Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When you use selinexor for relapsed/refractory myeloma, with what total weekly dose do you practically start?
The answer is it depends. For most older or more frail adults, I would start at 60 mg weekly. For more robust, 80 mg weekly. More important, is whether I am combining with another anti myeloma agent other than steroids. In that case, I typically stick with 60 mg weekly. This helps not only with non-...
How do you treat colorectal cancer with heterogeneous loss of mismatch repair protein expression?
My approach, broadly, for stage IV (nonsurgical) patients is to try to treat with IO agents, and then address tumors that may not be responding (SBRT, ablation, etc) down the road (presumably those that aren't as sensitive to IO). The other option would be to use something like FOLFOX+checkpoint inh...
How do you integrate surgery in treatment of recurrent tenosynovial giant cell tumors (TGCT) when using Pexidartinib?
This is an interesting question, but one that has little (if any) data to guide management. With recurrent TGCT, the patient presumably already had surgery. It is possible that a good response to pexidartinib may reduce the morbidity of a repeat surgery but the risk of additional recurrence would re...
When and how would you consider utilizing checkpoint inhibitor immunotherapy in EGFR mutated metastatic lung cancer?
I typically reserve checkpoint inhibitors as a last resort treatment option in patients with EGFR mutant non-small cell lung cancer. I have used the IMpower150 regimen on several occasions, though we now have multiple datasets confirming the generally minimal benefit from immunotherapy for patients ...
Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?
IO can affect the muscle in many ways. There is a myasthenia gravis and myositis overlap. I am not sure we know whether it is rhabdomyolysis versus a CK leak vs steroid myopathy vs muscle necrosis due to something else. Did the patient have EMG or muscle biopsy? There is a lot we do not understand a...
What would your approach be for a patient with early stage gastric cancer who declines a gastrectomy?
I would first clarify if less invasive endoscopic or operative strategies such as endoscopic resection (EMR vs ESD) or local resection/partial gastrectomy are appropriate and feasible based on the patient and disease related factors. If not, I’d recommend definitive chemoradiation, 50-50.4 Gy in 25-...
In a patient with otherwise low-risk prostate cancer, does presence of a small component of Grade Group 3 disease up-stage to unfavorable intermediate?
I agree with Dr. @Dr. First Last's response and will just add a couple of additional thoughts. There are many things that go into making a decision about whether treatment is necessary, and what type of treatment is performed. In this case, it's important to consider patient factors (i.e. age, co-mo...
How do you follow up a patient with esophageal adenocarcinoma who is not a surgical candidate after finishing chemoradiation?
I am assuming that this patient has adenocarcinoma and also had definitive dosing radiation (50.4 Gy +) and not neoadjuvant dosing as was used in the CROSS trial (41.4 Gy). If that is the case, you would use the same surveillance as you would after surgery which is H&P every 3-6 mo with labs and sca...
How should you work up calvarium or other osseous lesions when found during the initial staging of a patient with a new diagnosis of NSCLC otherwise non-metastatic?
In general, I try to "prove" metastatic disease to ensure appropriate staging. I have had several situations where a skull or other osseous lesion is suspicious on CT and have tried to assess by PET or NM bone scan - ultimately though, have referred for biopsy and have actually diagnosed several int...
Which chemo regimen, if any, would you use as adjuvant treatment in a young patient with primary malignant thyroid teratoma?
There is no evidence base to guide you here. The term "malignant teratoma" is not particularly helpful here and does not distinguish between benign teratoma, somatic transformation, or active germ cell malignancies. If classic markers AFP and HCG are significantly elevated, that would favor a malign...