Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred first-line therapy for a patient with standard risk multiple myeloma?
Tough question. Let's do the easy ones first. The low risk (R-ISS 1) fit patient could be treated any number of ways with Bortezomib+Lenalidomide+Dexamethasone (RVd), Carfilzomib+Lenalidomide+Dexamethasone (KRd), or Daratumumab+Lenalidomide+Dexamethasone (Dara-Rd). Bortezomib can lead to neuropathy...
How would you treat a patient with a refractory primary splenic marginal zone lymphoma with symptomatic splenomegaly (20 cm) and a mild pancytopenia?
Radiation therapy is utilized in two primary settings to palliate symptoms of splenomegaly in patients with hematologic malignancies.First, extramedullary hematopoiesis within the spleen can lead to symptomatic splenomegaly in a variety of hematologic malignancies (e.g., myelofibrosis). In this sett...
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...
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...
In transplant-eligible, fit patients with multiple myeloma who have an inadequate response to front-line therapy, what regimen would you choose for second-line?
for transplant eligible patients who you want to get to transplant but have not achieved an adequate response for stem cell collection, there are 3 senarios: 1: if no response at all to front line therapy (VRd) say <PR: would do VDPACE x 2-3 cycles, using the last cycle as chemo mobilization with co...
In staging Hodgkin's lymphoma, would you identify a PET+ bony focus as disease when there are no associated bone changes on CT and a biopsy was not obtained?
PET is generally the most sensitive indicator for-involvement with HL, so I would not let the absence of CT findings deter one from diagnosing bone disease if the PET is convincingly positive. One should also weigh the clinical circumstances and consider how likely the pt is to have bone involvement...
How do you approach front line treatment for TP53 mutated mantle cell lymphoma?
For patients with TP53 mutations based on the information presented by Eskelund et al. and previous experience. Given the knowledge that the mutation is a dominant negative which eliminates and functional activity of the tumor suppressor it stands to reason that an durable response with chemotherapy...
In a patient with Waldenstrom's macroglobulinemia doing well and feeling better on ibrutinib & rituximab, but with a rising IgM, do you switch treatment or continue?
A lot depends on the pace of increase of the IgM and the line of therapy. If the pace is rapid, I would think about changing therapy. If the pace of increase is small and the patient is asymptomatic, you could continue a little longer. If planning to changing therapy, it may be reasonable to restage...
Do you routinely order double-hit assessment in cutaneous DLBCL?
There are certainly reported cases of primary cutaneous DLBCL that harbor double-hit mutations. Guidelines do not distinguish the workup of cutaneous DLBCL from other sites, and if a skin DLBCL were to be of germinal center immunophenotype with IHC expression of myc and bcl2 and/or bcl6, FISH would ...
Would detection of an adverse cytogenetic marker such as dup(1q) alone in the setting of MGUS satisfy criteria for a diagnosis of multiple myeloma?
Short answer, no.Longer answer -The important transition between MGUS/SMM to MM is CRAB criteria (hypercalcemia, renal disease, anemia, bone lesions), OR the development of a myeloma defining events -- >60% clonal plasma cells on bone marrow, multiple lesions on MRI, or FLC ratio > 100. These myelom...