Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the role for maintenance lenalidomide in elderly patients with DLBCL?
The REMARC study was a phase III trial of maintenance with lenalidomide versus placebo in patients aged 60-80 years old who were in a PR or CR after RCHOP for newly diagnosed DLBCL (Thieblemont et al. JCO 35:2471-2481, 2017.). The results of this large study (650pts) with a median follow up of over ...
Does isolated del(5q) have the same prognostic implications for post-PV secondary myelofibrosis as it does in MDS?
Karyotypic abnormalities are rare in PV and ET. Abnormalities in myelofibrosis (MF) that are associated with an inferior prognosis are: 20q-, 13q-, +9, chromosome 1 translocation/duplication, -Y or sex chromosome abnormality other than –Y. There are few reports of del5q in MPN in general and not eno...
How do you manage a breast cancer patient with discordance in hormone receptor status with IHC and Oncotype?
Given the therapeutic window of endocrine therapy, and evidence of efficacy at even low ER expression (but not no expression!), the bar is set low for use of ET. IHC staining is the gold standard and I treat accordingly, so a tumor that is positive on staining for ER but negative on the single RNA b...
How would you approach adjuvant therapy for low-risk stage III colon cancer (T2N1) in an elderly patient with a good PS?
Patients with stage III colon cancer should receive adjuvant therapy to reduce recurrence risk. FOLFOX adjuvant treatment should reduce relative recurrence risk by about 1/3 (e.g from 35% to 25%). Based on the IDEA collaboration, 3 months of treatment is approximately equal to 6 months of adjuvant t...
How long do you continue caplacizumab in relapsed refractory TTP?
While there are no data from studies to guide our answer, general practice is to continue caplacizumab until the ADAMTS13 activity is at least 20% on two occasions, or greater than 30% assuming it was measured at least 4-5 days after the last plasma exchange procedure. The goal is to have stable rec...
Would you consider the use of ctDNA as part of surveillance in high risk TNBC patients?
Patients with significant residual TNBC following NAC have an increased risk of recurrence and death within 3 years, despite SOC adjuvant capecitabine (EA1131). The presence of ctDNA following initial active treatment (using Signatera or other platforms) has reliably shown to predict risk of recurre...
Would you offer a RET inhibitor for a RET-mutated medullary thyroid carcinoma after R1 resection in a patient with elevated calcitonin?
RET inhibitors have not yet been studied in the adjuvant setting in MTC (or in other RET-driven cancers for that matter). Thus, it is not considered SOC to start a RET specific inhibitor in the adjuvant setting following surgery for MTC, even when calcitonin and/or CEA are elevated. In the post-oper...
Will you offer adjuvant BEP after orchiectomy to a patient with embryonal carcinoma, solely based on the size at presentation, such as a 6 cm testicular mass?
I would not consider adjuvant BEP in this setting. While the risk of relapse is likely higher than smaller non ECC predominant tumor, it likely does not exceed a 50% chance of recurrence. Our general stance is active surveillance for all CS 1 seminoma and non seminoma patients. Adjuvant anything imm...
What would be the treatment options for metastatic clear cell carcinoma of kidney who develops recurrent thrombosis despite therapeutic anticoagulant on cabozantinib in second line treatment after failing immunotherapy?
Any TKI will potentially increase the risk of thrombosis, so this is a bit of a challenge for the patient. However, cabozantinib, based on personal experience, is more likely to cause this complication and other TKIs may be better in this regard. If you need to completely avoid TKIs, everolimus mono...
How would you proceed for a patient with metastatic gastric-type adenocarcinoma, with vaginal and inguinofemoral disease only, who experiences complete response to her vaginal tumor but residual inguinal disease?
There is no ideal data to guide this. I would recommend surgical nodal excision of the residual inguinal disease, followed by pelvic and inguinal radiation (with or without platinum if the patient can tolerate further). Another approach would be with cisplatin-based chemoradiotherapy with treatment ...