Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage refractory hyponatremia in patients on active therapy in small cell lung cancer?
The classic teaching is that if this is a paraneoplastic SIADH then treat the underlying cancer. If hyponatremia is worsening despite treatment, it might herald progression. I have used tolvaptan in the past as bridge but without effective treatment, this is likely not going to be very effective. Of...
Would you prefer nivolumab/ipilimumab combination over single agent pembrolizumab for a metachronous low volume MSI-H, metastatic colon cancer, with KRAS mutation?
To date, I don't think there are any single negative or positive predictive markers of response to immunotherapy in dMMR/MSI-High.The ones identified retrospectively on subset analyses include KRAS as you mentioned Other studies with BRAF, Or liver metastatic disease Elderly However, my take/experi...
How do you initially treat patients with cN3 cM0 esophageal cancer?
This is an extremely heterogenous group and requires expert multidisciplinary review to generate an individualized plan. In fact, we discussed several patients with N3 disease -- very extensive but technically locoregional lymphadenopathy -- at our Disease Management Team meeting yesterday morning.O...
For a patient requiring adjuvant endocrine therapy for localized breast cancer, would you use fulvestrant if they were intolerant to both aromatase inhibitor and tamoxifen?
I think you may run into coverage issues since fulvestrant is not approved for the treatment of early breast cancer. For patients who don't tolerate AI or tamoxifen, I normally try Fareston (toremifene). I have a small handful of patients in my panel that have tolerated that when they haven't tolera...
Would you consider trastuzumab deruxtecan as next line of therapy for patients with ERBB2 mutation positive, stage IIIB NSCLC, who progress within 6 months of chemo- radiation?
Yes, I would consider trastuzumab deruxtecan as the next line of therapy for patients with ERBB2 mutation-positive, stage IIIB NSCLC, who progress within 6 months of chemo-radiation. We typically use recurrence within one year as the time frame between completion of chemo-radiation and recurrence fo...
For patients with NSCLC on osimertinib who progress, would you continue osimertinib when moving onto chemotherapy for 2nd line therapy?
It all depends if we have systemic vs non systemic acquired resistance. You can continue osimertinib if you have slow progression or oligomets can be treated with local therapy like radiation. Sometimes you can increase the dose to 160mg if only CNS progression and asymptomatic. In case of systemic ...
How do you manage hyponatremia in patients with renal cell carcinoma on cabozantinib and nivolumab?
Since ICPI can cause thyroiditis and adrenal insufficiency, the TSH and AM cortisol should be checked -- in addition to the usual evaluation for hyponatremia (serum and urine Osm, urine electrolytes, and an assessment of the patient's volume status). If adrenal insufficiency is present, the hyponatr...
What imaging surveillance do you do after SABR of oligo lung metastases?
Since these are metastatic patients I would recommend chest CT scans every 3-4 months for the first and second years. Abdomen and pelvis CT scans could also be done depending on the patient and their disease. I do not recommend PET-CT after SBRT for lung metastases or after SBRT for lung primaries. ...
What are your recommendation for vaccines in patients while on immunotherapy?
It's ok to give.
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 ...