple of
• 43:20histologies,
• 43:21however,
• 43:22where it seemed like there
• 43:23may be a trend towards
• 43:25radiation being beneficial.
• 43:27But during that time, the
• 43:29chemotherapies
• 43:29that we were using
• 43:31and the supportive care that
• 43:33we were using
• 43:34has improved significantly.
• 43:37So that
• 43:39they decided to look at
• 43:40this question again. If we
• 43:42give chemotherapy
• 43:43upfront
• 43:44followed by surgery, is it
• 43:46any better than surgery alone?
• 43:49And they this was
• 43:51started a few years ago,
• 43:54just before COVID, unfortunately,
• 43:56and then it the study
• 43:57really didn't accrue very well.
• 43:59But now we're part of
• 44:00that particular study. So if
• 44:01you have any patients
• 44:03who have these retroperitoneal
• 44:05masses,
• 44:06definitely send them to the
• 44:08surgeon,
• 44:09but also send them to
• 44:10medical oncology to see if
• 44:12they would be eligible for
• 44:13this trial. And this trial
• 44:15is open at all of
• 44:17our network sites.
• 44:19In other words, you can
• 44:20refer them to a local
• 44:21oncologist, and they can get
• 44:22their treatment there.
• 44:24Basically,
• 44:25they will get three cycles
• 44:28of treatment depending on what
• 44:30histology they have. If they
• 44:31have liposarcoma,
• 44:33they get one particular regimen.
• 44:35And if they have leiomyosarcoma,
• 44:37they get a different regimen
• 44:39and then go on to
• 44:40surgery. So a very
• 44:42simple trial,
• 44:43but a very much needed
• 44:45trial to see if we
• 44:46can improve
• 44:47on the treatment of these
• 44:49patients.
• 44:51Doctor Alino has really been
• 44:53working
• 44:54extensively with immunotherapy
• 44:56in her lab and
• 44:58her patients.
• 45:00And you can see she's,
• 45:03mentioned that there are many
• 45:04different types
• 45:06of
• 45:07of soft tissue sarcoma as
• 45:09shown in this particular slide.
• 45:12And
• 45:13some of them can affect
• 45:14the immune system
• 45:16more than others. I'm not
• 45:17gonna go too much on
• 45:18this complicated slide.
• 45:22So she
• 45:23treated a seventy seven year
• 45:25old, very fit gentleman,
• 45:28found with a left adrenal
• 45:29mass,
• 45:30resected and found to be
• 45:32a different kind of sarcoma
• 45:33from the one I just
• 45:34mentioned. This is an undifferentiated
• 45:37pleomorphic
• 45:38sarcoma.
• 45:39It recurred in twenty nineteen,
• 45:41and he underwent a partial
• 45:43colectomy
• 45:45and partial left nephrectomy.
• 45:47It recurred again,
• 45:50in twenty twenty, and he
• 45:51had completion of left nephrectomy
• 45:53and resection of the mass.
• 45:55And it recurred
• 45:57following that in twenty twenty
• 45:58two.
• 45:59And what they did was
• 46:00they tested his tumor at
• 46:02that time, and they found
• 46:03he had a very high
• 46:05score
• 46:05of PD L1. This is
• 46:07one of the markers that
• 46:08we use in other cancers
• 46:10to predict
• 46:11for response to immunotherapy.
• 46:16Now we know that certain
• 46:18sarcoma types
• 46:19respond to immunotherapy
• 46:22better than other sarcoma types.
• 46:25And this is a slide
• 46:27of all the different patients
• 46:29with sarcoma
• 46:30who have been treated with
• 46:32immunotherapy.
• 46:33And you can see the
• 46:35UPS, this is not the
• 46:37postal company, but this is
• 46:38undifferentiated
• 46:40pleomorphic
• 46:41sarcoma,
• 46:42often can have a very
• 46:44good response to immunotherapy,
• 46:46probably because they have
• 46:48a lot of heterogeneity,
• 46:50and this is a key
• 46:51for many cancers to respond
• 46:53to these immune treatments.
• 46:57So in twenty twenty two,
• 46:59he was treated with seven
• 47:00cycles of pembrolizumab.
• 47:02Unfortunately,
• 47:03he had
• 47:05autoimmune
• 47:05hepatitis.
• 47:07And any time,
• 47:08as you've probably all seen
• 47:09in your practice, you have
• 47:11a patient
• 47:12who has an immune related
• 47:13side effect,
• 47:15The first thing to do
• 47:16if it's very severe
• 47:18is to give steroids.
• 47:19This will very quickly, in
• 47:21the vast majority of cases,
• 47:23reverse the side effect,
• 47:25but it does mean that
• 47:27you can't restart the immunotherapy
• 47:30until they've
• 47:31tapered their steroid down to
• 47:33the equivalent of ten milligrams
• 47:35of prednisone a day.
• 47:39In twenty twenty four, he
• 47:40was unable to restart the
• 47:42immunotherapy,
• 47:43but he had still fairly
• 47:45stable disease
• 47:46probably because of the immunotherapy
• 47:48that he's had all that
• 47:49time before.
• 47:51And he started pazopanib, which
• 47:53is what we call a
• 47:54targeted therapy.
• 47:56It goes after it's a
• 47:57tyrosine kinase inhibitor
• 48:00that goes after some of
• 48:01the enzymes that we think
• 48:03will promote cancer growth.
• 48:06Again, I won't spend too
• 48:08much time on this slide
• 48:09that doctor Alino put together,
• 48:12but you can see there
• 48:13are many ongoing clinical trials
• 48:16that we use now or
• 48:18that are being used now
• 48:20for immunotherapy.
• 48:22We just closed one that
• 48:23we had here, but we
• 48:25we will have others
• 48:27that will open either in
• 48:28our sarcoma group or in
• 48:30what we call our phase
• 48:32one early trials group.
• 48:35So I'm actually gonna
• 48:37end the talk there. I
• 48:38don't know, doctor Laditch or
• 48:40doctor Lee, if you have
• 48:41any closing comments.
• 48:45I I'm still here. I
• 48:46think doctor Lee, had to
• 48:48leave.
• 48:49I think this has been
• 48:50a whirlwind tour, and I
• 48:52think, there's nothing else that
• 48:53I can add that would
• 48:54make this any more glorious
• 48:55than it has been.
• 48:58Thanks, Igor. And,
• 49:00if any of you
• 49:02want to,
• 49:04refer a patient,
• 49:05then feel free to
• 49:08contact us. We're all on
• 49:09the Yale
• 49:10email,
• 49:12and in Epic as well.
• 49:15I'll just see if there
• 49:16are any
• 49:17questions at this time.
• 49:27We don't see any.
• 49:30So, Emily,
• 49:34are you still on the
• 49:34line?