Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What "adjuvant" therapy would you consider in patients with gallbladder cancer with liver metastases that are resected upfront?
The scenario is that of already metastatic disease. Adjuvant therapy does not apply. The only choice is patience, hoping for no recurrence. While knowing recurrence is definite, would wait to treat when recurrence occurs. Close monitoring and support would be best!
How would you approach the primary treatment of a rapidly growing uterine carcinosarcoma with local extension through the anterior abdominal wall?
This patient needs multimodal therapy - surgical resection is a mainstay of treatment followed by adjuvant therapy (most likely chemotherapy +/- vaginal brachytherapy). In terms of chemotherapy agents - up front adjuvant treatment is usually carboplatin/paclitaxel or ifosfamide/paclitaxel. I would p...
What is your approach to BK hemorrhagic cystitis not responding to cidofovir?
BK hemorrhagic cystitis can range from completely asymptomatic infection (with positive BK viremia and viruria by PCR) or grade 0 to massive macroscopic hematuria requiring instrumentation for clot evacuation and urinary obstruction requiring bilateral nephrostomy tubes for urine diversion (grade 4)...
How would you treat a patient with bilateral synchronous breast cancers and evidence of metastatic disease on imaging when one breast has a triple negative cancer and the other breast has a ER/PR negative HER2+ cancer?
Herceptin, perjeta, and taxol
For a patient with PE undergoing procedures like port placement in the first month, how do you manage anticoagulation?
Due to their convenience, efficacy, and safety, I think direct oral anticoagulants (DOC) are the agents of choice for most cases of PE, DVT, or chronic prophylaxis. As per the package insert for Apixaban, for moderate or high risk invasive procedures, stop 48 hrs in advance, and for low risk, stop 2...
How do you approach treatment of a grade 4 IDH-mutant astrocytoma, a diagnosis now distinct from glioblastoma according to the 2021 WHO Classification for CNS Tumors?
This is an excellent question. The short answer is that until we have more data on this new entity, I would treat an IDH mutant (mt) grade 4 astrocytoma as I would have prior to the 2021 WHO revision, that is to say, with concurrent chemoradiation therapy and adjuvant Temodar for 6 cycles (or a clin...
Which patients with acute promyelocytic leukemia do you consider maintenance after completing consolidation?
Before we address the role of maintenance in APL, several principles are important to note. First, APL is now a highly curable disease with contemporary therapeutic strategies. Second, we now divide patients into low-risk and high-risk based solely on the presenting WBC (< or =10,000/uL vs >10,000/u...
How would you treat a patient with active lupus nephritis (class 3/4) who requires PD-1 immunotherapy for refractory metastatic renal cell carcinoma?
This is a complex question and there is a paucity of data to address it. The critical issues are of timing (new onset or existing nephritis, disease activity) and treatment regimen. Given that oncologists will not use checkpoint inhibitors on patients requiring more than 10 mg of prednisone at base...
Would you consider adding durvalumab to second-line chemotherapy for cholangiocarcinoma which progressed on gem/cis alone?
Yes. Data is needed, however, a scaffold approach maintaining durvalumab and adding different chemotherapies like NIFTY or FOLFOX as walls to the building frame of immunotherapy is appropriate and justified.
What treatment would you recommend for a patient with recurrent oligometastatic abdominal leiomyosarcoma, with two liver lesions?
I would ask for needle ablation. Leiomyosarcoma is unusual among cancers in that serial oligometastatic recurrence is not uncommon. These people can be managed with serial destructive therapy - resection, needle ablation, or radiosurgery. I have met people with LMS who have had many resections and a...