Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage a patient with low risk MDS who achieves transfusion independence with luspatercept but continues to have fatigue?
This is a challenging question and I'm not sure there's clear data to support a practice one way or another. Anecdotally, I have noticed that when using Luspatercept, it seems to improve hemoglobin reliably and therefore lead to less transfusions, but I have not observed a consistent concordant impr...
How would you approach dose modifications and/or frequency of lenalidomide in patients with advanced renal impairment (eGFR <30)?
Great question - comes up a lot in discussion with community providers. The dosing is dependent on what your target dose would be. If normal dosing was 25 mg and CrCl <30 and not on dialysis, then I follow the package insert "15 mg every other day". If the patient tolerates that ok, I increase to 10...
What genetic testing would you consider for recurrent arterial events (cryptogenic strokes, MI) in patients with limited risk factors?
This would be a case-by-case evaluation with additional history, examination and imaging features. I would take a multidisciplinary approach and also consult with hematology and cardiology. I am assuming all other workups are negative. I would probably repeat APLS labs in 6 weeks with lupus anticoa...
In patients with cholangiocarcinoma who qualify for HAIP therapy, would you recommend treating with chemotherapy and immunotherapy?
While HAIP is considered promising (again - 20 years later), no appropriate phase III trial has shown benefit in any diagnosis. Since phase III trials support immunotherapy, that is preferred.
What is the recommended initial treatment for spinal cord compression due to non-Hodgkin lymphoma (e.g. diffuse large B-cell lymphoma)?
The answer depends greatly on clinical circumstances, such as stage of disease, degree of neurological impairment, prior treatment if any, etc. First, I would argue there is seldom a role for surgical intervention ( other then biopsy to establish diagnosis) since lymphomas are uniquely radiosensitiv...
What is your approach to treatment of infection-triggered HLH that does not respond to treatment of the underlying infection?
The algorithm our center follows is to Recognize hyperinflammation (see answer to question above -- in addition to baseline labs, we obtain an infectious disease consult) Look for and treat the trigger. A concern, if the patient is responding, is that we are missing a trigger (HLH does not occur sp...
Do you offer ultra-hypofractionated 5-fraction RT regimens for DCIS s/p lumpectomy?
The premise of this question attempts to "split" DCIS from early-stage invasive disease. When we live in an eternal present-tense, we naturally repeat the mistakes of the past. Again, as for modest hypofractionation, we are not going to see a "separate" clinical trial for pure DCIS in this space. In...
Do you use the same criteria for offering neoadjuvant chemotherapy in a lobular breast cancer as you would in ductal?
HER2+ ILC is uncommon but can be seen in about 5% of ILC cancer cases. A retrospective review by MD Anderson suggested similar outcomes for HER2+ ILC vs IDC. (JCO 2012, ASCO Absract 612) I would confirm the HER2+ and low grade in this case, as that is discordant. As for regular ILC which is usually ...
Would you anticoagulate an SMV thrombosis caused by malignant obstruction in the setting of metastatic colorectal cancer?
Superior Mesenteric Vein Thrombosis is a rare phenomenon, within the category of Splanchnic thrombosis. While portal vein thrombosis is most often associated with cirrhosis (though also seen in many patients without cirrhosis), SMV thrombosis is more commonly seen in the context of either local prov...
Would you anticoagulate an SMV thrombosis caused by malignant obstruction in the setting of metastatic colorectal cancer?
Superior Mesenteric Vein Thrombosis is a rare phenomenon, within the category of Splanchnic thrombosis. While portal vein thrombosis is most often associated with cirrhosis (though also seen in many patients without cirrhosis), SMV thrombosis is more commonly seen in the context of either local prov...