Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a patient with T1aN1 breast cancer when the ER/PR/HER2 status cannot be determined by IHC?
This situation is unusual. Was the 2mm on the diagnostic biopsy and no other cancer found on the resected specimen? I would wonder if there is another undetected invasive component still in the breast if they did a lumpectomy and slnb. If the 2mm focus was depleted for IHC, I would try to test recep...
How would you approach giving concurrent chemoradiation for Stage IIIB lung adenocarcinoma in the setting of concurrent Int-2 myelofibrosis which has been stable without cytopenias on ruxolitinib?
That is certainly a rock and a hard place. At this point, it seems as though the lung CA would be the most pressing issue. If the MF is asymptomatic (cytokine related symptoms, there are minimal spleen-related symptoms and there are no cytopenias), I would not start any treatment for the MF until th...
How do you treat metastatic adenocarcinoma of the ampulla of Vater?
True adenocarcinoma of the ampulla of Vater is an extremely rare cancer of the GI tract (<5 pts per million). Consequently, data is mostly derived from retrospective studies or large databases with few clinical trials available, especially with locally advanced and metastatic disease. I personally h...
Would you offer immunotherapy for a patient with a history of kidney transplant on immunosuppression who has clear cell RCC in the native kidney?
While data to address this question remains retrospective in nature, a number of small series suggest a very high solid organ rejection rate (37-41%) and worrisome morality rates in the 40+% range. Fully understanding the potential for survival benefit from ipi/nivo or pem/axi, I would be inclined t...
How would you treat Burkitt Lymphoma during an uncomplicated pregnancy?
For many malignancies, therapy in a pregnant woman can wait until delivery of the child. However, this is not possible in Burkitt's lymphoma, due to its repaid growth rate. After the first trimester, it is relatively safe to give most chemotherapies. However, severe neutropenia with risk of more sig...
Would you continue pembrolizumab in an asymptomatic metastatic NSCLC patient with high PD-L1, who develops granulomatous mediastinal lymphadenopathy biopsy proven as sarcoid?
Sarcoid-like granulomatous reactions have been described with checkpoint inhibitors. It is important to diagnose them when they occur, in order to not confuse these findings with disease progression, especially in a patient with lung cancer. I have had two patients at least show growing mediastinal ...
Would you recommend PMRT for a patient with a right breast mastectomy with closest margin less than 0.1cm?
I would consider this if there were other high risk factors like T2 disease, high grade or LVSI. In absence of these factors, favor systemic treatment alone. Here is one reference.
What are the first line treatment options in HCC patients with significant baseline proteinuria?
Tough problem! Treatment of advanced HCC is quite challenging since medical oncologists have to account for the compromised liver function (due to the underlying liver disease) over and beyond the disease burden, when making treatment decisions. Therefore, treatment decisions are often made after we...
How do you treat a patient with a history of clinical stage IIb cN2, mixed germ cell embryonal carcinoma treated with BEP and RPLND five years ago, who now has signet ring cell adenocarcinoma with abdominal carcinomatosis with an unknown primary?
My experience would suggest that this is a second primary unrelated to his germ cell tumor. I would predict that the i12p will be negative and, if it were available, the MiR371 would be negative. I presume his current AFP and HCG are negative. I have seen this situation once with a young man almost ...
How would you approach a patient with a locoregional recurrence TNBC who requires neoadjuvant treatment?
My assumption is that the patient developed this currently unresectable LRR after completing neoadjuvant chemotherapy and surgery, and has to be considered at high risk for both local complications, which is why you want to administer 'neoadjuvant' therapy (although I'm not sure that the term is app...