William D. Tap, MD: Before we get into more metastatic disease, what about the role of people who have oligometastatic disease on presentation regarding pulmonary metastasectomies or the things you do? Do you try to clear a patient of disease if possible, in the primary site and other sites? What are the thoughts on that?

Richard F. Riedel, MD: I think oligometastatic disease is complicated, and you can have a patient who presents de novo with oligometastatic disease or you can have a patient who has had their primary site addressed and then they develop oligometastatic disease at some point in the future. To me, those are 2 different scenarios. For a patient who presents with oligometastatic disease de novo and their primary site hasn’t been addressed, I think of the comments that were made earlier. A multimodality approach is certainly reasonable. That would be a situation in which I would consider chemotherapy and then after chemotherapy, resecting, if possible, the oligometastatic disease. For a patient who presents separately, let’s say a couple years after the primary site is addressed, I would treat that with surgery alone. But I think it’s certainly a patient population where, for the right patient, being aggressive and rendering them with no evidence of disease has potential for long-term benefit.

William D. Tap, MD: Does everyone take the same approach? If you can make a patient disease free, do you use that?

Victor M. Villalobos, MD, PhD: It’s all the biology, right? If this thing is blowing up and the tumors are growing quite quickly, I would not put them through a surgery. I think we need to figure out whether we can get control, because otherwise you’re playing whack-a-mole. You take one out and something else pops up quickly. We all have these patients. They have metastatic disease that pops up once a year, once every 2 years. You take it out and they’re trucking along for many, many years with just taking out a couple of sites with surgery and without even receiving any systemic therapy. They do quite well. But we need to be able to distinguish those from patients who actually are going to really have aggressive disease and are not going to benefit from surgery.

Kristen N. Ganjoo, MD: But putting patients through surgery every 6 months for a pulmonary nodule doesn’t make any sense, so we’ve been doing a lot of ablations, microwave ablations, cryoablations, and maybe a little bit of focused radiation. Patients have been doing really well. I have patients 5 or 10 years later where every now and then, we just zap a little thing. That’s also an option for those patients.

William D. Tap, MD: I agree, and that includes your disease management team always being engaged throughout care. Even when you’re really pushing chemotherapy, there are times to really engage them and ask what procedures may be available, what the cost of the procedure is, what the cost in the sense of what patients go through is, what the timing is, what the goal of the procedure is.

Jonathan C. Trent, MD, PhD: I think there’s an aspect of the biology, to add on to Victor’s statement, and that’s the chemosensitivity of the tumor. When we see a patient with oligometastatic disease, it’s metastatic, and so we generally, especially if there’s a fast growth rate or the metastases have shown up in less than a year, would consider chemotherapy with doxorubicin plus olaratumab, based on the data that you’ve published; doxorubicin/ifosfamide; or a very compelling phase I clinical trial of doxorubicin plus ifosfamide plus olaratumab.

William D. Tap, MD: Yes, I think these are all emerging data.

Transcript Edited for Clarity