Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a patient with squamous NSCLC with NRG1 amplification (no fusion) who has progressed on first-line treatment?
NRG1 amplification may be associated with NRG1 fusions, but can also occur without fusion. The occurrence is rare and therapeutic outcomes have not been described in the same way as they have been with NRG1 fusion. Given the differing mechanisms and unclear therapeutic benefit, I would not use afati...
How would you treat a patient with recurrent malignant perivascular epithelioid cell neoplasm (PEComa) arising from the kidney and metastatic to lungs?
At our institution, first-line systemic therapy would be with mTOR inhibition.
When would you consider adjuvant chemoradiation in a patient with esthesioneuroblastoma?
In both situations, I would give cisplatin concurrently with post-operative RT. One could make an argument for the combination regimen as this is a rare tumor lacking in randomized controlled phase III trials to establish standard of care. Multimodality management is extrapolated from HNSCC and neur...
Would you offer treatment for asymptomatic CLL with WBC of ~300k or greater, high risk cytogenetics, or doubling time of 6-12 months?
Generally, starting treatment in a CLL patient is recommended based on the iwCLL criteria (Hallek et al., PMID 29540348).There is no WBC threshold that would require to treat, but the vast majority of patients with a WBC of 300K will have other reasons to start therapy. If this would be a patient wi...
Are there any reasons to consider a prolonged course of steroids with taper over a shorter course of pulsed steroids in the treatment of ITP?
As a general rule in pediatric ITP, I would say the answer is "no" but there are some exceptions. I'll defer to adult hematology colleagues to address this question for older patients, but some basic principles apply. 1. Steroid doses after an initial pulse, should be as low as possible because of ...
Would you consider atezolizumab-bevacizumab combination in a patient with metastatic hepatocellular carcinoma who presented with paraneoplastic myasthenia gravis?
Paraneoplastic myasthenia gravis from HCC is extremely rare with only a few handful of cases have ever been reported (Choi et al. AJG 2018; Fussner et al. Neurology 2019; Vautravers et al., PMID 19046712). The mechanism of pathogenesis is not known although it is thought to be related to the cross r...
How do you approach diagnosing a patient with Iron Refractory Iron Deficiency Anemia (IRIDA)?
Iron-Refractory Iron Deficiency Anemia should be suspected when there is a lack of response to oral iron and only a partial response to intravenous iron. One should make sure there is not a chronic underlying inflammatory process to explain the lack of iron absorption or lack of the expected respons...
How would you consider use of high dose IL-2 for metastatic renal cell carcinoma, in light of novel checkpoint therapy combinations now available?
In the context of significant favorable impacts of PD-1 combinations for RCC treatment, including [in alphabetical order] axitinib/avelumab, axitinib/pembrolizumab, cabozantinib/nivolumab, and ipilumimab/nivolumab and [to this point non-randomized data for lenvatinib/pembrolizumab], there remains th...
Would you treat an ER/PR+ inflammatory breast cancer that is HER2 2+ by IHC but 5% positive by FISH as HER2 positive?
Yes, because it is inflammatory breast cancer and the standard of care is to include neoadjuvant chemotherapy anyway. In this case, I'd use neoadjuvant TCHP and then retest breast biomarkers at surgery (MRM, with ALND, is standard surgery for inflammatory breast cancer at this time) to see if there ...
Do hemoglobin S levels always correlate with SCD phenotype?
The severity of sickle cell disease (SCD) is usually associated with the level of hemoglobin S (HbS). For example, HbSS and HbSB0 thalassemia, which generally have higher HbS levels, are usually more severe than HbSC and HbSB+ thalassemia. While patients with HbSC and HbSB+ thalassemia typically hav...