Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What would be your choice for re-induction in a young patient with FLT3+ refractory AML after 7+3 induction therapy with no FLT3 mutation on the day 14 marrow?
I would use a 5+2 regimen with midostaurin and would not put much stock in an absent FLT3 mutation at day 14. If there had been no cytoreduction, some would switch to another chemotherapy regimen but there is little data for that especially in an FLT3+ AML. We are not told what the degree of respons...
What would be your choice of therapy in a fit patient with relapsed CLL previously treated with bendamustine and rituximab who does not want BTK inhibitor therapy?
I am assuming that this individual who has relapsed was receiving initial therapy with bendamustine rituximab is a young, under 65 years of age, CLL patient who does not prefer to have a BTK inhibitor. This is not an uncommon situation given the increasing knowledge of the chronic low-grade toxiciti...
Is a patient with secondary myeloid sarcoma a candidate for hematopoietic stem cell transplant?
There are circumstances where these patients would be candidates for stem cell transplant. The extramedullary presentation is thought to be a high-risk feature and many of these patients will have a relapse in marrow or other sites, so a stem cell transplant done after remission is achieved may help...
Should venous thrombosis in a patient with Behcet syndrome be treated with both immunosuppression and anticoagulation?
They should be treated with immunosuppressive medications, however, the additional benefit of anticoagulation is much debated. Various studies and metaanalysis have shown that anticoagulation, on average, does not add any benefit. There may be exceptions to this in the early part of treatment for so...
How do you risk stratify complex karyotype in newly diagnosed multiple myeloma in the absence of specific high-risk cytogenetic abnormalities?
Complex karyotype with >3 abnormalities is high risk independent of high risk FISH abnormalities. It tells you that the cancer cell is able to divide in culture and that is a bad sign as they are able to survive outside the marrow. It typically portends a highly proliferative signature of myeloma si...
Would you offer rituximab maintenance for 2 years after a successful response to induction in a patient with splenic marginal zone lymphoma?
The answer will depend on age, performance status of the patient, thrombocytopenia, etc. No difference in OS was noted but freedom from progression was noted in rituximab group. 1 year did as good as 2 years maintenance.Kalpadakis et al., PMID 29914978
Would you offer treatment for asymptomatic CLL with WBC of ~300k or greater, high risk cytogenetics, or doubling time of 6-12 months?
Generally, starting treatment in a CLL patient is recommended based on the iwCLL criteria (Hallek et al., PMID 29540348).There is no WBC threshold that would require to treat, but the vast majority of patients with a WBC of 300K will have other reasons to start therapy. If this would be a patient wi...
Are there any reasons to consider a prolonged course of steroids with taper over a shorter course of pulsed steroids in the treatment of ITP?
As a general rule in pediatric ITP, I would say the answer is "no" but there are some exceptions. I'll defer to adult hematology colleagues to address this question for older patients, but some basic principles apply. 1. Steroid doses after an initial pulse, should be as low as possible because of ...
What is your approach to VTE prophylaxis following hematopoietic stem cell transplant?
My general approach is to offer VTE prophylaxis for patients with acceptable platelets count/absence of coagulopathy upon admission to the BMT unit for transplant and to continue until platelets are < 50k. I do not offer routinely VTE prophylaxis after SCT at discharge from the BMTU unit, with the e...
How do you approach diagnosing a patient with Iron Refractory Iron Deficiency Anemia (IRIDA)?
Iron-Refractory Iron Deficiency Anemia should be suspected when there is a lack of response to oral iron and only a partial response to intravenous iron. One should make sure there is not a chronic underlying inflammatory process to explain the lack of iron absorption or lack of the expected respons...