Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For cases of foraminal and extraforaminal monophasic synovial sarcoma post excision with note of residual tumor, would your approach be a second look surgery with re-excision or delivery of adjuvant RT with boost to residual disease?
Great (and tough!) question. In the setting of residual disease post-surgery, many studies have shown that even with adjuvant radiation therapy, leaving gross disease behind leads to inferior outcomes. In the setting on non-oncologically excised tumors, I would first have a discussion with the surg...
What is your preferred treatment for CML that presents with thrombocytosis?
In short, I do not change my TKI recommendations for patients with newly diagnosed CML who present with thrombocytosis. Prognostic scores demonstrate that thrombocytopenia is associated with poorer outcomes (Pfirrmann et al., PMID 26416462), but thrombocytosis does not seem to have any specific prog...
In addition to supportive transfusions, do you consider other interventions for symptomatic anemia and thrombocytopenia associated with chronic neutrophilic leukemia?
Assuming the CSF3R mutation that is seen is the T618I mutation, you can consider ruxolitinib. Dao et al., PMID 31880950, reported on a prospective trial of ruxolitinib in 44 patients with CNL or atypical CML. The overall response rate was 35%. However, responses were enriched in patients with CSF3R-...
In addition to supportive transfusions, do you consider other interventions for symptomatic anemia and thrombocytopenia associated with chronic neutrophilic leukemia?
Assuming the CSF3R mutation that is seen is the T618I mutation, you can consider ruxolitinib. Dao et al., PMID 31880950, reported on a prospective trial of ruxolitinib in 44 patients with CNL or atypical CML. The overall response rate was 35%. However, responses were enriched in patients with CSF3R-...
Do you add ADT to RT for a patient with intermediate-risk prostate cancer with discordant Decipher and ArteraAI results?
This will be a long response to try to provide transparency to these tests from what I know as a researcher and clinician. I also clinically see this situation frequently. We have made incredible progress in developing biomarkers in prostate cancer, but it is important to know that no single test is...
Is there a role for extended adjuvant neratinib with pCR after neoadjuvant chemotherapy in triple positive breast cancer?
The benefit of adjuvant neratinib is generally proportional to the residual risk of recurrence following definitive therapy including HER-targeted adjuvant therapy. In the ExteNET study final efficacy report, the absolute difference in overall survival at 5 years was estimated at 9.1% in 295 patient...
How have you used Hedgehog pathway inhibitors as neoadjuvant/adjuvant therapies?
I am presuming that the question is directed towards Basal cell cancer. We don't use Hedgehog pathway inhibitors (HHIs) in an adjuvant setting, but sometimes in the neoadjuvant setting, when the risk of getting a positive margin is high. I prefer alternate-day dosing of vismodegib (less muscle cramp...
What dose constraints do you use when treating gastric MALT or DLBCL with radiation therapy?
Treatment of the entire stomach is recommended for gastric MALT lymphoma. A dose of 24-30 Gy is recommended, generally in 1.5 Gy fractions to limit acute toxicity. I am starting to utilize 24 Gy more frequently though, most studies have used 30 Gy. Gastric MALT tends to be multifocal, is not well vi...
How do you prescribe a steroid taper for radiation and checkpoint inhibitor related pneumonitis?
I subscribe to the philosophy of "hitting hard, tapering slowly" for cases of pneumonitis, either radiation pneumonitis, or checkpoint inhibitor-related pneumonitis (some of those cases probably have mixed origin, with contributions from radiation and/or checkpoint inhibitors). For severely symptoma...
What is your surveillance protocol for patients with common variable immunodeficiency receiving chronic IVIG therapy?
No target IgG level per se- dose/interval should be titrated to clinical condition. In general, trough IgG on treatment should be higher than 500 mg/dL, or 500 mg/dL higher than baseline. Most patients will not be in optimal clinical condition (minimal fatigue, arthralgias, absence of chronic cough,...