Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In small cell lung cancer with effusion that is negative on thoracentesis twice, do you assume limited stage disease?
Although we know the sensitivity of a single thoracentesis to detect malignant pleural effusion is fairly low (perhaps 65%), effusions in SCLC can sometimes be reactive - if there is any lung collapse, for example. If otherwise limited stage and multiple attempts have been made to rule out malignant...
In the Nebraska/Mayo transplant protocol for perihilar cholangiocarcinoma, do you ever offer prophylactic biliary drainage/stenting to prevent obstruction post-chemoradiation?
We use an ERCP-placed nasobiliary approach to biliary brachytherapy as part of our pre-transplant CRT regimen for patients with peri-hilar cholangiocarcinoma (Murad et al., PMID 22504095). Our technique is described by Deufel et al., PMID 29776892. Patients with baseline tumor and/or comorbid diseas...
Do you check beta 2 microglobulin in patients with MGUS?
I think this question can be answered in two ways - firstly, from the vantage point of clinical utility, and secondly, from the vantage point of cost-effectiveness. I think the short answer to both is no. For patients with suspected smoldering MM awaiting bone marrow biopsy, PET-CT, wbMRI, etc. I ...
Do you always start treatment for patients who meet diagnostic criteria for multiple myeloma by SLiM criteria alone?
No, I definitely do not always start treatment for patients who meet the so-called myeloma defining events. These are guidelines, like the Pirate Code. Sixty percent plasma cells mean reaching CRAB criteria in 2 years in 95% of patients, greater than one 5 mm MRI abnormality means CRAB criteria in 7...
When patients develop headaches from luspatercept, do they tend to improve over time?
I've seen two common scenarios with this. One is headaches related to hypertension as a result of luspatercept. By treating the hypertension, the headaches often improve. If the headaches are in the absence of hypertension, I do use a low dose beta blocker to see if it helps, and have had some resul...
How would you treat an elderly patient (ECOG 0-1) with locally advanced rectal cancer and synchronous Merkel cell cancer of the extremity requiring adjuvant RT?
Interesting - the flurry of activity came several months after I treated the patient. The patient was not going to get further surgery for either. I choose to treat with definitive CRT (Xeloda) to 54 Gy w VMAT. I treated the Merkel Cell with 30/10 at the same time, presuming the patient would have a...
What clinical or pathologic features would make you more concerned that a new skin SCC is from metastatic disease or a new cutaneous primary?
Histologic examination should reveal an epidermal connection in a primary SCC. If one cannot be found, the pathologist must raise the possibility of a metastatic lesion and state that alternatively could be a portion of primary SCC (epidermal connection may not be included in biopsy sampling). If th...
What chemotherapy backbone would you use with trastuzumab in patients with HER2+ esophagogastric cancer that relapse after perioperative FLOT4?
As with many of these head-scratchers, there's no right answer here. But, I would begin from the starting point that the current standard-of-care for 1st-line treatment of Her2 positive GEJ/gastric cancer is pembrolizumab/trastuzumab and a fluoropyrimidine/platinum doublet, as the question acknowled...
How would you approach a sarcoma that was initially diagnosed as UPS of the distal femur with groin lymph node spread, resected, and found to have an EWSR1-FLI1 fusion diagnostic of Ewing's on NGS?
If this is a primary bone tumor with EWSR1-FLI1 fusion, I would treat it as if it were Ewing sarcoma.