Gastroenterology
Expert perspectives on IBD, liver disease, motility disorders, and GI diagnostic and therapeutic procedures.
Recent Discussions
Has pelvic MRI replaced EUS as the standard of care for rectal cancer staging?
I think looking at data both show very similar sensitivity and specificity for staging and is matter of expertise and resources available at the institution.
When do you perform BRAF testing in colon cancer?
I now perform BRAF testing as close to diagnosis of metastatic cancer as possible. While it is not a predictive test, the prognostic value is important. We discuss prognosis with our pancreatic cancer patients differently than our CRC patients. Now, I think we should discuss prognosis differently wi...
When do you perform HER2 testing in patients with colorectal cancer?
HER2 amplification is seen in a small but distinct subset of colorectal cancer. This subset has 2 unique characteristics: They are predominantly RAS wild type tumors. They do not respond to anti-EGFR agents, i.e. HER2 amplification is a negative predictor of anti-EGFR antibody (cetuximab and panitu...
Could a non-cirrhotic patient with a single HCC lesion measuring >5cm who is ineligible for liver transplant by Milan size criteria alone become a candidate if the tumor shrinks after TACE?
While the Mazzaferro (Milan) criteria still represent the primary basis by which HCC candidates for liver transplant are chosen, certain centers such as ours (UCSF) have studied the strategy of expanding eligibility criteria for OLT. This includes both increasing upper tumor size limits, as well as ...
Would you recommend sorafenib as an adjunct to liver targeted therapy in patients with hepatocellular carcinoma who are awaiting liver transplant?
There is not a clearly defined role for adjuvant sorafenib following locoregional therapy for HCC. The two main prospective randomimzed trials that inform this recommendation are:- The SPACE trial (Lencioni et al, J Hepatol 2016) -- no improvement in TTP when DEB-TACE was followed by sorafenib vs pl...
Is it necessary to hold immunotherapy during a 4-6wk steroid taper after resolution of immunotherapy related toxicity?
This is an excellent question. Most of the clinical trials with checkpoint inhibitors required complete taper of steroids prior to rechallenging wtih immunotherapy following toxicity. As we use immunotherapy in the clinic, and have utilized combinations with chemotherapy, including regimens that use...
What is your treatment algorithm for solitary hepatocellular carcinoma, 3-5 cm, non-operative candidate but Child-Turcotte Pugh A/B?
This really boils down to two issues: CTP score and size of the lesion. For patients who are CTPA with a lesion <3 cm, RFA/MWA or SBRT are good options although there is some data from the University of Michigan (Wahl et al., JCO 2014) that lesions > 2 cm are better served with SBRT. For solitary le...
Are you categorically using lenvatinib over sorafenib for unresectable HCC in the absence of contraindications?
I have done that is recent patients, yes. I am doing it because "on paper" I see better PFS and better ORR, of course in addition to the non-inferiority when compared to sorafenib in the randomized trial that is now published. However, I am building experience with respect to tolerance in my particu...
How do you manage venous thromboembolic events or bleeding events in RCC or HCC patients on anti-angiogenic TKIs?
I generally would not discontinue for a bleeding event for an RCC pts on anti-VEGF therapy. I may hold drug while managing the event if I can control the source of bleeding, but given most options include such an approach would restart cautiously. Similarly for venous thrombotic events I would manag...
How do you sequence antiviral therapy and cancer-directed therapy in a newly diagnosed patient with hepatocellular carcinoma and incidentally found hepatitis C?
According to the recent publication by Cabibbo G, et at, J. Hepatol. 2019, 71, 265–273, yes direct-acting antivirals after successful treatment of early hepatocellular carcinoma improves survival in HCV-cirrhotic patients. No such data or evidence for advanced disease though. in that case, antiviral...