Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach the workup and initial treatment of systemic AL amyloidosis?
1: Ensure that this is light chain. Mass spectroscopy of the tissue to identify/confirm is very important. Even if a patient has positive serum monoclonal protein or light chain, it does not indicate that this is light chain amyloidosis. I have had patients with MGUS and smoldering myeloma with ATTR...
How do you approach the workup and initial treatment of systemic AL amyloidosis?
1: Ensure that this is light chain. Mass spectroscopy of the tissue to identify/confirm is very important. Even if a patient has positive serum monoclonal protein or light chain, it does not indicate that this is light chain amyloidosis. I have had patients with MGUS and smoldering myeloma with ATTR...
How extensive of a workup do you do for systemic AL amyloidosis for a patient with a resected amyloidoma, localized AL amyloid deposition in their airway or lungs, who has no other symptoms?
It's common to over-test in these patients. We in hematology/oncology, often order bone marrow biopsies, PET/CTs, and cardiac MRIs without realizing that each test costs around $10,000 and can potentially harm the patient.Here are two points to assist with the work-up for these patients: Understand...
How do you choose between therapies for newly diagnosed ITP that is refractory to steroids and IVIG?
The important questions here are what are the symptoms and what are the platelet counts? In patients who fail to respond to either corticosteroids or IVIG, the concern is whether this is actually immune thrombocytopenia or another cause of thrombocytopenia. With "normal" flow and bone marrow results...
How would you approach the management of a patient with stage IIIA lung adenocarcinoma and multifocal hepatocellular carcinoma with Child-Pugh A cirrhosis?
The HCC is likely the more pressing diagnosis, but if a multi-focal liver-directed treatment can be used like ablation to all sites of disease, that is appealing and opens up space to treat the lung cancer (likely with chemoRT over surgery). Immunotherapy may be a systemic treatment that could (for ...
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...