Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
What is your preferred first line therapy for metastatic cholangiocarcinoma, if the patient is cisplatin ineligible or cisplatin is unavailable?
While there is a lack of direct comparative trials, the whole development of the platinum drugs suggests oxaliplatin should be equally or more active for GI cancers. I would, therefore, use Gem-Ox, a very active regimen for pancreatic cancer, studied in phase 3 trials. Alternatively, gem-carboplatin...
Would you consider continuing or re-trialing hydroxyurea for sickle cell patients after development of a leg ulcer?
I do not think HU is the cause of leg ulcers, neither does ASJ. Habibi et al., Blood 2023 Most cases of ulcers are multifactorial and studies have also included patients with thrombocytosis (even myeloproliferative disorders!!). Low nitric oxide is part of the cause of leg ulcers in most cases. HU r...
What, if any, role does systemic therapy have in the treatment of HCC amenable to definitive locoregional therapy?
For ablation, TACE and Y90, I traditionally hold back on systemic therapy so that I have something I can use if they develop metastases. Also, sorafenib has been not shown to be effective in the adjuvant setting so I apply that principle here. Bruix et al., PMID 26361969
What is the management strategy for patients who develop AKI and nephrotic range proteinuria secondary to biopsy proven FSGS during immune checkpoint inhibitor therapy?
For glomerulonephritis induced by ICI would recommend rituximab 1 gram for a total dose of 2 doses 2 weeks apart. Based on limited case reports there has been a good response to rituximab with maintained remission of glomerulonephritis and the ability to continue on ICI without relapse. Please refer...
How would you treat an elderly patient with Stage IIA cHL with 3 nodal sites of involvement who has a contraindication to bleomycin?
With the publication of the SWOG Cancer Research Network's collaboration with the National Clinical Trials Network, Protocol S1826 results allow a definitive recommendation of nivolimab plus doxorubicin, vinblastine, and dacarbazine (N-AVD) as the treatment of choice for this patient.
How do you manage severe lenalidomide-associated drug rash in a transplant-eligible patient with multiple myeloma?
A rash with lenalidomide occurs in up to a third of patients exposed, and it's likely that dose corresponds directly with rash severity. While excellent desensitization protocols appear effective (PMID 31400463), most of us want to be able to deal with this with a phone call or text message that inc...
How do you manage severe lenalidomide-associated drug rash in a transplant-eligible patient with multiple myeloma?
A rash with lenalidomide occurs in up to a third of patients exposed, and it's likely that dose corresponds directly with rash severity. While excellent desensitization protocols appear effective (PMID 31400463), most of us want to be able to deal with this with a phone call or text message that inc...