Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients with metastatic adenocarcinoma of the lung, do you base any treatment decisions on EGFR gene amplification?
There are no proven predictive uses for EGFR amplification in lung cancer. In a negative trial of necitmumab, patients with EGFR amplification had a positive outcome in the EGFR amplified subset, but this was an unplanned analysis and is thus hypothesis generating rather than proven. The hypothesis ...
Is it true that a ferritin above 200 essentially rules out iron deficiency?
No, I do not think that a ferritin >200 ug/L essentially "rules out" iron deficiency. Ferritin is an acute phase reactant and can be elevated in myriad conditions including kidney disease, autoimmune disorders, etc. The transferrin saturation (measure of serum iron/TIBC) is an important marker of ir...
How would you manage a recurrent uterine leiomyosarcoma, now status post secondary cytoreduction, with no gross residual disease?
NCCN guidelines recommend that isolated metastases that have been resected can be considered for treatment with postoperative systemic therapy and/or postoperative external beam RT. Observation is also an acceptable alternative for those who have no evidence of disease on postoperative imaging. This...
What is your approach to management of a subtotally resected pineal parenchymal tumor of intermediate differentiation (CNS WHO grade 2)?
In full disclosure, I have had only one adult patient with PPTID. Although PPTID was first described in 1993, it was not recognized by the WHO until the 2000 classification and represents only 1% of primary central nervous system tumors. Prognosis falls somewhere between that of a pineocytoma and pi...
Does PT/PTT elevation due to severe vitamin K deficiency protect against thrombosis?
Yes, most of us think that vitamin K deficiency increases the risk for bleeding rather than protecting against VTE.
In what situations would immunotherapy alone be appropriate for non-metastatic NSCLC?
Based on our current SOC treatment paradigms for patients who don't have contraindications to definitive treatment options, my short answer would be no. However, few caveats to that no as always. Few examples where I think this would be an appropriate approach based on currently available data. Poor...
How would you approach a stage II colon cancer with negative ctDNA but markedly elevated CEA level post-colectomy?
Thanks for the question. Highly complicated case. Few things matter here. First, what platform is used for ctDNA testing (whether tumor informed or not), and second whether this is T4 or T3 disease. It would be unusual to have high CEA but negative ctDNA in a true minimal residual disease (MRD). For...
What is your preferred way of administering nivolumab/ipilimumab in GI cancers?
Thanks for the question.My preference would be Nivo 3 Q2W & ipi 1 Q6W due to the more favorable toxicity profile seen in the first-line CheckMate-142 trial (Lenz et al., PMID 34637336) compared to CheckMate-142 that was conducted in refractory setting (Overman et al., PMID 29355075). Thanks
How would you approach Grade 2-3 rash due to erlotinib for a patient with metastatic EGFR mutated lung adenocarcinoma that is well controlled for > 5 years and NED by PET?
This is a favorable challenge to approach given the complete response on erlotinib for more than 5 years. In addition to treating the current grade 2-3 rash with a 7-10 day interruption of erlotinib, a short course of oral steroids, and aggressive local skin treatment, I would approach based on seve...
How would you optimally manage a patient with a MDS/MPN overlap syndrome who has both transfusion-dependent anemia and marked thrombocytosis?
Patients with MDS/MPN marked by severe anemia and thrombocytosis likely have the MDS with ring sideroblast with thrombocytosis (MDS-RS-T) subtype and have a high frequency of SF3B1 and JAK2 mutations. Clinically, they resemble a fusion of MDS-RS and essential thrombocythemia (ET), both of which tend...