Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you routinely perform next-generation sequencing on otherwise "low-risk" GIST to guide adjuvant therapy?
Yes and no. Defining the molecular make up of a newly diagnosed GIST is recommended and helpful in defining therapy. But the mutational status generally does not dictate adjuvant therapy. That decision is based on clinico-pathologic factors and if "low-risk" based on those criteria, close observatio...
How would you adjust therapy for a patient with high risk, stage III choriocarcinoma (lung mets) in the context of renal insufficiency (Cr 3.8)?
Risk score might dictate chemo regimen. There are dose adjustments for Methotrexate & Cytoxan based on renal function for MAC which you could use if risk score 7 or 8. I’d follow MTX levels & dose folinic acid until nontoxic MTX levels. If higher score I’d use EMA +/- CO. Consider neupogen on off-ch...
How do you manage testosterone replacement therapy-induced erythrocytosis?
Testosterone is a known risk for thromboembolism. What is not known is whether it is the hematocrit or the testosterone itself that is the trigger for thrombosis. Note also that epidemiologically, the age group that generally is prescribed testosterone also has a high prevalence of thrombosis. My ap...
What clinical factors impact your upfront treatment decisions in transplant-ineligible MM?
My approach is to start with up-front adjustments in choice of drugs, dose, and schedule based upon many factors: age, organ function/other comorbidities, concurrent medications, insurance/other economic factors, personal physical mobility, and access to transportation, patient goals, etc.Myeloma tr...
Are there any circumstances in which you would recommend adjuvant chemoradiation for resected olfactory neuroblastoma?
Agree with Dr. @Dr. First Last. Our experience treating 29 patients with Kadish B and C neuro esthesioneuroblastoma with local RT if positive margins, and no neck RT when the neck was N0, resulted in 27% neck failure including in the contralateral neck. 5-year LRF rate was 29% in patients who did no...
What is your approach to platelet transfusion in heparin induced thrombocytopenia?
In general, I avoid giving platelets in intensely prothrombotic disorders, except in the circumstance of severe bleeding. Severe thrombocytopenia is uncommon in HIT, though DIC may occur in some patients. However, bleeding is relatively uncommon and platelets not generally necessary.
How would you treat a patient with metastatic clear cell renal cancer who has progressed on immunotherapy and developed bleeding on cabozantinib?
This is not an uncommon situation. Any VEGFR inhibitor can indeed raise the risk of bleeding. An answer depends on the details of the bleeding-like one episode vs ongoing chronic bleeding, severity, arterial vs venous, location, GI vs CNS vs elsewhere, other contributing factors like anti-coagulants...
What dose of PEG-asparaginase do you recommend for teens with high BMI treated on a pediatric ALL regimen?
The peg-asparaginase dosing we use in ALL regimens for B and T cell is below: Patients less than 21 years old – 2500 units/m2 Patients 21 years and older – 2000 units/m2 For obese patients (defined as > 95% BMI for patients less than 20 years old or BMI > 30 for patients 20 years and older), ...
Would you offer adjuvant chemotherapy to a young adult with undifferentiated embryonal sarcoma of the liver?
This is an "ultra" rare and interesting entity, predominantly seen in the pediatric population, but I have seen a few in adults. This should not be confused with embryonal RMS - totally different entity. Clearly there is no data, and there will never be any data to support an evidence-based recommen...
Is there an absolute IgM level, in an asymptomatic patient on surveillance that initiation of therapy would be considered for Waldenstrom's macroglobulinemia?
The rate of progression of a paraprotein in a plasma cell disorder or LPL is always concerning, but it's not enough to bring about action. That said, we clinicians are always looking for bad behavior by cancer cells -- these are the indications for treatment more than the rate of rise or attainment ...