Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your experience with transesophageal lung mass biopsies?
Thoracic lesions requiring FNA in the mediastinum are often best approached with EUS–FNA, as the sedation and airway management are less complex than the EBUS, and the needle does not need to break through cartilage rings to access the lesion. On the other hand, a lung mass would require the needle ...
For a patient with well differentiated de novo triple positive metastatic breast cancer who did not respond to THP, do you sequence all available HER2 targeted options before endocrine therapy?
Endocrine combinations for triple positive breast cancer are honestly a bit understudied. We are starting to get more data in this space, SUMMIT, for example, neratinib + fulvestrant + trastuzumab. I think endocrine based combinations are very interesting and there are likely some tumors that are mo...
Would you consider omitting platinum from neoadjuvant chemotherapy in women > 50 years of age with localized triple negative breast cancer?
I would not use the results cited above from the >50 subgroup (which was just 30% of their study population) of the study from the Tata Memorial Centre to justify omission of carboplatin from the neoadjuvant regimen for TNBC in otherwise healthy patients over 50 with TNBC. There is compelling data f...
How would you treat patient with a stage IV lung adenocarcinoma, an exon 21 p.H835L mutation, high TMB, and negative PD-L1?
EGFR H835L mutation is a rare variant that is in Ex21 of EGFR. Though there is not a lot of data with this particular mutation, the available data suggest that it is a sensitizing mutation with a few case reports suggesting that patients harboring these mutations have a good outcome with EGFR TKI. T...
How would you manage symptomatic superficial vein thrombosis during pregnancy?
The best evidence for the treatment of SVT comes from the CALISTO trial, which endorsed a prophylactic dose of fondaparinux as the treatment of choice. However, the CALISTO trial excluded pregnant women. Because data on the use of fondaparinux in pregnancy remain limited, with some traces of fondapa...
For patients undergoing bladder preservation therapy with trimodal therapy, how do you manage the urinary urgency and frequency during and after treatment?
This can be a difficult problem to manage because I try to avoid treatment interruption if at all possible, which is different from my approach in patients with prostate cancer, where treatment interruption is a safe and effective alternative. In patients with bladder cancer, the first thing I will ...
How long would you recommend a woman with HR+ node-positive breast cancer treated with surgery and chemotherapy during pregnancy can breastfeed, prior to starting adjuvant endocrine therapy?
I agree. This is unfortunately, an area with a lack of data, though in my experience, most women who are treated for breast cancer during pregnancy are still in the middle of therapy (systemic or local) after delivery, so we typically recommend against breastfeeding to avoid delays, particularly wit...
What are your top takeaways from ESMO 2023?
Lung Cancer New first line therapy for advanced EGFR Exon 20 NSCLC patients: The PAPILLION trial [Zhou et al., PMID 37870976] was a Phase 3 clinical trial among patients with locally advanced or metastatic non-small-cell lung cancer (NSCLC) with documented epidermal growth factor receptor (EGFR) ex...
Are there data to support full-dose anticoagulation added to an antiplatelet in recurrent peripheral arterial thrombosis requiring revascularization and stenting?
This question comes up frequently at our institution. I previously consulted with our vascular surgery team who referred me to this trial of Edoxaban with SAPT, trying to avert what may be limb loss if the bypass graft/stent fails. We've often promoted rivaroxaban 2.5 mg po BID per VOYAGER PAD if we...
If a patient diagnosed with seminoma after orchiectomy has margin positive disease noted in the spermatic cord and no overt metastasis on imaging and normal tumor markers, how should this patient be staged?
I believe that the staging would be pT3cN0M0S0 in this case. Margin-positive disease suggests continuous rather than discontinuous spermatic cord invasion. In case this was felt to be discontinuous, NCCN v1.2024 now has a note on staging such patients as pT3 (high-risk stage I) and not as M1 (stage ...