Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What options are available for patients with relapsed/refractory AL amyloidosis after Dara-CyBorD, other than clinical trial?
No great answers, unfortunately. Lenalidomide still tends to make me a bit nervous in AL amyloidosis, as does carfilzomib in patients with known cardiac involvement. But pom-based regimens are an option, or carfilzomib-based in the appropriate population.If the patient's BMBx shows t(11;14) by FISH,...
For lymphoma, how long after chemotherapy can you wait to start consolidative radiation therapy?
My general practice is to have patients return 3 weeks after their last cycle of chemotherapy with labs and post-treatment imaging and then proceed with consolidation RT. Depending on the complexity of planning, I am generally starting RT ~4-5 weeks after their last cycle of chemotherapy. This is co...
What are your considerations for peri-operative anticoagulation in patients with a mechanical heart valve undergoing a major noncardiac surgery?
For a patient with a modern (e.g St Jude bi-leaflet) mechanical valve (with or without AF) and who does NOT have a h/o of stroke or TIA, the available evidence suggests that "bridging" may have more risk than benefit: See Kovacs et al., PMID 34108229 and Siegal et al., PMID 22912386. Based on this e...
What is your treatment of choice for triple class refractory multiple myeloma?
To define triple-class refractory means the patient is refractory to FDA-approved IMiDs (up to Pomalidomide), proteasome inhibitors (bortezomib and carfilzomib), and CD38 naked antibodies (e.g. daratumumab or isatuximab). Refractory is defined as progression or within 60 days of the last dose. I ag...
Does testing for elevated serum homocysteine have any relevance in thrombophilia management?
Homocystine levels is part of a DVT workup. Although rare, it is a factor in DVT risk. The gene mutation in MTHFR contributes to the elevation and the mutation frequency is extremely high. However, elevation is almost never seen due to added and natural folate in the diet.
What are contraindications for growth factors in patients with hematologic malignancies?
This is a challenging question where little data exist to support a good conclusion. In real world situations, patients with cytopenias and suggestion of TR-MN warrant aggressive antibodies find yourself deciding which is the "best of class" in its nature. John
Do you adjust the dose of ruxolitinib in primary myelofibrosis based on hemoglobin?
This is a tough question. It generally depends on how bad the anemia is. You can expect at least a gram (or more) drop in the hemoglobin when starting ruxolitinib, so baseline hemoglobin is important. Also, assuming that the patient is symptomatic, you would want to reduce the dose as little as poss...
How would you approach a resected solitary osseous plasmacytoma?
With a few exceptions, surgery is rarely pursued as a definitive modality in hematologic malignancies. I have never seen an orthopedic oncologist attempt an oncologic resection for a solitary plasmacytoma of bone, so my subsequent thoughts are theoretical. In the (very unusual) situation posed, if t...
How should one manage a patient with leukocytosis and borderline detectable BCR-ABL without other clinical features of CML such as basophilia or splenomegaly?
Leukocytosis has many causes and I will assume within the context of this question that we can narrow the definition to neutrophilic leukocytosis, and that it has been persistent without evidence of an underlying infection, cancer, inflammatory disorder, significant obesity, exposure to a drug or to...
How do you manage severe thrombocytopenia due to splenomegaly and bone marrow involvement in CLL when starting obinituzumab and venetoclax?
This is a tough question without any information about the case. I am assuming the patient is untreated. For this setting, there are really three options supported by randomized phase 3 trials. Venetoclax + Obinuzumab has a single randomized phase 3 trial that showed improved progression free surviv...