Oops, you're using an old version of your browser so some of the features on this page may not be displaying properly.

MINIMAL Requirements: Google Chrome 24+Mozilla Firefox 20+Internet Explorer 11Opera 15–18Apple Safari 7SeaMonkey 2.15-2.23

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

The tiered approach of ESMO in delivering a guidance for cancer patients during the COVID-19 pandemic is designed across three levels of priorities, namely: tier 1 (high priority intervention), 2 (medium priority) and 3 (low priority) – defined according to the criteria of the Cancer Care Ontario, Huntsman Cancer Institute and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS), incorporating the information on the value-based prioritisation and clinical cogency of the interventions

  • High priority: Patient's condition is immediately life threatening, clinically unstable, and/or the magnitude of benefit qualifies the intervention as high priority (e.g. significant overall survival [OS] gain and/or substantial improvement in quality of life [QoL]);
  • Medium priority: Patient's situation is non-critical but delay beyond 6 weeks could potentially impact overall outcome and/or the magnitude of benefit qualifies for intermediate priority;
  • Low priority: Patient's condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is non-priority based on the magnitude of benefit (e.g. no survival gain with no change nor reduced QoL).

 

Priorities for Sarcoma patients

Outpatient visit priorities

High Priority

  • 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

High/Medium Priority

  • 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

Medium Priority 

  • 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

 Low Priority

  • 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

Priorities for Sarcoma patients: Diagnostics and imaging

High/Medium Priority

  • 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

 Low Priority

  • 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

Priorities for Sarcoma patients: Surgical Oncology

High Priority

  • 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

High/Medium Priority

  • Discordant biopsies likely to be malignant

Medium Priority 

  • 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

 Low Priority

  • 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

Priorities for Sarcoma patients: Radiation Oncology

High Priority

  • 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

High/Medium Priority

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

Medium Priority 

  • 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

Low Priority 

-

Priorities for Sarcoma patients: Medical Oncology - Primary tumour

High Priority

  • 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

High/Medium Priority

  • 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

Low Priority 

-

Priorities for Sarcoma patients: Medical Oncology - Metastatic disease 

High Priority

  • 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

High/Medium Priority

  • 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

Medium Priority 

  • 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

Low Priority 

  • 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

-----------

General recommendations
  • Chemotherapy schedules may be modified so as to reduce clinical visits (for instance, using 3-weekly dosing instead of weekly dosing for selected agents when appropriate). Patients should receive G-CSF/EPO growth factor and, eventually, antibiotic support so as to minimise neutropaenia, while dexamethasone use should be limited as appropriate to reduce immunosuppression
  • If possible, schedule imaging exams and blood tests near home
  • Implement telemedicine safety monitoring whenever possible
  • All patients must be managed with the best home-based supportive care and enhanced symptom control via telemedicine
  • Bone agents for patients with bone metastases should be delivered with minimal time in the hospital environment
  • Oral systemic therapy (e.g. pazopanib) should be prioritised, whenever possible, and prescribed for multiple courses. The predictable and manageable toxicity of oral systemic therapy should be managed via telemedicine
  • In the metastatic setting, following multidisciplinary tumour board discussion and according to the preference of an individual patient, drug holidays, delayed regimens, de-escalated maintenance regimes as well as best supportive care should be discussed when contemplating later lines of systemic therapy

 

  

List of abbreviations: COVID-19, SARS-cov-2-related disease; CT, computed tomography; ECG, electrocardiogram; EPO, erythropoietin; G-CSF, granulocyte colony-stimulating factor; GIST, gastrointestinal stromal tumour; MRI, magnetic resonance imaging; RT, radiotherapy; STS, soft tissue sarcoma. 

Essential bibliography

    1. Ontario Health, Cancer Care Ontario, “Pandemic Planning Clinical Guideline for Patients with Cancer”, https://www.accc-cancer.org/docs/documents/cancer-program-fundamentals/oh-cco-pandemic-planning-clinical-guideline_final_2020-03-10.pdf  (April 2nd 2020, date last accessed).
    2. European Society for Medical Oncology (ESMO). The ESMO-MCBS Score Card esmo.org https://www.esmo.org/guidelines/esmo-mcbs/esmo-magnitude-of-clinical-benefit-scale  (April 2nd  2020, date last accessed).
    3. World Health Organization. COVID-19: Operational guidance for maintaining essential health services during an outbreak. Available at: https://www.who.int/publications-detail/covid-19-operational-guidance-for-maintaining-essential-health-services-during-an-outbreak (1st April 2020, date last accessed).
    4. Casali PG, Bielack S, Abecassis N, et al. Bone sarcomas: ESMO-PaedCan-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018; 29(Supplement_4):iv79-iv95.
    5. Casali PG, Abecassis N, Bauer S, et al. Gastrointestinal stromal tumours: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018; 29(Supplement_4):iv267.
    6. Casali PG, Abecassis N, Bauer S, et al. Soft tissue and visceral sarcomas: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018; 29(Supplement_4):iv268-iv269.
    7. Society of Surgical Oncology. Resource for management options of sarcoma during COVID19 available at: https://www.surgonc.org/wp-content/uploads/2020/03/Sarcoma-Resource-during-COVID-19-3.30.20.pdf (14th April 2020, date last accessed). 
    8. ASTRO. COVID-19 Recommendations to Radiation Oncology Practices. Available at: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information (1st April 2020, date last accessed).
    9. National comprehensive cancer network. Coronavirus Disease 2019 (COVID-19) Resources for the Cancer Care Community. Available at: https://www.nccn.org/covid-19/ (1st April 2020, date last accessed).

 

This site uses cookies. Some of these cookies are essential, while others help us improve your experience by providing insights into how the site is being used.

For more detailed information on the cookies we use, please check our Privacy Policy.

Customise settings