Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you give adjuvant chemotherapy for an incidental cholangiocarcinoma found at time of liver transplant (done for HCC or other reason) in the explanted liver?
I am not sure I would offer chemo here. You don’t state the T stage of the tumor or if nodes were involved, both of which are critical in understanding the risk of relapse. Regardless, chemo in someone who is in the fragile state of a newly transplanted liver has a risk of the chemo causing rejectio...
What are your top takeaways from ASCO GI 2024?
ALL CTDNA IS NOT CREATED EQUAL (the only way I reconcile the negative findings of COBRA using a tumor-uninformed assay in predicting the efficacy of adjuvant chemo in stage II colon cancer: https://www.cancernetwork.com/view/ctdna-does-not-confer-chemo-efficacy-in-stage-ii-crc-following-surgery wit...
When would you consider aspirin for long term management of unprovoked VTE after initial therapeutic anticoagulation?
The WARFASA trial randomly assigned patients with first unprovoked VTE who had completed 6-18 months of anticoagulation to 2 additional years of aspirin versus placebo. While the study demonstrated a 40% reduction in recurrent thrombotic events, the rates of VTE in those receiving aspirin were still...
How do you approach duration of immunotherapy in patients with metastatic NSCLC?
If someone manages to continue the ICI maintenance up to 2 years without progression, I am comfortable counseling the patient to stop the ICI treatment as per the regulatory approval indication. I have had occasionally, patient's anxiety level driving the desire to continue beyond the 2 years treatm...
For muscle-invasive bladder cancer with predominant (>90%) squamous differentiation, would you consider cisplatin-based neoadjuvant chemotherapy prior to radical cystectomy or upfront surgery?
While muscle-invasive bladder cancer (MIBC) patients with a minor variant histology component are treated similarly to conventional urothelial carcinoma (i.e., neoadjuvant cisplatin-based combination followed by surgery), there are no definitive data to guide the perioperative systemic therapy of th...
When giving FOLFOX/FOLFIRI and skipping 5FU bolus, do you still give leucovorin?
In general, if I am not giving the 5-FU bolus, I will also not give the leucovorin. The purpose of the leucovorin is to increase the time that 5-FU given by bolus binds to thymidylate synthase. Since the 5-FU bolus is being withheld, the leucovorin has limited purpose, as the 5-FU continuous infusio...
Would you consider starting immunotherapy concurrently with whole brain radiation for newly diagnosed metastatic (BRAF negative) melanoma with multifocal symptomatic brain metastases?
This is a challenging clinical situation. In part, the approach depends on the number and size of the CNS lesions. However, I do not recommend the use of WBRT for my patients, as it has not demonstrated a survival benefit. In addition, in the adjuvant trial comparing WBRT to observation, it did not ...
For patients with recent post-delivery symptomatic ovarian vein thrombosis on anticoagulation, how would you approach periop AC management for upcoming procedures like D&C?
Nevertheless, I would first determine if the D&C needed to be performed so soon after diagnosis of the ovarian vein thrombosis or if it could be delayed. If it needs to be performed sooner, communicate with the proceduralist to determine if the anticoagulation needs to be interrupted. A number of in...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
What is your threshold to diagnose light chain MGUS with only a slight elevation in the light chain ratio, in a patient without other CRAB symptoms and no M spike?
Mild increase in kappa light chains can be a result of antigenic drift seen with the assay, in renal dysfunction both can go up but kappa may go up a bit more skewing the ratio. If a 24-hour urine with electrophoresis and immunofixation is negative and the rest of the work up is negative, would cont...