Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider a somatostatin analog for a patient with carcinoid involving ileum and appendix with positive mesenteric margin after right hemicolectomy and liver metastases that have been resected?
I generally would not unless there was a substantial amount of residual disease per se and/or there were symptoms of the carcinoid syndrome which is very unlikely after near total resection of metastases.Patients with small bowel NETs (carcinoid tumors) and liver metastases are rarely, if ever, cure...
How do you manage dry eye related to Pluvicto Lu-177?
This is a real but uncommon side effect of Pluvicto therapy. Per VISION, it will happen in maybe 3% of patients but almost never high grade. Interestingly, the absorbed dose for the lacrimal glands is 2.1 Gy/Gbq - which over 6 cycles full dose at 7.4 GBq/200 mCi per cycle means 92 Gy. There was a me...
How do you approach a patient with prostate cancer with sclerotic/lytic lesions found on a CT scan but not seen on a bone scan or PET-PSMA?
This can be a tough situation, as sometimes healthy individuals can have sclerotic or lytic foci in various bones for reasons unrelated to any type of malignancy. The first thing I would try to do is compare the CT scans to any prior imaging if possible. If these lesions are completely unchanged fro...
How would you approach grade 2 neurologic toxicity in a patient on daratumumab, dexamethasone, and lenalidomide for relapsed multiple myeloma?
Clarification of the question was made, and it was focused on peripheral neuropathy. The polyneuropathy in Dara/Rev/dex is mostly due to the Revlimid. Most neuropathy from rev, if any, is grade 1- 2. The first step will be to start with gabapentin without reducing the dose of Revlimid. It is a very ...
How would you treat ESRD patients on HD with locoregional squamous cell carcinoma of the anus?
Both FU and MMC may be used but one must modify the treatment around the dialysis since the FU infusion will be removed with dialysis. You could use 5 day bolus 5FU and give bolus after dialysis. It would be better to use capecitabine however and try to schedule between dialysis episodes (for exampl...
What is your approach to adjuvant therapy for an R0, ALK+ resected lung adenocarcinoma with N2 disease?
This is a timely question for me as well as the community. For me as I have just had my first patient presenting with ALK-positive 3A cancer PREOPERATIVELY. For the community as there was a recent presentation at ESMO of the ALINA trial. In the ALINA trial, patients with ALK-positive NSCLC were rand...
How do you approach a patient with CP-CML who has a history of inadequate response and severe myelotoxicity to multiple TKIs such as imatinib, nilotinib and dasatinib?
This depends in part, on the status of the disease (transcript levels), the doses of TKIs that have been used, the nadir blood counts, what lineages are involved in myelosuppression, and the comorbidities of the patient. In principle, ponatinib or asciminib could be used. If ponatinib, I would start...
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 ...