Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In extremely obese patients with spontaneous DVT/PE who have been anticoagulated for > 6 months, do you feel comfortable reducing the DOAC to prophylactic dose or do you prefer continuing full dose indefinite anticoagulation?
According to the ISTH guidelines (Martin et al., PMID 34259389) in patients with a BMI >40 kg/m2 or weighing >120 kg, it is suggested to use the standard doses of apixaban or rivaroxaban for VTE treatment and prevention regardless of BMI and BW. The ISTH did not discuss dose reduction after 6 months...
How long should we treat patients with newly diagnosed myeloma with bisphosphonates or RANKL inhibitors for their myeloma bone disease given recent data?
The excellent context within the question by @Dr. First Last answers 99% of what I was going to say. This is the MAGNOLIA trial that prompted this question:Lund et al., PMID 38622134 This was a randomized trial of 2 versus 4 years of zoledronic acid in myeloma. Of the 30 cases of bone lesions they f...
How are you dosing IVIG following BCMA CAR-T or bispecific antibodies in multiple myeloma?
At our institution, primary prophylaxis is the rule because we forget. All patients on a bispecific get IVIG 0.4 g/kg (ideal body weight) starting day 1 of the second month and this continues while they remain on the BsAb. Each physician/APC team can stop the IVIG if the IgG > 500 and is self-susta...
Do you use FVIII levels to differentiate between DIC and coagulopathy of liver disease?
DIC is a clinical diagnosis that is difficult to establish in the absence of bleeding or thrombosis, particularly in patients with liver disease. I do think that following DIC laboratory markers (FDP, fibrinogen, D-dimer) serially may be helpful as you would not expect them to acutely drop simply be...
How do you optimize a beta thalassemia patient on luspatercept who is interested in becoming pregnant?
Unfortunately, luspatercept is not approved to be used during pregnancy - there is no data available on the safety of the drug during pregnancy. So would say that if the patient is planning a pregnancy, would stop luspatercept at least 3 months prior. It is strongly recommended to optimize iron bala...
What approach do you use when treating adult diffuse gliomas with H3-G34 mutations, now classified into their own category under the 2021 glioma guidelines?
Although DHG H3G34-mutant diffuse gliomas are more commonly associated with pediatric patients, they can occur in young adults as well. In a recent paper describing 17 patients harboring this rare mutation, the median age at diagnosis was 25 years (range: 19–33). All tumors were hemispheric. All cas...
Would you offer consolidative scrotal RT for patients with bilateral testicular lymphoma involvement s/p bilateral orchiectomy and chemotherapy?
I assume you are referring to bilateral scrotal involvement by DLBCL. The initial stage of the disease is also not clear. If both testes have been removed, the risk of involvement with the scrotal sac may be assumed low. However, I would take a good look at the pathology report concerning extratesti...
What induction regimen would you choose for a patient with newly diagnosed multiple myeloma with incidental amyloidosis noted on bone marrow biopsy, but with no end-organ damage as a result of amyloid deposition?
Congo red on a bone marrow is a challenge. The expertise with Congo red is low at most sites in the U.S., hence the sensitivity of the stain in the marrow is 50%. It's worth testing a patient with any Congo red positivity with appropriate cardiac biomarkers, transthoracic ECHOcardiogram, and 24hr ur...
How would you approach treatment of a patient with adenocarcinoma of unknown primary only found in a left supraclavicular lymph node?
Systemic therapy. Palliative RT if necessary
How do you counsel patients with elevated factor VIII levels for their thrombosis risk?
I don't check the factor VIII level as part of a thrombosis workup because the result rarely if ever affects my management of these patients. I would explain to the patient that factor VIII levels are a function of several variables, including age, vascular health (and hence blood pressure, smoking,...