Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach timing of adjuvant chemotherapy in a Stage 1 TNBC lost to follow up for >1 month since surgery?
Delayed initiation of adjuvant chemotherapy beyond 60-90 days has been linked to inferior outcomes in several studies (see for example Chavez-MacGregor et al., PMID 26659132). However, if this worse outcome is primarily due to time delays in chemotherapy or driven by other variables (e.g. ability to...
Are you treating patients with RET-fusion+ metastatic NSCLC with RET inhibitors as the first line of therapy regardless of PD-L1 expression?
Yes, I do treat with RET inhibitors regardless of PD-L1 status given the response rates on the order of 70-85% in treatment naive patients with selpercatinib and pralsetinib. If we look to the data of immunotherapy in other actionable oncogene driven subsets of lung cancer like EGFR mt NSCLC, the re...
How would you treat patient with a recurrent thymic carcinoma after prior surgery and concurrent chemoradiation?
This is a bit difficult to answer as the background is a bit vague with uncertainty about the patient's primary therapy. In general, the approach I would take is that the curative approach is in the first-line setting, once there is a recurrence, it is typically incurable but they have a number of t...
How would you treat an older patient with stage IIC nonseminoma who is unfit for platinum chemotherapy due to comorbidities?
These are difficult questions to answer. The definition of a patient unsuitable for cisplatin in an elderly patient varies from oncologist to oncologist. Cisplatin + etoposide for 4 courses is the “standard“ therapy for patients over the age of 50. For elderly patients with poor performance status f...
How do you manage VTE in the setting of persistent severe thrombocytopenia?
The thrombosis versus bleeding risk ratio should be weighed. The risk of VTE recurrence or propagation is highest in the first 30 days and we know that thrombocytopenia does not attenuate this risk. Providers should favor anticoagulation. In the case of cancer-associated thrombosis and chemotherapy-...
Are TKIs safe for a patient with metastatic renal cell carcinoma and a transplanted kidney?
No contraindications from my experience, and does not look like there are any known interactions or interactions with metabolism. It is helpful to make sure the treating nephrologist is aware of the diagnosis and therapy in order to monitor immunosuppression levels. Often we will change the immunosu...
What is your approach to the treatment of gamma heavy chain disease (Franklin's disease)?
This is such a rare entity and it has been treated with so many different regimens.It is hard to diagnose and I have seen very a handful of cases over the years. The presentation can be variable and include lymphadenopathy, anemia, splenomegaly, skin involvement, thrombocytopenia, and rarely hepatom...
How would you approach moderate neutropenia (ANC < 1000) in a solid organ transplant recipient?
There are limited data addressing the safety and efficacy of G-CSF in the solid-organ post-transplantation setting. Most case series report no increase in graft rejection with G-CSF treatment, although this question is not rigorously answered. Most cases of neutropenia in the post solid-organ transp...
Do you incorporate immunotherapy in your multi-modality treatment after chemoradiation for patients with potentially resectable stage III superior sulcus NSCLC?
No. Durvalumab therapy in NSCLC is currently limited to patients with unresectable disease. PACIFIC clearly demonstrated an enduring survival benefit of consolidative Durvalumab therapy after combined chemo-radiation therapy in patients who did not undergo surgical resection. The NeoCOAST trial is c...
For patients with metastatic thymic carcinoma, what would you offer patients who progress after platinum doublet chemotherapy?
Thymic carcinoma is a rare tumor and carries a much different prognosis than thymoma, which is often more indolent and for which surgery is the mainstay of treatment. Unfortunately, thymic carcinomas tend to respond poorly to chemotherapy. For an unresectable thymic carcinoma, radiation is typically...