Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage a patient with T4N1 duodenal adenocarcinoma by EUS with ampullary invasion that is dMMR?
This is a practical question since Lynch syndrome patients do get upper GI (including duodenal) polyps and cancers. Vos et al., JCO 2021 39.3_suppl.244 The standard of care here would be to do surgery at some point, so any deviation from that would need to be discussed carefully with the patient and...
When do you offer SBRT for a small, slowly growing lung lesion?
I caution ALL radiation oncologists from pulling the trigger on a case like this in a vacuum. Why did I use the word "caution"? It's because we recently studied how often a radiation oncology program is comfortable delivering SBRT w/o histopathological confirmation, and the range was between 0 - 61%...
Would you treat a patient with a pancreatic head mass based on common bile duct brushings suggestive of malignancy, with repeated negative EUS biopsy?
Yes, I would if everything else is consistent with pancreatic cancer.
Are you now using luspatercept as your first choice for anemia management in patients with low-risk MDS otherwise appropriate for EPO initiation, regardless of presence of SF3B1 or ringed sideroblasts?
Only use luspatercept if the patient is transfusion-dependent. FDA approves luspatercept as first-line treatment of anemia in adults with lower-risk MDS (aabb.org). In patients with MDS who are candidates for epo and transfusion independent then epo is still my first choice.
What immunotherapy backbone do you utilize for patients with resectable Stage III melanoma when you offer neoadjuvant therapy?
This is one of the most debated questions in the melanoma community. We personally prefer using single agent anti-PD1 in the neoadjuvant setting based on the results of the SWOG-1801 study. The recently presented data at ESMO 2023 showed a 97% 2-year RFS in patients with complete pathologic response...
What is your preferred third-line therapy for a fit patient with symptomatic, relapsed follicular lymphoma who has failed bendamustine-rituximab and lenalidomide-rituximab?
This sounds like the patient where a CART may make sense. If that's not an option for whatever reason, I may go to bi-specific over say, copanlisib at this point. I suppose if EZH2 mutated, tazamezostat might be an option, but less appealing in a young otherwise healthy person.
How would you treat a patient with T1c HR-, HER2+ breast cancer, stage IV, with involvement of multiple bilateral axillary nodes and no evidence of distant metastasis?
Assuming biopsy proven disease in both axilla, would favor treating with definitive intent with TCHP followed by surgery (nodal surgery extent based on response to chemo) followed by RT.
How do you approach patients with recurrent papillary thyroid cancer following thyroidectomy who now has palpable cervical nodes and underwent neck dissection and RAI?
It would be helpful to know when total thyroidectomy was done and if there was I-131 uptake on pre- and post- I-131 treatment? When was the RAI treatment? Is the thyroglobulin rising? Typically, if this is happening several months after RAI treatment, I would biopsy the node to make sure it is not d...
When would you ever consider lifelong imatinib in adjuvant therapy for GIST?
The risk of recurrence and mutational status are important tumor related factors. Combine that with host factors including risk tolerance and physical drug tolerance helps with the conversation to reach a unanimous decision.
Would you ever use a PET dotatate CT to monitor response of a GEP-NEN that is SSTR positive?
I would use baseline PET/CT or PET/MR and then subsequent scans would be with cross-sectional imaging with CTs or MRIs (MRI EOVIST if the liver is involved). CTs and MRIs would give a much better assessment of sizes for the established lesions.