Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When treating with SBRT and immunotherapy for unresectable HCC, how do you sequence the treatment?
Great question. No great data in this space regarding optimal sequencing. In general, I would sequence SBRT first, followed by initiation of immunotherapy. Some data suggest that SBRT may best prime IO if administered prior to IO. Additionally, if the IO regimen preferred is atezolizumab/bevacizumab...
Would you offer systemic chemotherapy to a patient with at least 2023 FIGO stage IC high grade serous (p53-mut) endometrial cancer with extensive LVI for whom nodal assessment was not done?
This question was addressed in a large NCDB study in 2020 by Nasioudis et al (Nasioudis et al., PMID 32675056) who looked at USC confined to the endometrium, which found that 5-year OS was 91% for chemo alone, 91% for chemoRT, 85% for those who received radiation alone, and 82% who were observed. Ad...
Do normal methylmalonic acid levels absolutely rule out vitamin B12 deficiency?
An elevated MMA is a good indicator of B-12 deficiency but a normal level does not argue strongly against B-12 deficiency. Normal MMA levels have been reported in 10-25% of patients with known B-12 deficiency (B-12 levels below 100). Testing for an elevated homocysteine level might help but this tes...
If the patient has had prior partial nephrectomy for RCC, would you consider SBRT for a contralateral RCC?
It boils down to the estimated eGFR after SBRT/SABR. Urologists use 15 mL/min as the cut-off. Workup should include a comprehensive metabolic panel and NM renal scan to determine differential renal function. It helps to use a motion dampening technique like abdominal compression or gating to decreas...
Would you offer SBRT to a biopsy proven T1 renal cell carcinoma on a transplanted kidney?
Complex scenario. I am not aware of any cases worldwide of SBRT for RCC in a transplanted kidney. That being said, our group has previously published a case of SBRT for early stage lung cancer in a double lung transplant patient. This was one of 2 known cases at the time, and the details of the case...
Can tamoxifen be safely prescribed for breast cancer patients with cirrhosis?
Tamoxifen would definitely not be my preferred endocrine agent in a patient with cirrhosis. I have had many cases of tamoxifen-induced liver injury. The incidence of MASH due to tamoxifen is really underreported in the literature. In a case of pre-existing MASH or other liver disease, I switch to an...
For cases of foraminal and extraforaminal monophasic synovial sarcoma post excision with note of residual tumor, would your approach be a second look surgery with re-excision or delivery of adjuvant RT with boost to residual disease?
Great (and tough!) question. In the setting of residual disease post-surgery, many studies have shown that even with adjuvant radiation therapy, leaving gross disease behind leads to inferior outcomes. In the setting on non-oncologically excised tumors, I would first have a discussion with the surg...
What is your preferred treatment for CML that presents with thrombocytosis?
In short, I do not change my TKI recommendations for patients with newly diagnosed CML who present with thrombocytosis. Prognostic scores demonstrate that thrombocytopenia is associated with poorer outcomes (Pfirrmann et al., PMID 26416462), but thrombocytosis does not seem to have any specific prog...
In addition to supportive transfusions, do you consider other interventions for symptomatic anemia and thrombocytopenia associated with chronic neutrophilic leukemia?
Assuming the CSF3R mutation that is seen is the T618I mutation, you can consider ruxolitinib. Dao et al., PMID 31880950, reported on a prospective trial of ruxolitinib in 44 patients with CNL or atypical CML. The overall response rate was 35%. However, responses were enriched in patients with CSF3R-...
In addition to supportive transfusions, do you consider other interventions for symptomatic anemia and thrombocytopenia associated with chronic neutrophilic leukemia?
Assuming the CSF3R mutation that is seen is the T618I mutation, you can consider ruxolitinib. Dao et al., PMID 31880950, reported on a prospective trial of ruxolitinib in 44 patients with CNL or atypical CML. The overall response rate was 35%. However, responses were enriched in patients with CSF3R-...