Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For locally recurrent disease after surgical resection of EGFR/ALK positive NSCLC that appears suitable for chemoradiation, would you proceed directly to chemoradiation or consider TKI first?
It depends on a lot of factors—initial stage, whether adjuvant chemo was administered or not, how soon after completion of initial treatment did patient recur, was a complete restaging work up done? How bulky is the recurrence? If patients have limited loco-regional recurrence and did not receive ch...
Would you consider splenectomy for an early stage l/ll primary splenic diffuse large B cell lymphoma followed by R-CHOP?
No reason to remove the spleen in most cases unless it was removed to secure the diagnosis. In this case, I assume the spleen was biopsied already? I would treat as you would a stage I DLBCL (the spleen is nodal tissue), but consider 6 cycles of R-CHOP if possible. If CR by PET at the end of treatme...
Would you consider retrying a platinum based chemotherapy agent in a platinum resistant ovarian cancer patient?
Yes, I would consider the use of platinum agent again, especially if it has been a long time since their last platinum therapy. I could consider the use of Cisplatin in this case or Carboplatin.The GCOG consensus statement recommends the following timelines for platinum response classifications:(1) ...
What is your first line therapy for progressive symptomatic metastatic adenoid cystic carcinoma?
Although platinum regimens can be considered for treatment of metastatic ACC, I generally reserve such regimens for patients with large, bulky symptomatic disease. Over the past few years, TKIs have tested in this patient population with the last report published with lenvatinib (Tchekmedyian, et al...
What would be your chemotherapy/biologic sequence choice in a RAS wildtype metastatic CRC, for which FOLFOX and bevacizumab was given first line?
In second line RAS WT patients who have not had anti-EGFR and have not had irinotecan, anti-EGFR therapy with either irinotecan monotherapy or with 5-FU. There is no prospective data that supports using sidedness to withhold anti-EGFR for right sided patients who are RAS WT.References for 2nd line c...
Would you treat unfavorable intermediate risk prostate cancer in the setting of recently resected NSCLC?
This greatly depends on the stage of the lung cancer. If stage IIIA resected NSCLC, I would not treat the prostate cancer immediately, and effectively enter them into active surveillance until the patient is 2 years free of NSCLC on follow-up imaging. If they recur from NSCLC within 2 years, they ha...
How do you diagnose acute leukemia-mixed phenotype?
Mixed phenotype acute leukemia (MPAL) is extremely rare and is diagnosed by immunophenotyping studies demonstrating two distinct blast populations, one myeloid (AML) and the other lymphoid (ALL). Ultimately, these patients require an allogeneic stem cell transplant. I treat these patients according ...
Would you offer neoadjuvant chemotherapy for a patient with low-grade upper tract/renal pelvis urothelial carcinoma with concurrent bladder drop-metastasis?
This question has several aspects. How commonly does a low-grade urothelial tumor metastasize? Is the described lesion in bladder truly a drop metastasis from upper tract? How can concurrent lesions in upper urinary tract and bladder be approached?Underestimation of staging and grading is a problem ...
Which criteria do you follow to recommend low-dose CT screening in patients at high risk for lung cancer?
At this time, I still follow the USPSTF/NLST guidelines, but believe the criteria for screening should be updated to include more patients. The current recommendations from the USPSTF based on the National Lung Screening Trial demonstrating an improvement in lung cancer and all cause mortality inclu...
In what scenarios would you incorporate platinum for patients with localized TNBC?
In the neoadjuvant setting, I include a platinum - specifically carboplatin - in the chemo regimen in essentially all patients with TNBC. Not only have 3 randomized studies (CALGB 40603, BrighTNess and GeparSixto) demonstrated significantly higher pCR rates with addition of carboplatin, if you look ...