Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred approach to third-line treatment of metastatic HER2 positive esophageal adenocarcinoma after progression on FOLFOX/CAPOX + trastuzumab, then T-DXd?
If the patient's disease is still HER2+, I would strongly consider a clinical trial. Outside of a trial, my preferred 3L therapy would be ramucirumab/paclitaxel. The phase 3 RAINBOW trial (Wilke et al., PMID 25240821) showed a survival benefit of ram/paclitaxel over paclitaxel alone. In this trial, ...
For T cell ALL treated in CR (without transplant), how often do you do BM biopsies as part of surveillance, and for how long?
The role of surveillance bone marrow exams in ALL (either B or T-lineage) is a matter of some debate. Thoughtful clinicians can disagree, but in my practice, I do NOT routinely perform these procedures, instead reserving them for signs or symptoms suspicious for relapse. This is analogous to how the...
How would you manage stable/slightly enlarged pulmonary metastasis from non-seminoma testicular cancer after receiving 3 cycles of BEP, which resulted in a mixed responses on chest CT but normalized AFP?
This is a patient with nonseminomatous germ cell tumor, with presumably pulmonary metastases at start of BEP X 3. I am also assuming that his abdominal CT scan was either normal baseline or it reverted to normal post BEP. The issue now is a mixed response in the lungs, implying some lesions are smal...
Would you consider 177Lu-PSMA-617 for a patient with mCRPC that has neuroendocrine features on biopsy but PSMA-positive disease on PET?
That depends somewhat on the extent of PSMA positive disease. mCRPC is a heterogeneous disease - if the majority of the disease is clearly PSMA positive, then I think it would be reasonable to use PSMA-directed therapy regardless of what the biopsy is demonstrating.
Would you offer curative intent therapy to a patient with a new diagnosis of breast cancer with multiple small lung nodules (<1cm not amenable to biopsy) as the only possible site of metastatic disease?
I will typically give the benefit of the doubt to the patient in planning treatment for a potentially curative treatment. Finding small lung nodules on CT scans can be related to benign, granulomatous, or an old infection and not necessarily due to malignancy. It is important to understand the conte...
Would you prescribe ADT or AR inhibitors for a patient with moderate to severe dementia who has biochemical recurrent, non-metastatic prostate cancer, but otherwise good physical performance status and prognosis >5 years?
I would discuss with their caregivers. They are the ones who have to manage the patient's moderate to severe dementia daily and presumably are acting as the patient's medical power of attorney. Practical consequences to typically routine therapies can be serious. Substantial declines in cognition, m...
How do you approach a cervical node biopsy-proven follicular lymphoma in situ in a symptomatic patient with night sweats and PET findings of low SUV uptake throughout the body?
Follicular lymphoma in situ, aka in situ follicular neoplasm (ISFN) is an uncommon entity, representing an early precursor lesion and better conceived of as premalignant as opposed to a true malignancy, and a pathologic diagnosis of ISFN is not an indication for therapy. Most patients with ISFN will...
How would you approach the adjuvant treatment of a stage IVA adenosarcoma of the ovary?
Adenosarcomas have a benign/low grade epithelial component, unlike carcinosarcoma/sarcomatoid carcinoma. The sarcomatous component is the high grade element driving prognosis, so therapy should be directed a'la sarcoma based on usual predictive factors of age, PS, organ function, etc.
Would you recommend adding a TKI to a pediatric regimen for a AYA B-ALL patient with IKZF1 mutation?
I would not add a TKI to standard chemotherapy in this situation. Background/Rationale: IKZF1 mutations (specifically deletions) are associated with inferior prognosis. Specifically, the prognosis appears to be worst with mutations that lead to loss-of-function (e.g., focal deletions [Beldjord et al...
What advice do you have for the management of nail toxicity associated with pemigatinib and other FGFR inhibitors?
Pan-FGFR inhibitors as a class can cause significant dermatologic toxic effects (including alopecia, dry skin, nail changes, and stomatitis) anywhere in the range of 20% to 45%, depending on the specific agents (Lacouture et al., PMID 33021006, Bétrian et al., PMID 28538953).Lacouture and colleagues...