Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In a patient with liver metastases from a pancreatic NET, that have been successfully treated with ablation by interventional radiology, would you resect the primary pancreas lesion?
Grade absolutely matters here. The number of liver mets and other extent of disease also matter. For low-grade pancreatic neuroendocrine tumors (PNET) with liver only metastases who are good candidates for surgery, resection can be considered. Benefit was seen in this study with locally advanced PNE...
How would you treat DLBCL of the terminal ileum in an otherwise healthy patient?
Primary intestinal Diffuse large B cell lymphoma (PI-DLBCL), even if found incidentally on a screening colonoscopy in an asymptomatic patient, should be treated with systemic chemotherapy similar to what is done with nodal DLBCL. With this approach, the prognosis for PI-DLBCL is very good based on t...
Would you treat prostate cancer with hormone sensitive metastatic recurrence (after local treatment) the same as de novo metastatic hormone sensitive disease?
Yes, most of the phase 3 trials (ARCHES, ENZAMET, TITAN, STAMPEDE) permitted relapsed mHSPC patients in addition to de novo mHSPC patients. LATITUDE was the only trial that required newly diagnosed patients with mHSPC. For the AR inhibitors, a similar benefit in delaying radiographic progression or ...
In transplant-eligible, fit patients with primary refractory myeloma, what is the optimal timing for stem cell collection?
In fit patients with less than a partial response to induction therapy, i.e. primary refractory, the optimal timing for stem cell collection is NEVER. If they don't respond to three drug induction (proteasome inhibitor + IMiD + steroid), they are unlikely to respond durably to a standard high dose m...
Would you rather start radiation for Stage III NSCLC in the middle of a chemotherapy cycle or wait for the 2nd cycle if it could not be started on cycle 1 day 1?
While we all strive to provide streamlined multidisciplinary care, it may not always be possible to start at the same time. I usually discuss this with my collaborating radiation oncology physician. I usually like to time the radiation on D1 for logistical reasons. RT treatments for stage 3 disease ...
For patients who received neoadjuvant Imatinib for initially unresectable GIST tumours, do you routinely prescribe adjuvant therapy or rely on preoperative staging and preoperative mitotic index?
I agree with Dr Groisberg. Another way to look at it is that if the patient would have qualified by preoperative risk factors, I wouldn’t “downgrade” that by the improved risk tumor that comes out. Sometimes you can’t be sure ahead of time- for example I just saw a patient with a 3 cm duodenal tumor...
If you are treating a patient with palliative radiation for hemoptysis do you require chemotherapy to be held?
This is an interesting question. I would like to thank @Dr. First Last for his help with this. In recent years, I have rarely found myself asking colleagues from Medical Oncology to hold chemotherapy for patients who require palliative radiotherapy for hemoptysis. That being said, very few such pati...
When do you give exogenous albumin in an attempt to reduce risk of ifosfamide induced encephalopathy?
We don’t routinely give albumin as prophylaxis for ifosfamide induced encephalopathy (IIE). While there is an association between hypoalbuminemia and the risk of IIE, prophylactic replacement with albumin doesn’t appear to reduce the risk based on two retrospective studies at academic medical center...
How do you reconcile the difference with regard to adjuvant treatment recommendations when a breast biopsy reveals >10% ER+ but a subsequent lumpectomy of the same lesion is ER-negative?
Situations such as this typically involve review with pathology, including a second opinion review, to settle on one of two basic camps of possible explanations: 1. Heterogenous cancer or even possibly multiple primaries with differing receptors. Although not common, some cancers are heterogeneous w...
How would you treat a metastatic lung adenocarcinoma with MET exon 14 skip mutation on ctDNA, negative tissue NGS and PD-L1 of >50%?
I would treat this patient with single-agent pembrolizumab. If they had rapidly progressing disease with worsening symptoms or if they were a never smoker, I would favor carboplatin/pemetrexed/pembrolizumab in order to optimize rapidity of response. These recommendations are based on the results of ...