Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer additional systemic treatment to a stage II or III resected colon cancer that received 3 months of adjuvant capecitabine/oxaliplatin and now is presenting with a solitary lung metastasis?
Thanks for the question!First, it is important to clarify whether this lesion developed during or right after adjuvant CAPEOX, if so, there is no point in continuing adjuvant CAPEOX (it is very important to compare with baseline restaging scans performed before starting adjuvant therapy, as solitary...
Would concurrent CRLF2/IgH rearrangement affect your treatment recommendations for an adult patient with Ph+ p190 high risk (Age>35, WBC >30) B-cell ALL that was started on induction therapy with ponatinib + blinatumomab?
Short answer: No. Longer answer: We lack a clear understanding of how to change treatment for adults with CRLF2 fusions with Ph- ALL, and this is the situation where it is more clearly understood to have prognostic significance (Roberts et al., PMID 27870571). In my view, it would be very difficult ...
For a patient who has T4 squamous cell esophageal carcinoma on imaging, and who has biopsy-confirmed disease in an involved local lymph node, are EUS or EGD still indicated to complete workup?
EGD will help better define the mucosal extent of the disease. EUS would not help much but if upper thoracic, bronchoscopy may help to rule out invasion.
Do you prefer to use 7+3 or CPX-351 as standard induction therapy in younger patients with AML-MRC or t-AML?
I prefer to use 7+3 based on the fact that Lancet et al., PMID 30024784, that showed the benefit of CPX-351 was in adults over 60.A paper by Othman et al., PMID 37171402 showed no overall survival benefit to CPX-351 when compared to FLAG-Ida in younger adults with high-risk AML/MDS.
How would you manage a young patient with HL who develops HF (EF < 30%) after 4 cycles of A+AVD who obtained a PET2 CR?
This is a tough case, and the management would depend on the extent of disease. Assuming that this is advanced stage HL, given the use of BV+AVD, I would be in favor of completing 6 cycles of therapy with a non-anthracycline-based regimen. You can consider consolidative radiation, but this would nee...
What is your approach to the management of essential thrombocytosis in a woman planning to start a family?
This is an important question because it directly addresses what it means for a patient to have an MPN, and what it means for the physicians who treat them. The first is diagnosis: what is essential thrombocytosis (ET)? Some “experts” state that it is “related” to polycythemia vera (PV), or represen...
How do you manage de novo high volume mCSPC with both BRCA2 mutation and MSI-H on somatic testing?
This is a very rare but interesting scenario. Presumably in this case, the BRCA2 mutation is a passenger event in the setting of high TMB as a result of MMRD/MSI high disease, which has been reported. Typically these BRCA alterations are monoallelic and the tumors lack homologous repair deficiency a...
How would you approach a locally advanced ampullary carcinoma with BRCA1 mutation whose Whipple showed complete pathologic response after 5 cycles of neoadjuvant mFOLFIRINOX?
I assume this patient has pancreaticobiliary-type ampullary cancer. Unfortunately, no data to support adjuvant PARP agent. With BRACA positive status, one could complete the total of six months of treatment with gem/abraxane/cisplatin.
For patients who progress to mCRPC on ADT+ARSI started in mCSPC setting, do you continue the ARSI if patients have had a mixed response?
A "mixed response" can mean many things and the specific circumstances are critical for decision-making here. For example, bone scan flare, or pseudoprogression, with new unconfirmed lesions, is quite common with ADT/ARSI therapy and should not be a reason for treatment discontinuation as per PCWG2/...
How would you manage a patient with metastatic HCC on atezolizumab/bevacizumab who requires holding bevacizumab due to persistent proteinuria >2g?
This is a great clinical question, one that we often see since the approval of atezolizumab/bevacizumab in first line setting for HCC. Incidence of proteinuria with bevacizumab has been reported anywhere from 0.8%-4% for grade 3 (more than 3.5 g in a 24-hour urine protein level) (Brandes et al., PMI...