Heroic palliation for sarcoma

[Gfunk6]

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I have a very young adult patient with a large high-grade sarcoma of his extremity with extension into the pelvis. He underwent staging studies which showed a large > 15 cm mass without evidence of mets. He had a massive surgery at our local academic center which involved femoral artery bypass and abdominal wall reconstruction. 18.5 cm, high grade synovial sarcoma with negative margins.

> 2 month delay to XRT start due to wound dehiscence and healing issues. To r/o mets I went ahead and got a PET/CT simulation and . . . it doesn't look good.

He has a very large ~12 cm local recurrence with a couple of abdominal wall mets near the surgical incision sites. Symptomatically, he has pain in R pelvis area probably due in part to bony destruction from recurrence. Obviously, things are very bleak but I'm curious what people would do? Options include:

1. Referral to hospice
2. Send patient for chemo and hope he has a response
3. XRT for palliation (perhaps hypofractionated) to large local recurrence followed by chemo
4. ? ChemoXRT - I will have to discuss this with our local academic sarcoma experts

Input appreciated.

 

[thesauce]

I would not do 4

I'd start with 1, then fall back to 2 plus/minus 3. Of course a discussion in MDC would be worthwhile to see what chemo would be offered.

 

[Cancerdancer]

I would not do 4

I'd start with 1, then fall back to 2 plus/minus 3. Of course a discussion in MDC would be worthwhile to see what chemo would be offered.

Agreed...unfortunately...

 

[medgator]

#1, maybe #3 sans chemo if pain is uncontrolled on narcs

 

[Brim]

I'd do #3 (xrt) to maximize local control / palliation, then on to #1. I'm treating a somewhat similar case now, in fact.

 

[OTN]

My vote is for #3. I've had some success in palliation of sarcoma in situations like this.

 

[bobloblaw]

If the patient is young and has never seen chemotherapy, I would at least discuss the option of palliative chemotherapy with med onc.
Synovial sarcomas can have better response rates to chemotherapy than other histologies - kind of like rhabdomyosarcomas.
Could sequence hypofractionated palliative radiation before or after (or inbetween cycles of) chemo.
Sounds like a very difficult case...

 

[Gfunk6]

Thanks for your input everyone. After talking to academic med onc, rad onc, and surg onc the plan is for hypofractionated XRT to recurrence followed by likely chemo. Further therapy vs. hospice will be dictated by his clinical response and performance status.