Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a patient with vitreoretinal lymphoma without CNS or systemic involvement?
The optimal treatment approach for primary intraocular lymphoma is debated. This is a rare disease with only small retrospective series guiding therapy. There is no clear superior treatment approach in the literature. In clinical practice, younger patients are often treated initially with high-dose ...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?
My simple answer is “rarely, if ever” (but it can get much more complicated). Related to hepcidin changes, patients with chronic liver disease frequently have elevated serum ferritin and transferrin saturation, more so with alcoholic liver disease and non-alcoholic fatty liver disease. It is far fro...
How would you treat AML in a pregnant patient at 12 weeks' gestation?
My answer is under the assumption that, after a multi-disciplinary discussion with the patient, oncology/leukemia team, and maternal fetal medicine, the objective is to initiate AML-directed therapy while maintaining the pregnancy. The highest risk of deleterious impact to the fetus from chemotherap...
How would you treat AML in a pregnant patient at 12 weeks' gestation?
My answer is under the assumption that, after a multi-disciplinary discussion with the patient, oncology/leukemia team, and maternal fetal medicine, the objective is to initiate AML-directed therapy while maintaining the pregnancy. The highest risk of deleterious impact to the fetus from chemotherap...
If adjuvant radiation is offered to an elderly patient with H&N SCC s/p Mohs surgery who is planned for multi-stage reconstruction of the defect with plastic surgery, when should adjuvant radiation be started?
Tumor control comes first. If the surgical defect is such that reconstruction is required, it is even more imperative to focus on the above principle, as a recurrence would almost certainly risk ruining the entire collective effort. Vascular flaps could be safely performed post-RT in most cases by s...
How do you determine the timeline for healing after craniotomy prior to starting chemotherapy and radiation?
I typically wait at least 10-14 days post-op, always after neurosurgery has re-evaluated the craniotomy site for appropriate healing and has already removed staples or sutures.
How would you advise a younger patient with residual/recurrent optic nerve meningioma, proceeding with radiotherapy, about the risks of malignant transformation or induction of other brain malignancies because of radiation?
The risk of malignant transformation of an optic nerve sheath meningioma (ONSM) after RT appears to be remarkably low, much lower than the risk of blindness from an untreated, progressive ONSM. In a younger patient, I would lean toward RT for patients with imaging progression or early visual loss, ...
How do you conduct follow-up on patients with brain mets who have undergone GammaTile placement?
For patients with high-grade gliomas, they get an immediate post-implant CT and MRI for dose calculation, then I schedule serial follow up CE-MRI every 9-10 weeks for at least a year; if stable at the one-year mark, I "graduate" the patient to get MRIs every 12 weeks for the second year of follow-up...