DTRF Annual Patient Meeting September 22, Breelyn A. Wilky, MD. Assistant Professor, Sarcoma Program

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1 DTRF Annual Patient Meeting September 22, 2018 Breelyn A. Wilky, MD Assistant Professor, Sarcoma Program 1

2 2 1. I have a desmoid tumor. Do I have cancer? Do I have sarcoma?

3 Tumor vs. cancer Growth of abnormal, mutant cells Neoplasm Genetic mutation Multiple mutations Metastasis CANCER 3

4 What is a desmoid? Genetic mutation (beta-catenin or APC) Desmoid tumor Mutant but mostly normal appearing fibroblasts Local mass/tumor Benign (no metastasis) Desmoids are benign, non-metastasizing fibroblastic neoplasms Normal fibroblasts Multiple mutations (p53 etc) X Fibrosarcoma Very bizarre fibroblasts Malignant Potential for metastasis Cancer (sarcoma) 4

5 5 2. What triggers desmoid growth or development?

6 Factors that can impact desmoid tumor development and/or progression Surgery or trauma (scar desmoids), ~30% Hormone exposure (pregnancy ~8-18% 1,2 ), OCP/fertility treatments/hormone replacement therapy Foreign bodies that cause inflammation (silicone implants, bullet fragments) What about diet? (Soy?) 1 case report of desmoid influence by soy phytoestrogens 3 unless clear association with estrogen probably not helpful Genetic factors (inherited APC mutations in familial adenomatous polyposis), 10-20% of FAP patients will develop desmoids Robinson et al, Cancers (Basel), Rocha et al, Ann Surg Oncol, 2008) 3. Thanopoulou et al, Ann Oncol Gurbuz et al, Gut 1994

7 Does sugar feed cancer (and desmoids)? Sugar/carb-free diets is NOT a good idea to try to limit growth of tumor cells - Why? 7

8 Does sugar feed cancer (and desmoids)? Sugar/carb-free diets is NOT likely to limit growth of tumor cells - Why? Avoid obesity risk for cancer growth, pro-estrogen activities High processed sugar diets are not good for general nutrition But no-carb diets lead to additional stress on kidneys, weight loss, fatigue bad especially if on chemotherapy 8

9 9 3. What are my chances of desmoid recurrence?

10 Desmoid recurrence associated with pregnancy 92 women from multiple institutions Overall, good outcomes with pregnancy-related desmoids ~10% chance of spontaneous regression after pregnancy Repeat pregnancies, 27% progressed Fiore et al, Ann Surg,

11 Risk factors for desmoid recurrence GOOD RISK Chest wall or abdominal wall location History of hormone exposure Older patients Smaller desmoids NOT SO GOOD RISK Extremity or inside abdominal cavity location Involvement of organs, blood vessels, nerves FAP associated Younger patients Bigger desmoids (> 7 cm) Multiple recurrences Takehome and disclaimers There are exceptions to all of these observations Outcomes vary between different series of patients Numbers and percentages are not absolute Decisions regarding treatment (or not) need to be made with desmoid-experienced physician(s) who know your case the best Crago et al, Ann Surg, 2013; Salas et al, JCO, 2011; Mankin et al, J Surg Oncol, 2010; Huang et al, J Surg Oncol

12 The dream biomarker : A set of criteria that could predict Chances of growth? Response to treatment? BEST treatment? Your desmoid is likely to burn out and we can just observe You desmoid has a very good chance of cure, but the best way to induce that is chemotherapy (or targeted therapy) Your desmoid is likely to be cured with surgery alone 12

13 Image quora.com; Lazar et al, Am J Pathol Genetic Mutations and Desmoid Prognosis β-catenin (95% sporadic desmoids) APC (inherited desmoids, a few sporadic) S45F T41A S45P always on Increased risk of recurrence with S45F relative to T41A (and probably S45P) S45F present in 29% of desmoids in this series (others ranging from 9-45%) HR 4.28 [95% CI , p= ) Several follow up papers, most with small numbers some confirmed, some did not NOT recommended for treatment decisions yet

