Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What treatment regimen would you choose for a patient with gastric adenocarcinoma who is found to have peritoneal and omental implants at the time of surgery after receiving preoperative FLOT?
I think there are 2 ways to answer this question. The more straightforward scenario is if the patient had a diagnostic laparoscopy prior to starting pre-operative chemotherapy and did not have either gross peritoneal disease or positive peritoneal cytology. In this case, this would be clear progress...
Assuming an absolute contraindication to immunotherapy and good PS, what is your preferred first line for metastatic squamous cell carcinoma of the lung?
As with many situations we face, there is likely no definite "one" answer to this question. That being said, I tend to like gemcitabine + platinum (usually carboplatin) since it is generally well tolerated and, for those who feel strongly about retaining hair, usually does not lead to hair loss. In ...
In what situations would you offer systemic therapy for HER2+ microinvasive invasive ductal carcinoma?
I usually do not treat microinvasive HER2+ ductal cancer as most screen-detected cases still have a good prognosis and there is limited data for therapy benefit. A review by Padmore et al. (PMID 10717623) and a Chinese series (Si et al. Front Oncol 2020) suggested a higher risk of recurrence in youn...
How do you advise patients on duration of first line maintenance PARPi and the potential risk of MDS or AML?
For patients, who could derive significant survival benefit from first line maintenance PARP-inhibition (BRCA+ and HRD tumors), we advise them to take PARP-inhibitors up to 2 years (olaparib) or up to 3 years (niraparib) if no disease progression or unacceptable toxicity. I counsel patients that dev...
Why are autoantibodies not often detected on monoclonal gammopathy assays (SPEP/IFE, quantitiative immunoglobulins)?
Autoantibodies do not cause a false positive M protein. Even though autoantibodies may target a specific antigen, they are polyclonal. Rarely, a very high rheumatoid factor titer can produce a broad-based (polyclonal) peak in the electrophoretic pattern. UpToDate
Is there an equivalent test for serum viscosity in sickle cell disease?
I would not typically order serum viscosity outside of the setting of paraproteinemia. In that setting, I still think serum viscosity is useful, especially as opposed to plasma viscosity, which might be elevated in a sickle cell patient due to the acute phase reactant fibrinogen. It is true also th...
How do you utilize serum viscosity in the clinical management of plasma cell disorders?
In brief, I discourage checking serum viscosity in almost all cases. Why? Hyperviscosity syndrome is a clinical diagnosis. If IgG >7000 mg/dL, IgA > 5000 mg/dL, or IgM > 3000 mg/dL, and the patient has symptoms of hyperviscosity (altered mentation, shortness of breath, tinnitus, mucosal bleeding, e...
Is there a role for reassessing somatic mutation status at relapse in patients with epithelial ovarian cancer?
No – I don’t think there is any role for reassessment at this point. If commercialization of testing for reversion mutations becomes available – and it will or a functional test of HR status – then yes – I would reassess but I don’t see a reason at this point.
How would you treat non-secretory myeloma in an inpatient setting?
This entity is rare with the use of free light chain assay. About 2% of all cases are non-secretory. In A Greek study, they were younger, less anemic, and had less often renal dysfunction and less extensive bone marrow infiltration. Presence and extent of bone disease were similar, however, hypercal...
How does clinical intramammary lymph node involvement in HER2+ breast cancer affect your neoadjuvant chemotherapy choice?
The AJCC 8th edition classifies an intramammary node as an axillary node (1). Intramammary nodes are associated with axillary involvement although their independent contribution to recurrence risk remains controversial. Accordingly, I would recommend neoadjuvant TCHP in this case (I drop carboplatin...