Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How often do you follow ferritin and organ iron-deposition in a patient who has known hereditary hemochromatosis, but no current evidence of iron overload?
Once diagnosis is made, I stress blood donation or less optimally, therapeutic phlebotomy. If donation every 56 days until ferritin <100 and TSAT <30. This assumes asymptomatic without LFT abnormality. Thereafter the intervals can be adjusted to keep parameters in the desired range. I never follow o...
What is the optimal initial therapy and management of Erdheim-Chester disease without actionable mutations such as BRAF or MAPK-ERK pathway alterations?
Would refer to the latest ECD consensus guidelines and NCCN guidelines on histiocytic neoplasms for the answer to that question: Goyal et al., PMID 32187362 In short, here are the considerations:1. Even patients without bonafide MAPK-ERK pathway mutations can respond to a MEK-inhibitor such as cobim...
How long do you continue caplacizumab in relapsed refractory TTP?
While there are no data from studies to guide our answer, general practice is to continue caplacizumab until the ADAMTS13 activity is at least 20% on two occasions, or greater than 30% assuming it was measured at least 4-5 days after the last plasma exchange procedure. The goal is to have stable rec...
What is your perioperative approach for a patient with severe hemophilia?
The optimal management of people with hemophilia is complex. Planning for elective surgery should include the patient, family/caregivers, and all relevant clinicians to ensure that best practices are followed. Collaboration with experts from a hemophilia treatment center to develop a hemostatically ...
What is your approach to a patient who has an ischemic stroke while on clopidogrel despite strict compliance and normal results on clopidogrel response assay?
Not all recurrent infarcts are from a failure of anti-thrombotics, some patients with large artery atherosclerosis are not taking their statin (as evidenced by no change in LDL-C) or are not exercising (based on subanalysis of SAMMPRIS), other lacunar subtype patients have uncontrolled hypertension,...
Can you use other iron formulations if a patient develops Stevens-Johnson Syndrome with ferumoxytol?
I have never seen it in tens of thousands of doses so it is difficult to answer. If this is actually real, it must be due to CHO component and not Fe (that would be awful). I would use another formulation and premedicate with steroid and H2 blocker before. Do not use antihistamine.
How would you approach immunosuppression for patients with severe aplastic anemia who are not transplant or ATG candidates?
There are relatively few alternatives. One is just supportive care with transfusion, antibiotics, etc. Many patients will adapt to low Hb and do ok with low platelets and do not require therapy. A calcineurin inhibitor alone or with eltrombopag can also be used - the response rate is not as good as ...
Should assessing for a MTHFR mutation be part of the thrombophilia evaluation in a patient presenting with a thrombus?
MTHFR mutation testing is of very little utility, given that the functional readout of MTHFR dysfunction is homocystinuria. The intake of the treatment of homocystinuria is folate, which is ubiquitous in the US diet. Thus, homocysteine levels would be adequate for testing, if such testing is indicat...
What regimen would you recommend for a younger, fit, transplant eligible patient with relapsed IDH1 positive AML?
If there was only one answer! The decision revolves around co-occurring cyto and molecular genetic abnormalities (in addition to IDH1) and the duration of remission in first CR. In general, IDH mutant AML - without other high-risk genetic lesions - is very responsive to all of our treatments whether...
With what agents can you replace PPIs if they cause thrombocytopenia?
The incidence of PPI-induced thrombocytopenia is very low - and really only reported in case reports. I would suggest ensuring the low platelet count is really from the PPI (in some cases may be reasonable to re-challenge the patient), and not from a more common reason. In a recent case report on La...