Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you recommend gastrectomy for a patient who has poorly differentiated adenocarcinoma in a resected gastric polyp?
This is a difficult question to answer as there is more information that I would need. I assume that the patient had cross-sectional imaging that was negative for metastatic disease. Was the polyp removed in its entirety at the time of polypectomy? I assume that all margins were negative. Are we sur...
How does the lack of mandated PET or brain MRI in the ADAURA trial impact your interpretation of the results?
The lack of mandated PET or brain MRI do affect study interpretation but I don’t think they change the bottom line. Lack of mandated PET (need for baseline PET scan has significant global variation) may understage some patients who might have occult local-regional or metastatic disease. This would i...
Would you give a HER2 targeted agent to a patient whose initial cancer was ER/PR positive, HER2 negative but now with metastatic disease that is ER positive, PR negative, HER2 2+, FISH equivocal?
Discordance of HER from primary to metastatic status is seen in about 5-10% of cases (1). Little data are available regarding outcomes of these cases, but responses have been seen in patients with HER2-negative primary tumors and HER2+ metastases (2), and I have certainly observed this personally. I...
How would you approach an early inguinal recurrence after surgical resection of Merkel Cell carcinoma in the popliteal region?
I would make sure there is no distant metastases with a PET-CT. Would try to enroll this patient in a trial. Current approach if localized in surgery followed by radiation, but with availability of immunotherapy, I would recommend at least an adjuvant immunotherapy after surgery. No one knows if rad...
How would you approach patient with metastatic anaplastic thyroid cancer with NGS revealing only ARID1A mutation?
It would be helpful to have the results of the entire NGS panel. Was ARID1A the only mutation noted on comprehensive tumor NGS? Was there any suggestion of MSI? ARID1A mutations usually result in either loss or decreased function of ARID1A which is a tumor suppressor. In-vitro and in-vivo data for P...
Would you offer PCI to a patient with LS-SCLC, who presented initially with paraneoplastic syndrome (encephalomyelitis), but had no neurocognitive sequelae after chemoradiation?
I am not a big fan of PCI. I think the term itself is a misnomer. PCI trials in LS-SCLC were conducted in an era when MRI brains were not performed.Let's look at the "outdated" data that all of us, including NCCN, quote. A meta-analysis conducted by Auperin and colleagues demonstrated a 5.4% 3-year ...
For patients on a bone-modifying agent for osteoporosis/severe osteopenia in the context of adjuvant AI therapy, how do you manage the bone-modifying agent once their AI course is complete?
In this case, I would be guided by the bone density (DXA) scan, if there is still osteoporosis or severe osteopenia, I would continue the BMA and repeat the DXA scan in one or two years. If the DXA shows improvement, I would discontinue the BMA, knowing that one can re-institute at a later date. Sev...
How do you workup erythrocytosis with a normal or elevated serum erythropoietin?
First, I would consider using the term erythrocytosis rather than polycythemia. Too often, use of the term polycythemia may suggest polycythemia vera (PV) (a malignancy) rather than something more benign.The recommended up front testing in the evaluation of erythrocytosis consists of up front JAK2V6...
How do you approach a patient with good PS and no treatment contraindications who has progressed on a RET inhibitor for NSCLC?
The management approach will be similar to how we approach patients receiving targeted therapy, i.e. oligoprogression vs widespread progression. Multimodality approaches with surgery or radiation to consolidate residual disease or oligoprogressing sites may enable patient to remain on the same targe...
How do you manage end-organ toxicity such as hepatotoxicity or pulmonary toxicity in a patient receiving RET-inhibitors for NSCLC?
For liver toxicity, I would hold the TKI for grade 3 of higher elevations in the transaminases, and monitor 3-5 days thereafter and then weekly. If the LFTs resolve, I would resume the TKI at a dose reduction. If the LFTS remain normal a couple weeks after resolution, I might even consider dose re-e...