Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
Is there any role for using Oncotype Dx to decide between neoadjuvant chemotherapy vs. endocrine therapy in a postmenopausal woman with T2N0 ER+,HER2- breast cancer?
Typically, my decision for NAC is motivated by the following where I'm convinced that there is enough risk that I will give a particular regimen: 1) NAC will help determine later therapy (e.g. triple ngtv and adj capecitabine OR HER2+ and TDM-1) and/or 2) NAC will assist with surgical approach (e.g....
What neoadjuvant chemotherapy do you suggest for a rapidly growing triple-negative breast cancer?
If the patient has non-metastatic, operable triple-negative breast cancer that is at least 2 cm in diameter or positive for axillary lymph node metastases, I would use the KEYNOTE-522 regimen (1 year of pembrolizumab in combination with 4 cycles of neo-adjuvant paclitaxel, carboplatin followed by 4 ...
Would you dose escalate neoadjuvant radiotherapy for T3 and/or N+ rectal cancer in patients who are unwilling or unable to get chemotherapy?
If a patient with rectal cancer is not able and/or unwilling to receive concurrent radio-sensitizing chemotherapy with pre-operative intent radiotherapy, I would recommend the use of short-course radiotherapy with 25 Gy in 5 fractions.Multiple trials, including TTROG 01.04 and Polish 1 Bujko et al.,...
Can a patient still have primary HLH even in the absence of any HLH associated genetic mutations?
Yes, a patient can still have primary Hemophagocytic Lymphohistiocytosis (HLH) even in the absence of identified HLH-associated genetic mutations.Primary HLH, also known as familial HLH, is typically linked to mutations in genes related to the immune system, such as PRF1, UNC13D, STX11, STXBP2, and ...
When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?
The number of antibodies is an important consideration.On the one end of the spectrum, I would not recommend any DOACs in a triple positive APLS (especially with arterial thrombosis). Having said that, I would not change treatment in a triple positive APLS patient if they were started on DOACs in th...
Do you always initiate hypercoagulable work up in a patient with recurrent stroke?
As always, this is a more complex problem than it appears. A history of both prior other thrombosis and family history of thrombosis is essential. Are there good reasons for the stroke and/or has it been worked out in past including carotid disease, atrial fibrillation, underlying malignancy, valvul...
Do you always initiate hypercoagulable work up in a patient with recurrent stroke?
As always, this is a more complex problem than it appears. A history of both prior other thrombosis and family history of thrombosis is essential. Are there good reasons for the stroke and/or has it been worked out in past including carotid disease, atrial fibrillation, underlying malignancy, valvul...
How will you treat a young man with recurrent cryptogenic strokes with no identifiable cause, with MTHFR A1298C homozygous mutation and normal homocysteine level?
The genetic variant you report seems to be a SNP that, while it has been reported to be statistically associated with various diseases in GWAS studies, is not pathogenic. SNPs that are significant in GWAS studies have very small effect sizes that can be measured when considered in thousands of peopl...
Can lupus anticoagulant be positive despite a normal aPTT?
aPTT is one of the assays that may be abnormal in the presence of lupus anticoagulant, but not always. Usually, when screening for lupus anticoagulant, there will be a "special" aPTT assay used that is a bit more sensitive to detect lupus anticoagulant. There are several different aPTT-based assays ...