Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred chemotherapy regimen for a fit younger patient with mantle cell lymphoma?
For a young fit patient with mantle cell lymphoma not suitable for observation and in need of treatment, without contraindications to intensive therapy, my preferred approach is to use the MCL Younger strategy of alternating RCHOP and cytarabine-based therapy as induction. I will routinely substitut...
What recommendations do you make regarding the use of biologics for uncontrolled Crohn's disease in patient's who have a history of DLBCL that developed while on infliximab and azathioprine and whose lymphoma is essentially cured?
This is a frequent question without a clear answer. There has not been a randomized study of anti-auto-immune therapy strategies to define the risk of a relapse or secondary lymphoma in patients with a clear need for treatment. I recommend the patient work with their rheumatologist to start a low i...
How would you manage CML first-line second generation TKI with a best response of MMR 4, but now with a loss of MMR with more than one log response loss but still in complete cytogenetic remission and mutation panel negative?
The easiest would be to repeat the test in 1 month or so. If the results show persistently increased levels, then I would monitor the patient closely. I would also review any new medications for possible drug to drug interactions. I would also review the patient's adherence, does the patient still h...
Is there currently a role for adding venetoclax to a hypomethylating agent (HMA) after failure of single-agent HMA therapy in MDS?
For patients with MDS who have failed single-agent HMAs, there is an intriguing small retrospective series suggesting that adding on Venetoclax at the time of HMA failure can lead to responses (Ball et al., PMID 32589727). Because of the retrospective nature of this publication and the small numbers...
How would you manage a patient with primary CNS lymphoma who is not a candidate for high-dose methotrexate?
This is a relatively rare situation in my experience, but I think WBRT is the second most active agent for PCNSL after high-dose MTX, so if MTX is not possible, I would strongly consider WBRT. Hypothetically, if patient has good PS and you are going for "curative intent", the standard WBRT alone app...
How do you manage classical early stage Hodgkin lymphoma patients when an ESR is not checked as part of their workup?
I personally don't think ESR plays a huge factor in the management of early stage Hodgkin Lymphoma now in the era of PET-adapted treatment selection. So, if a patient has very favorable stage I-IIA HL meeting all other criteria by the GHSH study and is interested to not have combined modality treatm...
With recent measles outbreaks occurring in the US, would you consider offering multiple myeloma patients s/p ASCT on maintenance treatment vaccination, or an alternate means of immunity?
Measles is on the rise and protection is appealing. The current guidelines for adult immunizations are not clear what patients with monoclonal gammopathy (MGUS), smoldering myeloma (SMM), or multiple myeloma should do. Are they all immunocompromised? Are they all immunocompromised to the same amount...
What stage is bilateral orbital/conjunctival NHL (limited only to the bilateral orbit/conjunctiva)?
By the Ann Arbor staging system, this is stage IV disease because more than one extranodal site is involved at initial presentation. However, NCCN and other guidelines acknowledge that MALT lymphoma involving both paired organs (e.g., bilateral orbital/conjunctiva) is often best treated with RT alon...
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.
How would you manage a patient with a MALT lymphoma (H. Pylori negative) found incidentally in the surgical specimen at the time of sleeve gastrectomy?
MALT lymphoma tends to be a multifocal disease. Furthermore, imaging is often suboptimal in delineating the true extent of disease within many extranodal sites, including the stomach. For these reasons, the entire organ is typically treated during a course of radiation therapy. Historically, radical...