Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a patient with muscle invasive urothelial carcinoma with squamous differentiation?
In general, pure and predominant urothelial carcinoma (majority or >50% of tumor consisting of urothelial carcinoma) have been treated similarly at least in trials. Patients with predominant or pure non-urothelial histology have typically not been enrolled in trials of urothelial carcinoma. There ar...
What is the appropriate RT dose for an advanced stage follicular lymphoma?
Depends on the specific clinical scenario. However, in general, RT in advanced stage follicular lymphoma is palliative. Therefore, I would start 2Gyx2. Repeat as needed. If cord compression or something serious, would consider 24Gy.
How long would you wait after a cycle of IT MTX to treat a spinal lesion causing cord compression in a patient with stage IV DLBCL?
Intrathecal methotrexate has biphasic half-lives of about 5 hours and 14 hours (Bleyer, Cancer Treat Rep 1977). ILROG recommends typically waiting minimum interval 2 weeks between last IT or high-dose IV methotrexate before starting CNS radiotherapy for CNS leukemia, but urgent radiotherapy may be c...
Do you utilize tumor treating fields in patients with anaplastic pleomorphic xanthoastrocytoma (PXA) III?
I would, but I haven't actually had the opportunity. With more information appearing that TTF is effective in brain metastases, mesothelioma, and pancreatic cancer, why wouldn't you use it if you didn't have a better option? The only real risk is financial.
How would you approach surveillance imaging for men with early-stage, hormone receptor-positive breast cancer after unilateral mastectomy?
As always, appreciate others' input. If you're referring to systemic imaging, I do not obtain surveillance systemic imaging as part of surveillance for any patient with early-stage hormone-positive breast cancer (male or female) unless there are symptoms or initial labs that suggest possible metasta...
When a patient with pancreatic cancer received neoadjuvant chemo + chemo-RT, how do you manage an in-field, post operative positive margin?
The data from MD Anderson indicates that patients have a similar survival duration when they have an R1 resection after chemoradiation as when they have an R0 resection, and longer than expected with a positive margin. The Mayo Clinic also has data in rectal cancer where there may be an increased ri...
Do you routinely repeat imaging for PE after anticoagulation treatment to establish a new baseline?
We only do imaging if the patient is symptomatic still after a few weeks or has persistent chest pain or clinical signs of pulmonary hypertension. Rarely I have seen recurrent or progressive thromboembolic disease on anticoagulation. Another possible reason if the patient needs to go to surgery in t...
In which situations do you omit the 5FU bolus in FOLFOX or FOLFIRI?
This is a very commonly asked question in the clinic.The original studies all included leucovorin (LV) and bolus 5Fu as part of the regimen (FOLFOX, FOLFIRI). However, in the clinic, we know that the 5Fu bolus is the main reason that this patient has significant cytopenia and worse side effects from...
Do you intensify treatment for patients with double-hit lymphoma or double expressor lymphoma?
My personal practice is that I DO intensify therapy for patients with DHL but not necessarily with DE lymphoma. Generally, the "intensification" of choice is based on age. Young fit patients (for which there are few) with DHL are candidates for CODOX-M/IVAC or DA-REPOCH. Older patients (which the ma...
Would you consider adjuvant osimertinib for NSCLC with an EGFR E746_S752delinsV exon 19 mutation?
Yes. While some uncommon EGFR exon 19 deletions appear to be resistant to first and third-generation EGFR TKIs (e.g., L747P variant with higher IC50 requirements preclinically and associated with worse response/survival in case analyses), EGFR E746_S752delinsV appears to respond well to EGFR TKIs (W...