Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you follow pulmonary embolism patients who have completed anticoagulation?
3 months after sustaining an acute PE, I asked the patients if they were back to their pre-PE level of functional capacity. If they are not, i.e. if they remain dyspneic, I get an echocardiogram and a VQ scan. If the echo during the acute PE shows RV strain or evidence of pulmonary hypertension, I r...
In a patient with primary mediastinal seminoma with normalization of biomarkers s/p EPx4 and residual non-FDG avid mass, would you consider resection of residual tumor vs surveillance?
Patients with a primary mediastinal seminoma will have > 90% cure rate with chemo alone, but will ALWAYS have a residual mass. Assuming the initial serum AFP was normal and pathology was definitive that this was ONLY seminoma, we would not even do a PET scan but just observe with serial CT scans, H ...
Is there still a role of brachytherapy in uterine cancer if intensity-modulated radiation therapy is available?
Yes. Brachytherapy is still more conformal than optimally planned IMRT.
How do you interpret NIAGARA efficacy given that adjuvant nivolumab was not administered in the comparator arm?
The NIAGARA trial evaluated the role of durvalumab as neoadjuvant/adjuvant treatment in muscle-invasive bladder cancer (MIBC). The combination chemoimmunotherapy (cisplatin, gemcitabine, and durvalumab) was given for 3 months prior to radical cystectomy, followed by adjuvant durvalumab every 4 weeks...
How would you manage a solitary unresectable liver metastasis?
Excellent question! Before starting any systemic treatments, has the patient undergone an MRI? Conducting an MRI prior to systemic therapy is crucial for accurately determining whether there are single or multiple liver metastases. The CAMINO study has shown that incorporating an MRI at the initial ...
How would you approach a poorly differentiated neuroendocrine carcinoma of the stomach with small cell morphology without any evidence of peritoneal or distant spread?
High grade neuroendocrine carcinoma (HG-NEC) is extremely sensitive to chemo-radiotherapy. Unfortunately, they often relapse/reoccur despite treatment with curative intent for early stage disease. In my practice, I would avoid surgery for the given clinical scenario and proceed with chemo-radiothera...
What is your preferred adjuvant systemic treatment for resected stage IV melanoma with a BRAF mutation?
I agree with @Dr. First Last and prefer single-agent anti-PD1 therapy for adjuvant setting as well, given better tolerance and preserved QoL for most patients. I use targeted therapy in contraindications to ICI therapy, or prior exposure to ICI, and now with resected NED setting.
Regarding CVST, what protocol of heparin dosing do you regularly use and does it change depending on clot burden/ICH status?
There is very limited randomized evidence for the use of anticoagulation in any form for CVST. We often rely on extrapolations from data on the acute management of DVT in the leg and pulmonary embolus. We are mainly limited to cohort studies and small RCTs. Recent trials in this area include the TO-...
What is the current role of ctDNA in guiding the selection of adjuvant treatment for stage II-IIIA melanoma?
There are only retrospective, not prospective data on Natera’s tumor-informed ctDNA platform (Signatera). I would be cautious in using the ctDNA result for clinical decision-making. The gold standard is still the radiographic imaging - there is no test that will replace being able to see a measurabl...
Would you favor PCI or CABG for younger patients with radiation-associated cardiac disease in the absence of any significant valvular abnormalities?
Despite the fact that the common and most serious radiation-induced coronary stenosis (RICS) are ostial lesions of the left main and ostial RCA, we heavily favor PCI when feasible due to fibrotic mediastinal changes causing significant technical challenges during CABG. Restenosis is another challeng...