Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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?
There are case series in which patients who were diagnosed to have CPI AKI were re-challenged without recurrent ATIN. Importantly, not all patients had biopsy-proven ATIN so there could have been other causes of AKI besides ATIN. This highlights the importance of obtaining a renal biopsy in these pa...
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?
It should be safe to add bevacizumab at this time. Radiation will reduce vascularity after 4-6 weeks. The incidence of bleeding with Bev (in the absence of anticoagulation) is quite low. Actually lower than the risk of thrombosis or wound healing complications. Go for it.
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...
Would you ever consider managing HR+ DCIS non-surgically?
In the wake of the COVID-19 pandemic, I think we've all gained experience managing early stage (0-1) HR+ breast cancers with endocrine therapy as a stop-gap until surgery was possible. However, outside of a clinical trial or unusual circumstances, I would not normally consider managing HR+ DCIS non-...
Can CAR T cell therapy be considered for heart transplant recipients with concurrent lymphoproliferative disorders?
The short version of my answer is: Possibly Yes. There is a very limited evidence from the literature in this topic, however, I will base my explanation on the following case reports: McKenna et l., PMID 37129856, Dang et al., PMID 33002249, Portuguese et al., PMID 36575360.The provided case reports...
Given recent studies investigating ICI myocarditis biomarkers such as Temra CD8+ cells, is there now a growing selection of clinical biomarkers, besides BNP and troponin, being measured routinely in ICI myocarditis cases?
At this time, Temra CD8+ cells have been shown in research experience only and not measured routinely. We hope that in the near future, we will have better, more specific biomarkers than troponin and BNP for the diagnosis of ICI myocarditis given how difficult it is. Diagnosis of ICI myocarditis is ...