Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider antiphospholipid syndrome to be a contraindication for checkpoint inhibitor immunotherapy?
While there have been several cases of antiphospholipid antibody syndrome (APS) induced by immune checkpoint inhibitor therapy (Gupta et al., PMID 28099367, Tota et al., PMID 34411840, Mintjens-Jager et al., PMID 33224503), I am unaware of any evidence that pre-existing APS contributes to additional...
How would you treat a patient with recurrent DLBCL 15 years after definitive treatment of initial de novo disease with R-CHOP?
As a new primary DLBCL, but with previous exposure to 6 cycles of doxorubicin, I would only give RCHOP x 2, then RCEOP x 4. If interim PET showed a poor response, I would switch to a CAR T-cell therapy as 2L therapy.
Based on the results of SWOG S1801, neoadjuvant vs adjuvant pembrolizumab for resected stage IIIB-IV melanoma, are you starting to recommend neoadjuvant pembro for your patients?
Yes, I now usually would recommend neoadjuvant therapy for melanoma stage 3. If a clinical trial is open, I prefer to enroll patients in it. Patients who have contraindications to immunotherapy are treated with surgery first.
What adjuvant therapy would you offer following adjuvant chemotherapy for a patient with Stage III lung adenocarcinoma with an atypical EGFR mutation such as EGFR L861R?
Mutations at position 861 (most commonly L861Q) have been described, occurring in approximately 2% of all EGFR-mutant patients [Mitsudomi and Yatabe, PMID 19922469]. These mutations are considered partially sensitizing to afatinib based on a post-hoc analysis of LUX-Lung 2, LUX-Lung 3, and LUX-Lung ...
Would you offer local therapy to a patient with GEJ adenocarcinoma with FDG-avid para-aortic node oligometastasis?
I have favored induction systemic therapy and interval re-assessment. If responsive or at least stable disease, I have offered extended field CRT as long as the treatment volume seems reasonable and my perception is that it would be tolerable when assessed in the context of a patient’s performance s...
Do you offer anticoagulation to patients with prior antiphospholipid antibodies detected in pregnancy without a history of pregnancy loss or thrombosis?
I do not know what the risk of pregnancy loss is in a woman without a prior history of VTE or pregnancy loss. I am sure the risk is affected by whether the woman has an underlying rheumatological disease (SLE) and whether she has single positive vs. triple positive LAC. I recommend a baby aspirin on...
For a rectal cancer with questionable T3 or questionable N+ by MRI, can short course radiation be given followed by surgery and the pathology still be interpreted to guide adjuvant chemotherapy?
This is a somewhat common scenario. In these situations, I have strongly favored short course RT followed by immediate surgery such that there is not a sufficient time interval between RT and surgery to allow any significant pathologic response. I think you can be confident in that the pathology aft...
How do you manage grade 3 enterocolitis from 5FU mitomycin and pelvic radiotherapy?
With infection ruled out and CT showing diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field, presumably, it is due to the 5FU/mitomycin. In the few cases I have had, it generally heals 2-3 weeks after counts nadir. Besides supportive care (Imodium, Lomotil, Gas-X, ti...
How would you approach cytopenias 5 weeks after initial dosing in a young patient with MDS treated with Azacitadine as a bridge to transplant?
Bridging with HMA to transplant in MDS patients is a common practice although it did not show improved outcomes. You will definitely have to r/o other potential causes of pancytopenia (i.e., infections, etc). I would repeat a BM A/Bx to make sure that blasts are not increasing (< 20% and preferably ...
Do you recommend adjuvant chemotherapy in a patient with node positive gastric adenocarcinoma with mixed dMMR/MSI histology?
Well, this is certainly a situation where treatment decisions are completely unburdened by data and one could do virtually anything, from observation to immunotherapy plus chemotherapy.A more straightforward version of this scenario is if the patient has a fully resected node-positive dMMR/MSI gastr...