Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat rapidly growing inflammatory breast cancer, invasive lobular triple negative subtype, after two cycles of neoadjuvant KEYNOTE 522?
This is probably the single most difficult subtype of breast cancer to treat as it tends to be horribly chemo insensitive and molecularly most are actually luminal B and not basal. If growing on the carbon/Taxol/pembro portion of KEYNOTE, I would switch immediately to AC/pembro with a low threshold ...
What is the best second line treatment for a HER2+ metastatic breast cancer treated with frontline paclitaxel and anti-HER2 therapy?
I would use T-DM1 (ado trastuzumab emtansine) in this situation as a second line therapy. T-DM1 has a very favorable side effect profile. Pertuzumab added a survival benefit when combined docetaxel and trastuzumab (median of 15.7 months) though this was a first-line treatment (Swain et al. NEJM 2015...
Would you offer neoadjuvant chemotherapy to high grade T1 urothelial carcinoma in a bladder diverticulum?
Due to anatomical considerations (lack of muscularis propria in the diverticulum wall), clinical staging is very challenging in this setting. That is a great example of how a multi-disciplinary clinic of experts, including Urologists, Med Onc, Rad Onc, Radiologists, and Pathologists, can help get a ...
How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?
The precise pathophysiology of deferiprone associated arthropathy is not well understood but some reports have suggested that there may be some deposition of iron in the synovial membranes, and some subchondral bone damage. Unfortunately, there is no specific treatment for this arthritis, other than...
How do you manage patients with embolic stroke of an undetermined source and a papillary fibroelastoma found on an echocardiogram?
The definitive treatment is surgical, and the only way of knowing for certain that the lesion is a fibroelastoma is to perform surgery and obtain pathology. If a patient is not a candidate for heart surgery, anticoagulation could be tried.
For patients with well differentiated NET whose carcinoid symptoms are controlled on SSAs but have persistently elevated 5HIAA, would you consider adding telotristat for prevention of carcinoid heart disease?
I do not think routinely adding therapies to treat biochemical parameters is appropriate.As many are likely aware, the tryptophan hydroxylase inhibitor telotristat was approved for the treatment of carcinoid syndrome diarrhea based on the TELESTAR study, which demonstrated a statistically significan...
What workup do you perform for elevated B12 levels in an adult who is not taking supplements?
There is no convincing evidence of the harmful effects of elevated serum B12 per se, so I have not vigorously pursued this lab finding. If excessive supplements are consumed, B12 is innocuously excreted in the urine once tissue receptors are saturated. Nonetheless, this question raises some interest...
When is SBRT or hypofractionated radiation appropriate as adjuvant treatment for pancreatic cancer?
There may be a variety of opinions about this question. 33 Gy in 5 looks to be as least as good as 50.4 Gy in 28 in unresectable pancreatic cancer and has had some improved pathologic responses in borderline resectable pancreatic cancer in experienced hands (Hermann et al., PMID 25538019). However, ...
How do you manage mild Type 1 von Willebrand disease undergoing wisdom teeth removal?
This depends on the patient's past personal and family bleeding history with past challenges and on the VWF levels. If past challenges are known and no bleeding has occurred, and if the VWF levels are 30 IU/dL or greater, I would give only EACA p.o. pre and post. Intranasal DDAVP 2 hours prior and 4...
Is there a correlation between spleen size and degree of thrombocytopenia?
In a normal individual, approximately 1/3 of total body platelets are sequestered in the spleen at any given time. As the size of the spleen increases, so too does the proportion of platelets in the spleen increase. This is due to the total volume of the spleen, not just longitudinal measurement. It...