Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage a patient with non-mutated oligometastatic NSCLC with a brain met who underwent resection of the brain met, had 4 cycles chemoIO, and had resection of the primary lung CA with pCR and now is NED?
This is a great question, and this scenario does come up occasionally within our Thoracic Tumor Boards. What makes this scenario more complicated is the integration of immune checkpoint inhibitors into standard practice. However, this question has been addressed in the pre-immunotherapy era with num...
What is your preferred approach for managing oligoprogressive NSCLC during second-line or later systemic therapy if patient is otherwise responding well at other sites of disease?
I would offer metastasis-directed therapy with SBRT or if necessary based on site, hypofractionated (8-15 fractions) RT to oligoprogressive disease in this setting which we now have Phase 2 randomized data to support due to the nice work of Dr. @Dr. First Last and her team in the CURB trial. Patient...
What adjuvant treatment would you give to a locally advanced esophageal adenocarcinoma status post neoadjuvant FLOT s/p resection with positive margins?
For an R1 resection, considerations would include re-resection if feasible or chemoradiation. I would not favor chemotherapy unless there was evidence of a really convincing response from FLOT. I assume MSI testing was done.
In a patient with esophageal cancer with lymph node involvement, would you consider treating with definitive chemo-radiation if they have a single area of retroperitoneal metastasis?
If a patient has non-regional retroperitoneal adenopathy without other distant metastasis (i.e., below the level of the celiac axis), that patient has M1 disease, and upfront definitive chemoRT would no longer be the standard of care (systemic therapy alone would be). However, I would then consider ...
Given that ESOPEC did not mandate PET staging, are the conclusions of the study still applicable for patients who are staged with PET?
I believe the study results are still applicable to patients who are staged with PET.ESOPEC supplementary data show that 7 patients (all in the pre-op CRT group) had M1 disease at diagnosis, which was discovered due to PET staging. The total number of patients in each study arm with M1 disease prior...
Would you consider proceeding with a sentinel lymph node biopsy after wide excision revealed 1.2 mm residual non-ulcerated T2a melanoma on the upper back?
Any melanoma with Breslow’s depth of more than 0.8 mm (more than T1a) needs a sentinel lymph node biopsy for complete staging, due to higher chance of lymph node metastasis. Ideally, it should be done at the time of wide local excision, as doing the sentinel lymph node biopsy afterwards may be more ...
What is the role of adjuvant radiation in R0 node positive resected pancreatic adenocarcinoma in light of the recently presented RTOG 0848 abstract?
There are three options here in my practice. 1) Treat, 2) don't treat, and 3) "watch and wait, then ablate" (for a local recurrence). In general, I treat patients with CXRT who have positive margins (IMRT 45 Gy/25# to regional volume with SIB of 62.5 Gy to the margin. If it is an R2 resection (which...
What adjuvant treatment approach would you recommend for a patient with early-stage MSI-high gastric cancer who received neoadjuvant ipilimumab (×2) and nivolumab (×6) per the NEONIPIGA regimen, followed by R0 resection with no pathologic response?
I would favor FOLFOX x6 as per classic. This scenario raises the question: Was this truly MSI-H? I would confirm MSI status with next-gen sequencing. I would have expected a response if MSIH on ngs with concomitant high TMB. Our institutional practice has been to review all MSI-H IHC cases done outs...
How would you manage endocrine therapy in a male patient with gBRCA2 with a metachronous contralateral ER+ breast CA that occurred while on adjuvant tamoxifen for a different ER+ breast CA?
This is a tough situation. There is very limited data on the risk of CBC in men with gBRCA2 pathogenic variants and its impact on survival. In general, men with breast cancer suffer a worse prognosis compared to their female counterparts, although a large part of this may be driven by late stage at ...
What treatment would you offer to a patient after resection of a solitary metastatic melanoma from the brain without evidence of other sites of disease?
Resected stage IV melanoma, including patients with resected brain metastases, was included in the CHECKMATE 238 study of adjuvant nivolumab vs. adjuvant ipi published by Weber et al in NEJM 2017, which was a positive study overall with improved RFS in the nivolumab arm. The magnitude of effect in t...