Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When and how do we do cytoreduction in CLL?
Cytoreduction is almost never needed in CLL just for the sake of lowering the number. Rare case reports exist of leukostasis with WBC counts over 700k, but these are exceptions. If there are leukostasis symptoms with lower WBC counts then the diagnosis of CLL should be questioned. Having said that, ...
How do you manage hypoxia induced by belzutifan?
Hypoxia is an on-target adverse effect (AE) of belzutifan. All-grade hypoxia was reported in 14.5% of patients (10.5 %, grade 3 and above) in the LITESPARK-005 trial (Choueiri et al., PMID 39167807). Discontinuation of belzutifan due to hypoxia was <1%. Of note, patients with hypoxia (<92% of oxygen...
What group of early pancreatic cancer patients, such as pT1a, can be excluded from adjuvant chemotherapy post resection?
Short answer is none - all patients who have undergone surgery for pancreatic cancer benefit from adjuvant chemotherapy, as long as they can tolerate it.But to be a bit more detailed: Both the Neoptolemos, ESPAC-4 adjuvant trial of gem+cap, and the Conroy PRODIGE 24–ACCORD adjuvant trial of FOLFIRIN...
Is there any role for palliative radiation in patients who are intubated due to malignant airway obstruction?
The literature is limited, but this small series showed about 1/4 of patients can have reversal of intubation.If the patient/family is interested in attempting, it occasionally works, but my own experience is less successful than 1/4. It is unlikely to worsen the situation, so after explaining that ...
How would you treat metastatic pure tubulocystic renal cell cancer?
Tubulocystic renal cell carcinoma (tcRCC) is a very rare diagnosis--particularly metastatic tcRCC. To my knowledge, there are no clinical trials that have reported on these patients even in the basket non-clear cell RCC trials such as ASPEN (Armstrong et al., PMID 26794930) and ESPN (Tannir et al., ...
What would be your approach in a patient who presented with a solitary brain metastasis that resolved after chemo without local therapy?
While I have not had this happen with my patients receiving chemotherapy alone, in the era of targeted therapies for oncogenic driver mutated NSCLC, we have had some great intracranial response rates with systemic alone, and for these, I have held off SRS to evaluate response. In someone with a comp...
How do you manage IgM related peripheral neuropathy?
First things first, let's make sure it's IgM related. In patients with precursor disease (MGUS or smoldering) and neuropathy, I check B12, HbA1c, TSH, free T4, hepatitis B surface Ag, hepatitis B total core Ab, hepatitis C antibody, and cryoglobulins. In patients with specific risk factors, I check ...
Is there any benefit to using desmopressin over vWF replacement therapy for vWD?
For mild type 1 and 2A, we do offer DDAVP testing and use. It was a much more useful drug when it was widely available as a nasal spray. It still has its place, but with patients whose level of VWF is <20% baseline, we have a lot of treatment failures and end up using factor.
In light of ARASENS presented at GU ASCO 2022, how do you approach treatment of de novo metastatic hormone sensitive prostate cancer?
There are multiple factors that go into treatment decisions for men with mHSPC, but two of the most important are volume of disease and de novo vs relapsed disease (i.e. prior local therapy). Volume of disease is one of the major factors for deciding on the benefits of docetaxel, with very limited b...
Is it reasonable to extrapolate data from Glioblastoma and discuss Tumor Treating Fields in patients with Grade 4, IDH Mutant, astrocytomas?
While more than 90% of Grade 4 gliomas are IDH wildtype tumors (GBMs), this question does come up occasionally. Since I have no personal experience with TTF, I asked my collaborator Chirag Patel, MD, a neuro-oncologist at MDACC who regularly uses TTF in his patients, to provide his opinion. So pleas...