Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What maintenance therapy do you recommend for metastatic gastric adenocarcinoma with continued response to FOLFOX with zolbetuximab after oxaliplatin removal?
In this scenario, I would recommend continuing infusional 5-FU and zolbetuximab. In my practice, I rarely continue oxaliplatin with any chemotherapy regimen for more than 8-10 cycles, due to increasing cumulative toxicity over time. My preferred maintenance therapy for any oxaliplatin-containing reg...
How would you manage presumed gestational thrombocytopenia with moderate thrombocytopenia for delivery planning?
Thanks for this question. First and foremost, it's critical to rule out a placental-mediated complication such as pre-eclampsia and HELLP, and to evaluate for other more nefarious causes of thrombocytopenia (TTP, aHUS, etc., though of course rare). While a diagnosis of exclusion, gestational thrombo...
Do you routinely use chemo cold caps?
The decision to use cold caps is very personal (one must consider financial implications, associated time commitment, personal feelings about alopecia etc.) and so I provide information to patients but I don't counsel them in any specific direction. Cold caps appear to be most effective for women re...
Do you add a platinum agent to neoadjuvant chemotherapy for triple negative breast cancer in BRCA 1/2 mutation carriers?
Several studies in the metastatic setting (e.g. the TNT trial) have suggested an improved response and progression free survival with platinums in BRCA –mutant breast cancer. In the neoadjuvant setting, a study of 107 women with breast cancer and BRCA1 mutation, treated with 4 cycles of cisplatin, h...
Can anti-cardiolipin or anti-beta-2 glycoprotein antibodies cause prolonged PTT in the absence of a lupus anticoagulant?
Lupus anticoagulants are a heterogeneous group of antibodies that do not have uniform activity in all assays. Furthermore, testing procedures are not well-standardized. Since relevant clotting factor deficiencies have been ruled out and the long PTT does not correct with mixing, and since there is o...
Given potential long-term CV toxicity concerns with lorlatinib and data suggesting that dose reduction does not compromise efficacy, do you ever recommend initiating and/or maintaining lower-dose lorlatinib in ALK+ NSCLC?
It depends. I'm a firm believer in the maximum dose a patient can tolerate and do well on with minimal side effects and maintain a strong quality of life as they live with this for a long time. For an older patient, I would start at 75 mg but for young, I would start at 100 and a low threshold to re...
When should surgical tumor resection be considered in patients with a low-grade glioma?
In adults with low-grade gliomas, there is substantial evidence suggesting that aggressive, early surgical resection improves outcomes and survival (Jakola et al., PMID 23099483). Historically, this has been particularly true for tumors that carry an IDH mutation or 1p/19q codeletion. This survival ...
Do you obtain MRI for cutaneous SCC with microscopic PNI to assess for gross perineural tumor spread?
I would recommend both an MRI as well as consulting the pathologist regarding the exact nature of the PNI. We had an experience with more than 100 patients (Sapir et al., PMID 27475277). Those with gross PNI (evidenced by MRI, with or without cranial nerve deficit) and microscopic extensive PNI (>2 ...
Do you offer systemic therapy for NSCLC (no driver mutation) after resection of a metachronous solitary brain metastasis occuring after definitive therapy for limited disease, with no evidence of active extracranial disease?
I'm not sure that I have any definitive evidence to present regarding this (ie no trial data), speaking primarily from experience and bias. As I take it, the patient presented in the question is now surgically NED and has had appropriate treatment of his isolated metastatic site of disease with no k...
How do you approach melanoma patients with a positive sentinel node with extra-nodal extension for definitive surgical management?
This is a multidisciplinary question so I reached out to our surgical oncologist (Dr. @Dr. First Last) at the Ohio State University Comprehensive Cancer Center for his thoughts as well. This is a grey area as the patients with extra-nodal extension (ENE) were not specifically studied in the landmark...