Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach an adult patient >50 years old with an intermediate risk extremity T2N0 fusion neg rhabdomyosarcoma who is progressing on neoadjuvant chemotherapy with VAC?
In the event of disease progression on chemotherapy, it would be advisable to re-examine the pathology of the patient to determine whether the patient has pleomorphic rhabdomyosarcoma, which is a subtype of adult rhabdomyosarcoma. If this is the case, treatment should follow the NCCN guideline for h...
When do you consider performing a diagnostic laparoscopy before neoadjuvant chemotherapy in pancreatic adenocarcinoma patients?
We recommend diagnostic laparoscopy in any patient that is considered a potential resectable candidate in the future. This is especially true for patients who have locally advanced disease, large tumors, elevated CA19-9, lymph node involvement, or tail of pancreas cancer. Diagnostic laparoscopy can ...
Is there a role for radiotherapy to the primary in high volume metastatic prostate cancer with well controlled disease on ADT?
Yes, for some patients. Recent evidence supports an emerging role for prostate RT in the de novo high volume mHSPC population with the goal of preventing serious and symptomatic events from local disease progression. A 2023 update of STAMPEDE arm H demonstrated a significant reduction in the 5-year ...
Do you recommend retreatment with an immune checkpoint inhibitor in a patient with a history of immune checkpoint inhibitor-related AKI that resolved with holding the immune checkpoint inhibitor and a glucocorticoid taper?
Have to use clinical judgment. On the one hand, was immunotherapy effective against the cancer? On the other hand, how severe was the AKI? If you decide to restart immunotherapy, then close monitoring is needed, regardless of what the case series say about rechallenge's safety (or not).
How would you treat a patient with metastatic urothelial carcinoma with early progression on maintenance immunotherapy?
It would depend on the clinical scenario, specifically the disease volume, degree of progression, and whether the patient is deriving clinical benefit despite radiographic progression. Significant early progression in a patient with high disease volume/symptoms is a poor prognostic indicator and we ...
How do you approach diagnosis and treatment of HLH/MAS following CAR T-cell therapy?
I maintain that immune effector cell associated hyperinflammatory syndrome is NOT HLH. Most patients post CAR-T cell therapy fulfill the criteria for HLH even if they don’t have hyperinflammatory syndrome, so it makes diagnosis very challenging. Many patients with this “HLH-like” hyperinflammatory s...
When do you feel comfortable adding bevacizumab to a BRAF-WT, KRAS-mutated colon cancer patient with previously hemorrhagic brain mets that responded to radiation?
Completely agree with Dr. @Dr. First Last. Colorectal cancer patients with brain metastatic disease are rare (a recent systemic review reported incidence of about 2.1%) (Müller et al., PMID 33669974) so data for this specific population is limited. However, there is a recent meta-analysis of bevaciz...
How do you approach patients with early stage resected melanoma (Stage IIA) for adjuvant treatment?
The current guidelines do not recommend adjuvant treatment for patients with stage I/IIA disease outside the setting of a clinical trial. Major trials including the KEYNOTE-054 and CheckMate 238 have excluded patients with early stage I/IIA disease. However, in patients with stage IIB/IIC disease ad...
How would you approach a patient with clinical T3N1 anorectal malignant melanoma referred by a surgeon for neoadjuvant therapy?
Anorectal malignant melanoma is quite rare and only <1 percent of all anorectal cancer are mucosal melanoma (Cagir et al., PMID 10496563) Patients with newly diagnosed anorectal malignant melanoma should undergo HIV screening since HIV infection is considered to be one of the main risk factors (Cagi...
What is your approach to systemic treatment of de novo metastatic hormone-sensitive prostate ductal adenocarcinoma with lung only metastases?
Nearly all patients with mHSPC/mCSPC deserve combination therapy based on multiple phase III clinical trials. There are very few exceptions to this. Even frail patients should be considered for intensified therapy since the published data suggests minimal to no worsening in HRQoL over ADT monotherap...