Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to bridging anticoagulation in patients with history of recent HIT?
One should not re-expose patients with past HIT to heparins. Even with remote HIT, there is a high rate of serologic recurrence (eg, Warkentin and Anderson, PMID 27114458) and while the rate of overt HIT relapse may be low with proper precautions, I have seen and published a couple of fatal HIT recu...
How would you approach an MSI-H HPV+ T2 N1 squamous cell carcinoma of the anus?
I would agree with Dr. @Dr. First Last's comments but want to add one point. Some patients with Lynch Syndrome may develop HPV+ Anal SCC and in this situation, the tumor could be dMMR (most likely) but also could be pMMR (uncommon but can happen). I am not sure if dMMR is the driver for the Anal SCC...
How do you manage patients with suspected cholangiocarcinoma that presents with biliary obstruction but has repeated negative brushings/biopsies?
This is often encountered in patients with PSC. Patients present with jaundice and biliary stricture, rising CA 19-9, and repeat ERCP with brushing/biopsies have shown no evidence of malignancy (often showed abnormal cells). Brushings have high specificity if positive (99%) but very poor sensitivity...
What is the preferred treatment for a patient with an EBV+ monomorphic PTLD (DLBCL) not currently on immunosuppressive therapy?
For patients who are candidates for an anthracycline-based regimen, R-CHOP is usually given if CD20+ PTLD. Patients whose tumors do not express CD20 are treated with CHOP chemotherapy alone. R-CHOP can lead to ~ 65% of CR (Trappe et al., PMID 22173060).
How do you approach an elderly patient (~80 years) with stage IIC melanoma post resection with oligometastatic brain lesion post intracranial resection which developed 2 years after treatment?
If I am understanding this correctly, then all known metastatic recurrence has been resected.In that case, I recommend cyberknife/SRS to the surgical cavity followed by single agent anti-PD1 therapy. Concurrent administration of anti-PD1 with SRS or GKRS is experimental at this point. There is no co...
For a patient with triple-class-refractory myeloma and cytopenias who has been collected for CAR-T, would you choose aggressive chemotherapy or a bispecific antibody for bridging?
The median time to response for bispecific antibodies targeting BCMA and GPRC5d is over a month. Usually, when we employ bridging therapy we want a much quicker response. Resistance likely doesn’t play a role here because of the short time that they are being used. I prefer to avoid VD-pace-like reg...
Would you offer adjuvant chemotherapy in a patient with MSS colon cancer who only has residual mucin left, without viable cancer cells despite no pre-operative chemotherapy, in the colon and lymph nodes?
This is a very specific question, and I would simplify the question to whether we should determine adjuvant chemotherapy based on the mucin seen in the lymph node for resected colon cancer. It would be very unusual that there is mucin without viable cancer cells in the colon cancer surgical specimen...
How would you manage a patient with mCRPC with a good clinical and >50% reduction in PSA to Lu-PSMA but evidence of radiographic progression on PSMA PET/CT?
As no guidelines exist today that incorporates use of PSMA PET to make a decision to change therapy; when changing therapy, I try to use PCWG criteria and the rationale to make a decision. My goal is to switch therapies only when there is clinical or radiographic evidence of clear progression (RECIS...
How do you approach a well controlled HIV patient with diffuse cutaneous kaposi sarcoma who failed to respond to radiation, paclitaxel and monthly liposomal doxorubicin?
Please consider using Pomalidomide 5 mg PO daily (21 days on and seven days off in a 28-day cycle). (Polizotto et al., PMID 27863194). There is significant activity in HIV-positive patients of this regimen (ORR-60%). The NCCN also endorses Pomalyst as a treatment for KS. Other than this, checkpoint ...
Do you switch therapy to sacituzumab in a patient with metastatic HR+ HER2- breast cancer who has stable systemic disease but new <1cm brain metastasis?
Not necessarily. Particularly, if this is the first CNS lesion that was detected and the patient was able to get definitive SRS therapy. In the ABC 5 guidelines for HER2+ CNS only progression, the committee did not endorse routinely changing therapy after local treatment. A similar argument could be...