Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach treatment of a patient with recurrent choroid plexus papilloma with intraventricular dissemination?
The management of choroid plexus tumors starts with diversion of the CSF flow, especially in this patient with a recurrence in the 4th ventricle. A gross tumor resection (GTR) is the most significant prognostic factor, but in this patient, it might not be feasible due to the dissemination in the lef...
Would you withhold adjuvant FOLFOX in stage III colon cancer if Signatera circulating tumor DNA testing is negative?
No, not yet. GALAXY data (Kotani et al., PMID 36646802) suggest that adjuvant chemo does not benefit the ctDNA neg population, but the median follow-up is 16.74 months. If the longer-term data shows the same, you can make a case for de-escalation. For now, I would offer adjuvant FOLFOX to all resect...
Are there any concerns regarding side effects in changing from denosumab to zolendronic acid or vice versa?
In patients with advanced solid tumors and bone metastases, the anti-resorptive agents, zoledronic acid (ZA) or denosumab (D) are administered to prevent skeletal related events (SREs). The key toxicity of concern is medication-related osteonecrosis of the jaw (MRONJ). While patient and oral health ...
Would you recommend radiation to a painful rib fracture in a patient with multiple myeloma on systemic therapy with ongoing response to treatment?
It depends if it’s a newly diagnosed MM setting versus relapsed MM setting with a rib fracture. Some possible scenarios: For the ND setting, systemic therapy with adequate pain management early on is preferred. For relapsed setting, if the rib fracture heralded the relapse then systemic therapy/pai...
How would you manage primary breast osteosarcoma?
Osteosarcoma of the breast is a rare and highly aggressive tumor, accounting for less than 1% of all primary breast malignancies. Due to its infrequent occurrence, there is a lack of prospective studies to determine the best treatment approach and most publications are case reports. Instead of focus...
How do you approach CLL in a patient not currently on treatment who has a solid tumor that requires treatment?
This is a very pertinent question for all of us who treat patients with CLL. Patients with CLL mostly are elderly in age. Second cancer occurs more often in one with CLL than in the population without CLL. These second cancers can be in any organ, but the frequent sites are skin, GI tract, and lung...
How do you interpret discrepancies between MMR testing and MSI testing?
Microsatellites are short repetitive sequences of 1 to 6 base pairs of DNA throughout the genome, mostly in noncoding regions. MSI tumors develop through a distinctive molecular pathway characterized by genetic instability in microsatellite DNA repeat sequences. MSI phenotype occurs due to germline ...
If an average-risk, physically fit, resected stage II colon cancer patient has a positive signatera result (3.2 MTM/ml), would you recommend adjuvant chemotherapy?
A Positive Tumor-informed assay like signatera is not just a prognostic or predictive marker, but more so signifies PERSISTENCE of disease. A stage-2 average risk is not average risk anymore once you have a positive ctDNA result. Maybe in the future, the TNM would be revised to say TNM-MRD (Stage-2 ...
Do you routinely incorporate G-CSF with chemo if you experience neutropenia after the first cycle of chemotherapy?
I am a GI oncologist, but I would say I have two approaches. One is to use prophylactic GCSF or similar agents upfront with cycle 1 with regimens with high rates of myelosuppression (20% or higher rates of neutropenic fever), like FOLFIRINOX or FOLFOXIRI/bevacizumab. The other approach I have is to ...
How would you treat a patient with colon cancer that is dMMR/MSI-high with a solitary liver lesion that is deemed resectable?
In patients with dMMR/MSI metastatic synchronous liver only resectable adenocarcinoma of the colon, synchronous or staged colectomy with liver resection or checkpoint inhibitor immunotherapy followed by synchronous or staged colectomy with liver resection are guideline recommended options. (NCCN Gui...