Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer definitive radiotherapy for prostate cancer (or another solid organ malignancy) to a patient on maintenance Rituximab for lymphoma?
Good question and a somewhat increasingly common issue in the general sense of patients with overlapping hematologic and prostate malignancies. For starters, I would think hard about the risk group of this patient and competing risks. If this patient has an aggressive or relapsed lymphoma with favor...
In cT4aN0 triple negative breast cancer would you still recommend PMRT if pCR, ypT0N0(sn), after neoadj chemo is achieved?
This case includes several distinct issues. The first is the accuracy of the initial staging. The AJCC 8th edition definition of clinical stage T4a is: "T4a is extension to the chest wall. Adherence/invasion to the pectoralis muscle is NOT extension to the chest wall and is not categorized as T4." E...
What adverse events would make you switch off nivo + AVD therapy and to what second line therapy in patients with Hodgkin Lymphoma?
The question of how to handle severe IRAEs when using the N+AVD regimen is an important one. First, of course, is to hold CPI therapy, empirically treat as indicated to avoid ongoing or worsening organ injury, and concurrently ensure that there is no other cause for the observed event(s). But if you...
What adverse events would make you switch off nivo + AVD therapy and to what second line therapy in patients with Hodgkin Lymphoma?
The question of how to handle severe IRAEs when using the N+AVD regimen is an important one. First, of course, is to hold CPI therapy, empirically treat as indicated to avoid ongoing or worsening organ injury, and concurrently ensure that there is no other cause for the observed event(s). But if you...
When do you recommend induction chemotherapy prior to concurrent chemoradiotherapy for locally advanced NSCLC?
I rarely recommend induction chemotherapy prior to definitive concurrent chemoradiation. This is because two randomized studies, LAMP (PMID 16087941) and CALGB 39801 (PMID 17404369) showed no survival benefit and added toxicity with induction chemotherapy compared to concurrent chemoradiotherapy alo...
What is your preferred induction chemotherapy for stage IIIA NSCLC squamous and adenocarcinoma?
I approach induction therapy for locally advanced disease in a similar way to adjuvant chemotherapy, and use many of the same regimens. For adenocarcinoma, I prefer a pemetrexed-based regimen–cisplatin or carboplatin depending on age and co-morbidities. I avoid bevacizumab in these patients if surge...
What radiation dose would you use to treat a symptomatic osseous lesion secondary to AL-amyloidosis?
Extrapolating from our tracheobronchial experience, we’ve used 20 Gy in 10 fractions to target the underlying plasma cells that produce amyloid production. We’ve also used this regimen for ocular and GU (ureteric and bladder) amyloidosis. If there are obstructive or symptomatic lesions, then surgica...
How do you approach pelvic radiation therapy for a patient with multiple myeloma who needs more intensive therapy (e.g., Dara-KRd or impending CAR-T) with a risk of cytopenias?
The role of RT in MM is palliative in nature, and the focus should be on symptomatic improvement while minimizing marrow toxicity.Rad Oncs, as a whole, should not generally be using solid tumor palliative doses (such as 3 Gy x 10) routinely in MM as that ablates the marrow in that area without hope ...
What is the role of anticoagulation in patients with septic thrombophlebitis?
The role of heparin anticoagulation in septic thrombophlebitis is controversial. There are limited to no randomized trials to document outcomes. A systematic review (Falagas et al., PMID 17222406) supported this practice, and the Infectious Disease Society also supports this practice. The role of or...
For a patient who is cisplatin-eligible with localized, high-grade upper tract urothelial carcinoma, but no muscularis propria seen on biopsy, what is your approach?
The risk of clinical under-staging is notorious in UTUC; therefore, we aim to maximize control of disease and address the meaningful risk of micro-metastasis. In that context and outside clinical trial option, we favor the use of neoadjuvant cisplatin-based chemotherapy using either dose dense MVAC ...