Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer adjuvant chemotherapy for a large, high-grade radiation-induced malignant peripheral nerve sheath tumor following R1 resection?
I assume a post op scan shows no gross disease. Technically this is not "adjuvant" since there is known microscopic residual disease. In a young patient with good PS and organ function, it's reasonable to discuss risks and benefits of systemic chemotherapy (Doxorubicin + Ifosfamide) now vs. close f/...
How do you approach the treatment of patients with an e14a3 (b3a3) BCR-ABL fusion in chronic phase CML?
The treatment is the same; the problem is how to monitor response as this rearrangement is detectable reliably by FISH and not by the typical RT-PCR. There is a report showing that CML with some rare fusion genes have a rapid response at early time points (3 and 6 months), but long term outcome seem...
How would you manage a patient who develops pleural and skin metastases shortly after completing neoadjuvant ddAC-T and surgery for a locally advanced triple negative breast cancer?
Any solid tumor refractory to frontline chemotherapy has three pathways moving forward:1. Clinical trial2. NGS on tissue to identify FDA approved targets (specifically BRCA in this case)3. Standard second line therapies.Under option 3: For PD-L1 > or = 1%, the combination of atezolizumab and nab-pac...
Can fulvestrant cause a tumor flare reaction in hormone receptor positive breast cancer?
No. Fulvestrant does not have agonist activity on the estrogen receptor, so it will not cause a true tumor flare. When it is paired with an LHRH agonist for a premenopausal woman, the LHRH agonist can cause an initial tumor flare because of the rise in estradiol before full ovarian suppression kicks...
How would you approach systemic therapy for a postmenopausal female with metastatic ER+/HER2+ breast cancer (liver/bone) who achieved a CR for 5 years on trastuzumab/pertuzumab and exemestane, with continued asymptomatic brain progression?
Switch to tucatanib, capecitabine, and trastuzumab. Consider returning to trastuzumab/pertuzumab based treatment at future systemic progression since currently there's no systemic progression. Consider continuing exemestane. This could be based on recent NSABP trials showing no detriment to concomit...
For pregnant patients progressing on anthracycline based chemotherapy (ex: FAC), would you consider other chemotherapeutics such as taxanes or proceed to locoregional treatment?
Typically we would treat with anthracycline based therapy, followed by surgery and post delivery taxanes. In this case, she would need to proceed with surgery sooner than later and receive post-delivery taxane based therapy.
How do you treat primary retroperitoneal choriocarcinoma with liver and lung metastases and markedly elevated B-HCG?
A primary retroperitoneal choriocarcinoma may or may not actually be an occult testis primary, despite the testis being a relative sanctuary site, with normal exam and ultrasound, and no indication for orchiectomy. He has poor risk of disease and needs 4 courses of triple drug therapy, usually with ...
How would you manage a young patient with newly recurrent metastatic triple negative breast cancer less than a year after completing adjuvant chemotherapy and worsening liver function due to intrahepatic disease?
Since she has a DFI less than 1 year from last taxane exposure, I would consider her taxane resistant. In general, I try to do carboplatin/gemcitabine, especially if the LFTs are abnormal. If her PDL1 is positive, you can try to add pembrolizumab similar to the KEYNOTE355 regimen. Following this oth...
How do you approach discrepancies between MRI and mammogram results for staging for breast cancer?
I assume that you're asking about discrepancies in primary tumor size/extent, not the detection of additional suspicious lesions by MRI elsewhere in the same breast that may need to be biopsied to determine if the patient is a candidate for breast conservation. MRI tends to slightly overestimate tum...
How do you dose chemotherapy (R-EPOCH or R-CHOP) in patients with aggressive lymphoma involving liver leading to elevated bilirubin and liver enzymes?
For patients with newly diagnosed diffuse large B-cell lymphoma presenting with hyperbilirubinemia due either to liver disease or extrinsic compression, I will most often consider a pre-phase treatment either with rituximab, cyclophosphamide, or prednisone (all of which can be safely administered in...