Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
If you decide to discontinue TKI after prolonged molecular remission in CML, how often would you follow the BCR/ABL after discontinuation?
The NCCN has updated the guidelines and included specific and detailed criteria for TKI discontinuation. Per the NCCN guidelines: "Monthly molecular monitoring for one year, then every 6 weeks for the second year, and every 12 weeks thereafter (indefinitely) is recommended for patients who remain in...
What is an appropriate dose for definitive radiation of a stage IE EBV+ polymorphic B-cell lymphoproliferative disorder?
This is a very unusual presentation for EBV associated polymorphic B-cell lymphoproliferative disorder as most cases are seen in the post-transplant or other immune-compromised patients. In immuno-competent patients, this condition is felt to be related to immune senescence. The range of clinical be...
Does CD5 positivity by itself in DLBCL pose a high risk of CNS recurrence and necessitate CNS prophylaxis?
There are convincing data that de novo CD5+ DLBCL does confer a heightened risk of CNS relapse - in the largest series reported, this risk was 12.7% after treatment with RCHOP chemotherapy, and this despite 15% of patients having received intrathecal methotrexate as prophylaxis [https://doi.org/10.1...
How would you treat an older patient with newly diagnosed B-ALL and significant cardiac and neurological co-morbidities?
Treating older patients with newly diagnosed B-ALL WITHOUT significant comorbidities is challenging enough! There is no accepted standard of care for the treatment of older adults with ALL, typically defined as over the age of 60. Lower intensity chemotherapy backbones with the addition of ABL kinas...
What is your preferred approach to therapy in transplant ineligible multiple myeloma initially treated with CyBorD owing to acute renal failure, after achieving a VGPR (+IFE alone) with continued mild-moderate renal impairment?
After completion of initial treatment, our practice is to offer patients maintenance therapy with Revlimid based on the meta-analysis of Revlimid maintenance done in patients following autologous stem cell transplant. This includes patients who have not had lenalidomide upfront. Using maintenance le...
Do you routinely add eight extra rituximab doses to six cycles of R-CHOP in elderly patients with DLBCL treated with miniR-CHOP as done in SMARTE-R-CHOP-14 trial ?
I rarely give R-mini-CHOP and even when starting with that regimen I will attempt to escalate as tolerated to standard dosing in elderly patients and as such don’t see much benefit in extra rituximab.
Is concurrent intrathecal therapy necessary with HD-MTX for CNS lymphoma?
Generally, high dose methotrexate has high penetration into the CSF so you do not need to give concurrent intrathecal therapy. The only time you might consider it is if they still have persistent disease in the CSF despite the high dose methotrexate. The approach does not change for primary vs secon...
What is your preferred treatment to ameliorate bone pain from G-CSF?
Loratadine (or cetirizine) used prophylactically before each dose is very effective. There are published cases : https://www.ncbi.nlm.nih.gov/m/pubmed/24664474/ and my experience is this is effective in a vast majority of cases.
What is your approach to the decision to use CPX-351 or standard 7+3 for de novo AML?
CPX-351 is a dual-drug liposomal encapsulation of cytarabine and daunorubicin that delivers a synergistic 5:1 drug ratio into leukemia cells to a greater extent than normal bone marrow cells. It was approved by the FDA in 2017 for the treatment of adults with newly-diagnosed therapy-related acute my...
For a patient with diffuse large B-cell lymphoma of the testicle, do you irradiate the contralateral testicle alone or do you recommend radiation to the lymphatics and remaining testicle?
The most common clinical scenario for primary testicular lymphoma is an older man presenting with a painless testicular mass who undergoes orchiectomy and is found to have DLBCL. Many patients will have stage I disease with post-orchiectomy PET-CT showing no other sites of involvement. Occasionally,...