Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is the difference between involved node and involved site irradiation?
In both involved node and involved site (ISRT), prechemotherapy GTV determines the CTV. However, ISRT accommodates cases in which optimal prechemotherapy imaging is not available to the radiation oncologist. In ISRT, clinical judgment in conjunction with the best available imaging is used to contour...
Should I decline to treat a patient with a first site of metastasis who refuses a biopsy?
Ideally, all patients with a first site of metastatic disease should have a biopsy. However, the details are critical. Is the location amenable to a bx? Is the patient's performance status poor? Has it been an extended period of time since treatment for the primary disease? Is it a solitary metastas...
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.
Should early referral to palliative care be standard of care for all patients with metastatic cancer?
There are data to support that early palliative care involvement can improve patient quality of life. One study that specifically comes to mind is a study published by Temel et al in NEJM 2010 (http://www.ncbi.nlm.nih.gov/pubmed/20818875) in the setting of metastatic NSCLC. This study randomized pat...
How do you take tumor seeding into account when staging NSCLC?
This is a rare situation but based on the current AJCC staging, if this is in same lobe then would stage as T3 disease. If discovered after treatment of the primary disease, we would still treat this like a localized process, as is not hematogenous spread and not like metastatic disease. Seeding of ...
How are patients on anticoagulation managed in the context of intracranial SRS?
At our institution, we do not withhold heparin or warfarin prior to treatment. This risk of intracranial bleed is not felt to be increased as a consequence of treatment. We do use a traditional headframe (using pins to hold to the skull). While there may be an increased risk of bleeding at the pin s...
For elderly patients with locally advanced rectal cancer who are not candidates for surgery or chemotherapy, what would be an appropriate palliative regimen?
There is an old paper from Princess Margaret Hospital ~1980, called "Is the Miles operation really necessary for the treatment of rectal cancer?". (Editor note: 1993 Update). These are patients who were medically inoperable or refused surgery. I believe doses were about 40 Gy. Remember that this was...
How do you handle post-op, pre-radiation breast seromas and hematomas?
It depends on what I'm doing. If the patient is being treated to only the whole breast, like with the Canadian protocol, then I tend to do nothing. I just go ahead and treat. The hematoma usually won't resolve enough to change the volume over the three weeks. If I feel this patient needs a boost, th...
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...
How do you perform geriatric assessment for cancer patients?
This is a HUGE topic. I would like to suggest the following 2 resources that you may find helpful. https://www.mycarg.org/?page_id=898 and the following one helps predict residual life expectancy independent of cancer diagnosis: https://eprognosis.ucsf.edu