Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What would be your approach in a patient with MET amplification and PDL-1 80% expression?
Need to clarify whether it is very high amplification ( need to verify with NGS provider). If high, can consider off-label Crizotinib ( these tend to metastasize to brain more frequently. Else, can start chemoimmunotherapy and switch to Crizo on progression , or one of the newer agents if approved b...
Would you offer adjuvant chemoRT to a patient with pancreatic adenocarcinoma who underwent neoadjuvant therapy with FOLFIRINOX and SBRT but had a positive (neck) margin on resection and is now s/p adjuvant chemotherapy?
This is why low dose, small volume SBRT is a flawed neoadjuvant treatment. This is possibly a marginal miss. It rarely happened in the past with conventional pre-op treatment but now it is happening commonly. Many patients are suffering because of it. It is important to assess the margin was in the ...
How do you approach CNS prophylaxis in patients with DLBCL?
I think the NCCN-CNS-IPI based on the German data is a reasonable place to start when it comes to making decisions regarding CNS prophylaxis. We typically do IT MTX for patients on the lower end of the risk spectrum and high-dose IV MTX for patients on the higher end of the risk spectrum.
What systemic therapy would you offer a postmenopausal women with oligometastatic sternal disease which developed while on tamoxifen?
For an isolated sternal metastasis, I would normally refer to radiation oncology for focused radiation, and I would change her hormonal therapy to an aromatase inhibitor, as these patients can have very long survival times. Some patients survive longer than a decade. (Milano MT et al). Having a sing...
If a patient achieves excellent clinical/radiographic response to neoadjuvant THP, would you omit AC and proceed with surgery?
If a patient has had only 4 cycles of THP (similar to the NeoSphere Trial preoperative component), then the standard of care is still to proceed with anthracycline-based therapy as we do not yet know if the favorable outcome associated with pCR applies to abbreviated therapy. However, for a patient ...
What is the role for "liquid biopsy" for patients with newly diagnosed metastatic NSCLC?
I send ctDNA on essentially every new diagnosis of metastatic lung cancer in my clinic. This is for a few reasons. The major reason is that I find these tests come back in about 7-10d on average, and while we have relatively rapid tissue-based NGS-based testing for actionable biomarkers with our pat...
How do you mitigate the risk of hearing loss for patients requiring cisplatin?
I have seen some centers do baseline audiometry testing for all patients to at least give a baseline if the patient then complains of tinnitus or other hearing changes during treatment. I'm not sure how much this helps without also doing surveillance during treatment and it hasn't become my standard...
Would you offer adjuvant chemotherapy in a patient with extensive LCIS/DCIS s/p mastectomy and multiple positive lymph nodes due to surgical seeding?
I don't believe that multiple positive lymph nodes should be attributed to 'surgical seeding' alone, as opposed to invasive disease not visualized in the breast specimen (or apparent on preop imaging that included the axilla). Would ask my pathologist to perform receptors on the disease in the nodes...
How would you approach systemic management of a patient with an early aggressive metastatic relapse of previously early stage triple negative disease in breast only but now with multiple distant metastatic sites (including contralateral breast) which is now high ER expressing?
There isn't sufficient information to answer your question succinctly. Did she receive neoadjuvant chemotherapy, and, if so, how did she respond? Have you biopsied a metastatic site other than the contralateral breast? if not, you should, to assess its ER expression. Even if she is PD-L1 positive, t...
How would you manage a patient with TNBC breast cancer with local recurrence at mastectomy site within 3 months of surgery?
Since the patient has not received any systemic therapy, and the recurrence occurred within 3 months of primary breast surgery, I would strongly consider chemotherapy followed by either surgical excision (if possible) or radiation to the site of local recurrence. CALOR trial provides some evidence f...