Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there a correlation between rectal cancer stage and dose response to radiotherapy?
Possibly. While some compelling data from Appelt et al. in 2013 reflected there may be a correlation between RT dose and rectal tumor response (Appelt et al., PMID 22763027), an extensive number of prospective trials examining the influence of boost doses of RT on pathologic response have produced m...
How would you approach a patient with HR+, HER2- metastatic breast cancer who is endocrine resistant, with bone marrow involvement and pancytopenia?
Symptomatic bone marrow involvement (bone marrow carcinomatosis) is extremely rare in metastatic breast cancer and carries very poor prognosis. It is often associated with microangiopathic hemolytic anemia and DIC. Anemia is the most common manifestation and WBC and platelet counts are often not tha...
Would you consider perioperative antifibrinolytics for mild factor 7 deficiency undergoing surgery?
I do use antifibrinolytics in factor VII deficiency; however, it depends on the specifics of the surgery (i.e., mucosal surface surgery, sequelae of bleeding should it occur - spine vs oral), the patient's bleeding history, and the factor VII level. Here, I wonder if the original diagnosis was corre...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
How would you treat a patient with newly diagnosed stage IV NSCLC who has an activating mutation in the ERBB2 extracellular domain and a concurrent classical EGFR mutation?
No high-level evidence/guidelines for such a situation since oncogenic ECD mutation in HER2 itself is quite uncommon (approximately <10% of HER2 mutations [Robichaux et al., PMID 31588020]), and co-occurrence with classical EGFR mutation will be even less common. Will generally treat based on the cl...
Can aplastic anemia present with multiple infiltrative bone lesions, such as in the spine and pelvis?
There are several studies showing diffuse hypointense pictures with an infiltrative-like pattern on MRI in aplastic anemia and MDS. Some aplastic anemia and refractory cytopenia of childhood show patchy pattern of hematopoiesis with some regions having increased fat fraction and some remnants of hem...
For patients with HCC that have stable disease on immunotherapy alone, would you consider adding bevacizumab at the time of disease progression and continue immunotherapy?
Yes, this is applicable to patients who are on single agent immunotherapy, since the atezo/bev combination carries different mechanism of synergistic potential than single agent immunotherapy. Notably, currently approved second line agents are indicated after progression on sorafenib, however, curre...
Does receipt of chemoimmunotherapy for LS-SCLC impact your recommendation for PCI?
Historic data showed that the addition of PCI for patients with limited-stage small cell lung cancer showing response after chemoradiotherapy improves overall survival and decreases brain failure rates by about 50%. Recently, the addition of consolidation immunotherapy after concurrent chemoradiothe...
What neoadjuvant therapy would you choose for a post menopausal woman with ER negative, PR positive high grade node negative breast cancer?
Assuming that there is no reason to doubt the results of the hormone receptor testing, and her HER2 is negative, I would treat her the same way I would a triple-negative cancer—I would not bother to send Oncotype as it should be high with the negative ER, and I wouldn't believe it if it came back lo...
How do you choose first or second-line systemic therapy for fibrolamellar hepatocellular carcinoma?
Fibrolamellar carcinoma is histologically unique from hepatocellular carcinoma. The disease is correctly called fibrolamellar carcinoma, and not fibrolamellar hepatocellular carcinoma, or hepatocellular carcinoma fibrolamellar variant. Even though the latter may be permissive if the lack of cirrhosi...