Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is sentinel lymph node biopsy several weeks after partial mastectomy as reliable as sentinel lymph node biopsy done at the time of partial mastectomy?
Great question! We do it all the time in the setting of invasion found after lumpectomy for DCIS or after a surgical biopsy finds an invasive cancer but the question is whether it's as accurate in this scenario? Does a previous surgery alter the lymphatic drainage pattern to a degree that renders se...
How do you decide between re-irradiation, chemotherapy, and alternating electric field therapy in patients with relapsed GBM post chemoradiation with TMZ?
The best care for patients with glioblastoma is multi-disciplinary. For that reason, we review these patients in our tumor board. The critical questions are - 1) Is this truly disease progression or could it be radiation necrosis/ pseudoprogression? 2) What functions are located in the area of recur...
Is there utility in molecular or proteomic testing (e.g., Foundation or Caris) for metastatic clear cell renal cell carcinoma when several lines have failed?
The role of genomics is not well-defined in mRCC. In my personal experience there are very few truly actionable mutations that will be discovered. I would generally favor alternative FDA-approved agents of novl clinical trials.
How would you approach metastatic hepatocellular cancer with neuroendocrine features?
I would consider having both specimens reviewed by an expert GI pathologist to determine the histology and apply additional IHC stains as indicated. Misdiagnosis of NETs is not all that uncommon and I have seen both HCC and cholangiocarcinoma called NETs and the other way around too. For a tumor tha...
In multiple myeloma patients on bortezomib and dexamethasone, who develop HZV reactivation while on HZV prophylaxis, do you stop bortezomib/dexamethasone permanently?
It is important to make sure compliance with the drug is good. If it is drug resistance may play a role and alternative approaches can be used. Permanent discontinuation is not really an option as many drugs used for myeloma carries the same risk of zoster and if the patient needs the treatment, the...
What is your preferred dosing and schedule for interferon in pregnant CML patients?
The ideal starting dose for interferon in pregnant patients is a bit of a challenge because of gaps in the evidence base. In the IRIS study, interferon alfa at a dose of 5 million units/m2 was administered on a daily basis (along with cytarabine) and the toxicities of this regimen are well known but...
How would you use Oncotype for adjuvant colon cancer treatment decisions?
Oncotype is an RNA expression profile validated in multiple prospective phase 3 trials. It is mainly validated for stage II colon cancer, but data for stage III also exist from NSABP C0-7. Since the stage II data is prognostic, not predictive it does not give the benefit of treatment (though data fr...
How do you approach the development of an LGL clone in a NHL patient actively getting therapy?
Most likely, i would monitor the clone and continue with the ongoing treatment plan. This is assuming the size of the clone was relatively small and that the patient was asymptomic in this regard. The development of a T-cell or NK-cell clone isnt necessarily indicative of a separate disease, does no...
Would you recommend anti-hormonal therapy in a patient with DCIS that is ER/PR positive between 1-9%?
In general terms, I consider tumors with ER and PR expression <10% as hormone receptor negative. Our analysis of outcomes for these patients at our institution suggest thy do just as well (or as poorly) as those with ER 0% and PR 0%. Therefore, I do not recommend the use of endocrine therapy of pati...
How do you approach choice of systemic chemotherapy for a young and otherwise healthy patient with HER2 negative esophogeal adenocarcinoma?
I really think that, in the US context, FOLFOX is the standard and preferred regimen. It is now the accepted regimen in US single-arm and randomized studies. Although there are differing toxicities, I would argue that cisplatin 60-80 mg/m2 (which is the dose in published regimens) represents cruel a...