14 Mutation status and response to treatment Large dataset of 200+ desmoid patients across three institutions Final stages results for ASCO 2019 Large numbers of patients treated with hormonal therapies, chemotherapy and targeted therapy Can your particular mutation with/without clinical features predict Recurrence? Length of time before treatment required? Best treatment? Chemo vs. hormonal? 14

15 Treatment Response rate Durability Notes Reference Observation ~20-30% 50% progression-free at 5 years Surgery alone 16-39% recurrence rates Requirement for clear margins is controversial Avoid disfiguring, highly morbid surgical resections due to high recurrences 1- Bonvalot, Ann Surg Oncol Fiore et al, Ann Surg Oncol 2009 multiple Radiation ~80% local control at 5 years Consider risk of long-term side effects including second cancers 3 Nuyttens et al, Cancer Keus et al, Ann Oncol 2013 Tamoxifen/ sulindac 15-20% shrinkage 25-30% symptom improvement and stabilization Benefit for FAP and sporadic 5. Brooks et al, Eur J Cancer, Hansmann et al, Cancer 2004 Imatinib ~80% response or stability 50-60% progression-free at 2-3 years? Better for sporadic vs. FAP? 7. Chugh et al, Clin Cancer Res Kasper et al, Eur J Cancer Penel et al, Ann Oncol 2011 Sorafenib 25-35% response 70% stable disease 70% symptom improvement Still early for durability of response in Phase 3 Probably not as good for FAP 10. Gounder et al, Clin Cancer Res 2011 Pazopanib 37% response 59% stable disease 86% > 6 months More side effects Long term data?? FAP vs. sporadic 11. Toulmonde et al, ASCO 2018, #11501 Liposomal doxorubicin 36% shrinkage 58% stability 92% clinical benefit Median 14 months Ongoing shrinkage after stopping chemo?fap vs. sporadic 12. Constantinidou et al, Eur J Cancer 2009 Methotrexate/ vinblastine 25% response % clinical benefit 30% progressed on or after therapy, median 10 months Long-term treatment (weekly, at least one year) Effective for FAP (intraabdominal desmoids) 13. Azzarelli et al, Cancer Skapek et al, JCO Skapek et al, JCO Dileo et al, JCO Palassini et al, Cancer J 2017 Doxorubicin/ dacarbazine 66% response 78% progression-free months after treatment High toxicity Effective for FAP (intraabdominal desmoids) 18. Patel et al, Cancer

16 16 4. How do I pick the treatment that is right for me? How often do I need scans?

17 Choosing a treatment or not Symptoms Location Risk to surrounding structures and organs Growth pattern over time Obvious estrogen exposure (pregnancy) Personal preferences (oral drugs vs. IV, particular side effect profiles) Other medical conditions Anxiety over doing nothing How long is acceptable to wait for a response? Can shrinkage or necrosis create a more definitive option? (surgery, electroporation?) What is the expected function or appearance after my desmoid surgery? Am I a candidate for any clinical trials? 17

18 General recommendations (my opinion!) Always consider the watch and wait approach particularly if minimal symptoms up to 20-30% of desmoids will resolve on their own Scans if not easily palpable or visible every 4-6 months depending on location and risk MRI with gadolinium contrast preferable because you can see activity of the desmoid, not just the size changes If you choose treatment Avoid the temptation to rush to a major surgery to get it out Choose the least toxic option based on the need for response Hormonal therapy is likely to stabilize rather than shrink, unless clear hormonal influence While on hormonal or targeted therapy MRIs every 3-4 months On chemotherapy, MRIs every 2 months 18

19 Thank you and have a great meeting! Questions? Breelyn Wilky, MD b.wilky@med.miami.edu (until Nov. 1) 19