Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider radiation therapy before chemotherapy in a patient with stage I-II high-grade B-cell lymphoma presenting with a large necrotic skin lesion?
I would add that it is important to have a reasonable overall plan with Heme-Onc agreed upon to increase the likelihood of a successful outcome. Ideally, chemotherapy is administered first. This allows "consolidation" RT to be customized based on response. For example, a lower dose is utilized in a ...
Is there a role for rituximab in refractory HIT?
If the patient has continued thrombosis/thrombocytopenia after the withdrawal of heparin, the patient could be considered to have autoimmune HIT as described in this excellent article by Warkentin, PMID 37959386.There are case reports of the use of rituximab for refractory HIT. Batra et al., ASH Abs...
In a patient with APS and obesity during pregnancy when switched to LMWH, do you cap the dose of dalteparin as per manufacturers labeling at 18,000U per day or do you use weight based dosing?
Hi @Dr. First Last, We use enoxaparin in our institution, but the general principle that we follow is that we do not cap LMWH dose at a set threshold. I am assuming that you're referring to thromboprophylaxis and not the management of a VTE in the past 6 months. We monitor anti-Xa levels in obese p...
Do the level of positive lupus anticoagulant titers correlate with the risk of VTE?
The lupus anticoagulant test is either positive or negative. It’s not reported out at a titer. The test needs a two-step confirmation, the first being the addition of mixed plasma to rule out a factor deficiency and the second confirmation being the addition of phospholipids and showing normalizatio...
What is the role of CNS prophylaxis in a healthy patient in their 60s with a large DLBCL of the cranium/dura with brain parenchymal invasion?
In general, the role of CNS prophylaxis designed to prevent CNS progression in aggressive B-cell lymphomas is controversial given that it has known toxicities (infections, cytopenias) without good data to support. We still do it at our institution for patients with biologically high-risk tumors, but...
Would you give transdermal hormone replacement therapy to a woman with remote history of provoked pulmonary embolism?
There is good evidence that transdermal HRT does not pose the same risks as oral HRT (Morris and Talaulikar, PMID 36573625). ASA or DOAC prophylaxis is likely not indicated.
Can a patient with MDS have ring sideroblasts in the absence of mutation such as SF3B1?
Yes, < 50% of MDS RS have SF3B1 mutation by NGS. Malcovati et al., PMID 32347921
How would you approach radiation therapy for indolent T-cell lymphoproliferative disorder of the gastrointestinal tract?
Indolent T-cell lymphoproliferative disorder of the GI tract was a provisional entity in the 4th edition of the WHO classification system. In the 5th edition, the disease has been renamed, "Indolent T-cell lymphoma of the GI tract" (Alaggio et al., PMID 35732829). The disease is rare, often mimickin...
Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?
I have checked M-M-R, Td, and pneumococcal titers in patients with hx of infection and low Ig levels to see if they are making an immunological response. If any of these immune titers are low or the immunization is “due” by routine schedules, I recommend immunization and repeat testing in 6 weeks. T...
How do you approach a patient with chronic low ADAMTS13 activity and low level of inhibitor without signs of thrombocytopenia or hemolysis?
I'm assuming there is a history of overt TTP that led to the ADAMTS13 level being measured.In patients with a history of TTP, I monitor the ADAMTS13 level every 1-6 months (more often if the level is lower or dropping) and administer a single dose of rituximab if it drops below 20%. In my experience...