Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What systemic therapy would you offer for a local, unresectable relapse of a mixed acinar neuroendocrine carcinoma of the pancreas?
This is a very interesting question. I agree with the overall discussion with some points that need to be clear: Did the pathology show mixed acinar and NEC with >30% of each component? or just acinar with NE features? I agree the data about MANEC is very limited and exclusively retrospective. What ...
For patients with triple negative breast cancer, currently undergoing neoadjuvant dd AC, would you consider adding pembrolizumab to weekly paclitaxel based on recent KEYNOTE-522 and continue as adjuvant?
I think the decision should be informed by the degree of response to AC and initial bulk of disease at presentation. In patients who complete the AC portion and still have clinical evidence of substantial residual disease, I would absolutely consider adding pembrolizumab and carboplatin to weekly pa...
Would you routinely use G-CSF prophylaxis in a CMML patient for decitabine-related neutropenia?
I would use G-CSF if the patient is in remission/responding to decitabine and neutropenia, is decitabine induced and not due to CMML. I will not use at diagnosis or when not in remission as neutropenia may be disease-related.
In patients who receive neoadjuvant pembrolizumab and chemotherapy for TNBC, how will you manage adjuvant treatment if they have a germline BRCA mutation?
For patients with clinically high risk early TNBC and germline PV in BRCA 1 or 2 undergoing neoadjuvant chemotherapy along with pembrolizumab, the course of adjuvant therapy will depend on pathologic response at surgery.For those with pCR - I would continue adjuvant pembrolizumab for patients who ar...
What is your preferred first-line therapy for metastatic extraskeletal osteosarcoma in a young, fit patient?
EOS behaves more like a soft-tissue sarcoma c.f. skeletal OS, so we treat with anthracycline plus Ifosfamide. Cisplatin and HD MTX routinely used for skeletal OS do not have significant activity in EOS.
Would you consider neoadjuvant chemoradiation with oral capecitabine for a locally advanced sigmoid adenocarcinoma 20 cm from the anal verge?
If the tumor is above the peritoneal reflection, and the patient has no metastatic disease, and the surgeon thinks a surgery with a negative margin is feasible, upfront surgery would be my choice followed by adjuvant chemo if appropriate.
For locally recurrent NSCLC after surgical resection but with subcentimeter ipsilateral nodules of indeterminate etiology, would you consider local therapy such as chemoradiation +/- durvalumab?
Time to relapse influences the treatment modality. Presuming relapse occurs at least a year or more after the initial surgery, we typically triage and re-evaluate if surgical resection is feasible again for local recurrence after prior resection. Since these are subcentimeter and of indeterminate et...
How would you approach treatment for cT4 stage IIIC colorectal cancer that is d-MMR and not amenable to surgery due to volume of disease?
As my more learned colleagues here suggest, an evidence-based approach if this is colon cancer, is to use chemotherapy alone, as we lack high-level data for immune checkpoint inhibitors in this scenario. If rectal cancer, then I think emerging data from MSKCC would suggest better response to concurr...
How do you treat localized prostate cancer with neuroendocrine differentiation?
Most hybrid or pure NEPC tumors lack PSMA expression as only 1/3 of metastatic NEPC tumors are PSMA PET+ and expression is typically very heterogeneous. For this reason, an FDG PET/CT would likely be a better staging test for this aggressive variant of prostate cancer. If this is also N0M0, RP is my...
How would you approach systemic therapy for a pre-menopausal woman with ER+/PR+/HER2 positive breast cancer who had a local recurrence 6 months after completing adjuvant TCH and a year of trastuzumab + tamoxifen?
This patient has high-risk disease. First point: Option 1: Since the cancer recurred 6 months from TCH, I think you can justify using TDM-1 and pertuzumab combination based on I-SPY 2 data (pCR achieved in 52% for women treated with TDM-1 and pertuzumab versus 22% for women treated with trastuzumab ...