ESMO-EURACAN management and treatment adapted recommendations in the COVID-19 era: Sarcomas

• Suspicion of sarcoma or newly diagnosed intermediate-/high-grade sarcoma
• Post-operative unstable clinical scenario (e.g. haematoma, infection, other surgical complications)
• Relapse detected at follow-up

• Initiation of systemic treatment for advanced sarcomas
• Visit for treatment administration and management of toxicities/side effects – Convert as many visits as possible to telemedicine visits. Intensify safety monitoring for those patients on oral chemotherapy or targeted agents

• Newly diagnosed low-grade sarcoma
• Operable metastatic sarcoma (e.g. single lung metastasis, >6-month relapse)
• Post-operative patients with no complications
• Follow-up for patients with suspicions of relapse or at high risk of relapse

• Asymptomatic newly diagnosed mesenchymal tumour of intermediate malignancy (i.e. atypical lipomatous tumour of the extremities/trunk wall, classic dermatofibrosarcoma protuberans, desmoid tumour, tenosynovial giant cell tumour [TGCT], giant cell tumour of the bone [GCTB])
• Asymptomatic very low-risk gastrointestinal stromal tumour (GIST), as defined by current guidelines
• Psychological support visits (convert to telemedicine)
• Negative follow-up: refer to telemedicine

• Primary tumour:
  • Diagnostic imaging (MRI/CT scan of the affected area, whole-body CT scan) in subjects with a suspicion of sarcoma (unexplained deep mass of soft tissues, or with a superficial lesion of soft tissues having a diameter of >5 cm; any suspected malignant bone lesion; any suspected soft tissue mass of the gastrointestinal tract)
  • Image-guided or clinically guided biopsy and pathology assessment to confirm diagnosis
• Relapsed tumour:
  • Diagnostic imaging (MRI, whole-body CT scan) in subjects with clinical evidence/suspect of locoregional and/or metastatic relapse
  • Image-guided or clinically guided biopsy to rule out metastatic relapse
  • Echocardiograms in patients with indication to anthracyclines
• Monitoring of active treatment response: restaging studies (MRI, CT scan) – Consider the possibility of a delay or lengthened intervals

• Primary tumour:
  • Asymptomatic pure fatty tumour of the extremities or trunk wall of any size
  • Superficial soft tissue tumours <5 cm
  • Submucosal small nodules of the stomach
  • Bony lesions without clear evidence of malignancy
• Follow-up of primary, completely resected sarcomas: imaging, restaging studies, echocardiograms and ECGs can be delayed or done at lengthened intervals – Implement telemedicine follow-up
• Follow-up of relapsed sarcoma adequately controlled after the end of a medical anticancer treatment: imaging, restaging studies, echocardiograms and ECGs – Implement telemedicine follow-up

• Surgery of primary localised resectable high-risk STS – After multidisciplinary tumour board discussion, consider starting neoadjuvant/preoperative RT, as defined by current guidelines
• Recurrent high-risk sarcoma
• High-risk GIST not amenable to neoadjuvant imatinib and symptomatic GIST of any size not amenable to neoadjuvant imatinib
• Ewing sarcoma/osteosarcoma/rhabdomyosarcoma
• Surgical complications of any type

• Discordant biopsies likely to be malignant

• Surgery of primary localised resectable intermediate-risk STS – After multidisciplinary tumour board discussion, consider starting neoadjuvant/preoperative RT, as defined by current guidelines
• Recurrent intermediate-risk sarcoma
• Intermediate GIST not amenable to neoadjuvant imatinib
• All other bony malignancies
• Resection of isolated metastasis in oligometastatic patients – A short period of active surveillance could be considered

• Discordant biopsies likely to be benign
• Surgery of primary localised low-risk sarcoma or mesenchymal tumour of intermediate malignancy (i.e. atypical lipomatous tumour of the extremities/trunk wall, classic dermatofibrosarcoma protuberans [DFSP], TGCT, GCTB)
• Recurrent low-grade sarcoma or mesenchymal tumour of intermediate malignancy
• Asymptomatic low-risk GIST at any site and very low-risk GIST, as defined by current guidelines

• Neoadjuvant/adjuvant RT for high-/intermediate-risk STS – Use of hypofractionated regimens should be considered to reduce hospital visits
• Patients already on radiation treatment
• Acute spinal cord compression, symptomatic brain metastases or any urgent palliative RT

• Palliative treatment of bleeding/painful inoperable mass, when control of symptoms cannot be achieved pharmacologically

• Neoadjuvant/adjuvant RT for low-risk STS – Use of hypofractionated regimens should be considered to reduce hospital visits
• Stereotactic treatment of isolated metastasis – A short period of active surveillance could be considered

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• Neoadjuvant and adjuvant chemotherapy for osteosarcoma, Ewing sarcoma, paediatric-type rhabdomyosarcoma, as defined by current guidelines
• Neoadjuvant and adjuvant imatinib for primary localised high-risk GIST, as defined by current guidelines
• Neoadjuvant/cytoreductive anthracycline-based chemotherapy in locally advanced STS in which tumour shrinkage could enable conservative surgical resection
• Continuation of treatment in the context of a clinical trial, provided patient benefit outweighs the risk, with possible adaptation of procedures without affecting patient safety and study conduct – Regulatory agencies and sponsors may provide guidance on rules on study conduct during the pandemics

• In high-risk primary localised STS, if anthracycline-based neoadjuvant chemotherapy is considered, the COVID-19-related additional risk should be factored into the decision-making process

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• Initiation of imatinib, sunitinib, regorafenib, in first-, second-, third-line treatment in GIST patients, as defined by current guidelines
• Continuation of treatment in the context of a clinical trial, provided patient benefit outweighs the risk, with possible adaptation of procedures without affecting patient safety and study conduct – Regulatory agencies and sponsors may provide guidance on rules on study conduct during the pandemics

• First- or further-line treatment for the advanced disease setting (chemotherapy or targeted agents), when therapy may provide clinical benefit and impact on outcome, taking into account the histological subtype as defined by current guidelines, and factoring the COVID-19-related additional risk

• Consider, discussing case by case, inclusion in a clinical trial, provided patient benefits outweigh risks, with possible adaptation of procedures without affecting patient safety and study conduct

• In asymptomatic, oligo-symptomatic and indolent tumours, systemic treatments can be postponed, and new assessment planned in a short time
• If clinically asymptomatic, follow-up imaging, restaging studies, echocardiograms and ECGs can be delayed or performed at lengthened intervals