Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For a patient with previously relapsed TTP but in clinical remission, what is the role of rituximab in treating asymptomatic ADAMTS13 deficiency to prevent relapse?
A very good and interesting question. In remission, there is no question that severely deficient ADAMTS13 activity (<10%) is a strong risk factor for relapse. In patients with a chronic relapsing TTP history (at least 2 episodes), the approach most commonly has been to treat them preemptively with r...
How would you treat an adult patient with T-cell lymphoblastic lymphoma with FGFR1 rearrangement and co-exisiting myeloproliferative neoplasm?
This is a rare condition only recently recognized as its own diagnostic entity by the WHO as part of a larger family of disorders referred to not-concisely as "myeloid/lymphoid neoplasms associated with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2" (Arber et al., PMID...
When would you perform a thrombophilia workup in a pediatric patient presenting with VTE?
I was trained to do workup in cases of unprovoked VTE and still practice that way mainly to guide the length of anticoagulation therapy as well as prophylaxis. I must admit though, in pediatrics I have come to realize there is more practice based on experience and extrapolation from adult data than ...
Are there any special considerations when evaluating patients with non-malignant hematologic or immunodeficiency disorders for allogeneic transplant?
In most malignant diseases, we prefer to take patients to allogenic transplant either in complete or partial remission as it will take few months before post-transplant immune-reconstitution results in effective graft-versus-disease response. In non-malignant diseases, we take patients to transplant...
How do you decide between blinatumomab or traditional chemotherapy in combination with TKI for upfront treatment of adult patients with Ph + ALL?
This question is likely inspired by the recent publication of a "chemotherapy-free induction and consolidation first-line treatment" for adults with Ph+ ALL (Foà et al., PMID 33085860; GIMEMA LAL2116). The authors reported relatively high rates of MRD- remissions by bone marrow BCR-ABL1 RT-PCR and i...
What is the role of hydroxyurea in variant sickle cell genotypes?
I have had little success using hydroxyurea in my patients with hgb SC disease and at this point in patients with two or more acute visits over 12 months for pain, I am using crizanlizumab as some of the subjects in the phase 2 study on which the drug received FDA approval had SC disease (Ataga et a...
How do you treat a low-grade B-cell lymphoma with plasmacytic differentiation (Waldenstrom's) confined to the CNS?
This is a rare complication of WM called Bing Neelapu syndrome. It is hard to find a standard of care. Patients tend to have shorter responses to standard therapies such as HD MTX based regimens. Ibrutinib has shown long-term responses (Castillo et al., PMID 30523119).
Do you offer iron supplementation to a non-anemic adolescent athlete with a low ferritin?
I prefer having a TSAT on an overnight fast. Extreme athletes have increased hepcidin. If ferritin is greater than 30, my cut-off, no. If TSAT is 19 or less, yes. I would not criticize someone who gave iron, but PO iron is pretty tough to take. I would prefer staying within the current parameters of...
Would you recommend stem cell transplant or gene therapy for a patient with CML and sickle cell disease currently on imatinib with worsening anemia?
That's a great question. The first question to figure out is what is the status of the CML? If the patient is in a molecular remission on imatinib, I think it's important to understand why the patient has worsening anemia and do a work up. If the patient has anemia due to the TKI, can consider dose ...
How would you manage acquired von Willebrand syndrome secondary to a myeloproliferative neoplasm in a patient who is already on anticoagulation?
Acquired von Willebrand activity is something that can occur with MPN patients. It should be part of routine testing of patients with both ET and PV. Although, historically, usually thought of as a phenomenon of when platelets are greater than 1000, a recent publication (Rottenstreich et al., PMID 2...