Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When would you consider splenectomy or other immunosuppressive/cytotoxic therapy for steroid-refractory warm autoimmune hemolytic anemia?
If it is refractory to prednisone, my next approach is Rituxan. If it fails to respond to Rituxan, I have had luck with Daratumumab. I avoid splenectomy since the response rate is no better than 30%.
What are your indications for pursuing a rheumatologic workup in a pediatric patient with ITP?
In regard to pediatric ITP patients and a rheumatologic workup, first, there is no data comparing pediatric ITP patients of all ages and both genders as to the exact rates of positivity and the implications of the positivity in any group. Having said that, there is some consensus that adolescent fem...
How would you manage a patient with Stage IVB DLBCL with refractory disease in the retroperitoneum and spleen after 6 cycles of RCHOP?
The management of primary refractory stage IV DLBCL is complex and generally not successful. See NCCN Guidelines for details. I would distinguish, however, between those patients who are clinically refractory and those who have clinically responded well but may have residual disease by imaging, i.e....
Would you consider just treating radiographic residual disease (as opposed to all original sites of disease involvement, per ILROG guidelines) in a patient with bulky early-stage Hodgkin's lymphoma of the mediastinum?
If the patient is treated with > 4 cycles of chemotherapy and the disease is considered chemo-refractory, and if dose constraints to critical structures especially to the lungs can be achieved, I would recommend treating all the original sites of disease involvement, then add boost to the residual s...
Do you recommend long term anticoagulation for all patients with first time unprovoked VTE?
I consider long term anticoagulation after a first unprovoked proximal DVT or PE in patients with low bleeding risk, especially if they are male. Risk/benefit discussion is employed for patients who have a higher bleeding risk after a first unprovoked VTE event.
When do you utilize lenalidomide in patients with MDS without del(5q)?
Lenalidomide is beneficial in low-risk and int -1 risk MDS patients with anemia even without del 5q in combination with EPO as shown in ECOG 2905 study.List et al., PMID 33439748These low-risk MDS tend to be MDS with refractory anemia and ringed sideroblasts.MDS RS with thrombocytosis tends to be re...
How would you approach a patient presenting with pancytopenia and splenomegaly whose bone marrow biopsy is morphologically normal but has a positive Philadelphia chromosome in bone marrow as well as peripheral blood?
Given pancytopenia and splenomegaly, I’m surprised bone marrow is read as normal. Look for evidence of myelofibrosis in marrow by performing reticulin stain. How big is the spleen? This picture is consistent with CML. What is the blasts % in blood and marrow? What is the basophil %? I would treat as...
How do you approach anticoagulation in patients with catastrophic antiphospholipid syndrome and thrombocytopenia?
Due to the rarity of CAPS, there are no evidence-based guidelines available and most treatment is empiric or based on expert guidance. Most would agree that the mainstay of treatment is anticoagulation, and the preferred anticoagulant is unfractionated heparin. In a recent guideline paper, therapeut...
Do you approach the diagnosis and treatment of HIT patients differently in the outpatient setting or in a resource-limited community setting?
The concern for heparin induced thrombocytopenia is a complex problem. If the patient has HIT by 4T score and thrombosis, then admission to the hospital for initial management including direct thrombin inhibitor is the correct path awaiting confirmation by ELISA and platelet release assay. If negati...
How do you manage a delayed hemolytic transfusion reaction in a patient with sickle cell disease?
The diagnosis and management of a delayed hemolytic transfusion reaction (DHTR) requires a high index of suspicion. In those patients in whom a DHTR is suspected or confirmed, further RBC transfusion should be withheld unless absolutely necessary, and if then only with the most compatible RBC units....