Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage an asymptomatic elderly frail patient with newly diagnosed mantle cell lymphoma with TP53 mutation?
While p53 mutations are known to impact clinical outcome after administration of cytotoxic chemotherapy in frontline MCL (Eskelund et al., PMID 29794145, Elhassadi E et al. Presented at: 2019 European Hematology Association Congress; June 13-16, 2019; Amsterdam, The Netherlands. Abstract PF493, Ferr...
Would you continue IO monotherapy in a patient with metastatic RCC started on first line IO-TKI combination but with poor tolerance to TKI?
Yes, definitely assuming no limiting irAEs. There is clear activity to IO monotherapy in mRCC as evidenced by KEYNOTE 427 and other datasets. Combination therapy is superior, however, so dose interruption/modification of the TKI should be attempted before discontinuing permanently.
How do you manage a patient with superficial venous thrombosis with close proximity (<3 cm) to deep veins and an inherited thrombophilia ?
I would treat the patient for 3 months with a DOAC and then repeat the scan. If the clot is resolved, I would order a d-dimer and Factor VIII level on anticoagulation. If the tests are negative, I would stop the DOAC and retest at 30, 90, and 180 days. If tests remain negative then stay off anticoag...
How do you approach decision making in terms to adjuvant chemotherapy after CSI in adult medulloblastoma?
Medulloblastoma is a chemotherapy sensitive disease. The NCCN guidelines have options for CSI alone or followed by chemotherapy for standard risk disease (M0, residual disease <1.5cm2, classic or desmoplastic histology) and recommend post-CSI chemotherapy for high risk disease. Unfortunately, 25% of...
How do you manage anaplastic thyroid cancer that is progressing through radiation therapy?
The algorithms for ATC, a rare disease, have gotten relatively complex including the incorporation and timing of XRT. It is unclear from the question what the presentation scenario is, i.e., localized disease or metastatic, and the mutational status, as ideally at a minimum BRAF status is known. Now...
Do you use breast cancer index (BCI) in patients with 1-3 node positive ER+/HER2- IDC?
The only clinical case where I would consider ordering a BCI in a female patient with 1-3 positive lymph nodes would be in a postmenopausal woman who is considering to take adjuvant tamoxifen for 10 years vs 5 years based on the aTTom trial (Bartlett et al., PMID 31504126).I do not order BCI in othe...
Would you give EP chemotherapy to a patient with Stage IIA nonseminoma with negative markers who underwent RPLND and had pN2 disease with predominant teratoma?
For CS IIA disease undergoing open RPLND by an experienced urologist, the long time practice of the groups that I have the fortune to work with closely has been to not given adjuvant therapy since there is a substantial chance of obtaining cure with surgery alone without any chemotherapy. The upstag...
How would you treat a patient with metastatic RCC and significant baseline proteinuria after progression on immunotherapy?
- Tough situation no doubt. I would look for actionable genomic aberrations on NGS though limited in ccRCC. - Consult with a nephrologist and depending on severity of proteinuria, closely monitor proteinuria (urine checks as well as serum protein/albumin levels) with use of VEGFRi (short-acting ones...
What is your typical workup for a patient with a spontaneous renal infarct?
Broadly speaking, in the setting of a renal infarct, consider a thromboembolic event (venous thrombosis with paradoxical embolism or an arterial source) or a local vascular event such as dissection. The latter can be easily missed because the appropriate imaging is generally not performed. Once a va...
How do you approach transplant eligible myeloma patients with a partial or minimal response to treatment with 3-4 cycles of RVD?
This is something that occurs more often than is reported. Put another way, what to do when a patient's response plateaus after achieving a partial response? Evidence suggests that achieving at least a PR during induction is associated with better post-autologous transplant outcomes. What about VGP...