Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the optimal choice of therapy for a patient with Hodgkin variant of Richter's transformation from underlying CLL/SLL?
I treat it similar to denovo Hodgkins Lymphoma with Brentuximab AVD for high risk versus ABVD for standard risk. If EBER-positive lymphoma, then there is a role for rituximab use in addition to chemo. Gupta et al., PMID 35291669
Should immunotherapy be added to standard of care neoadjuvant chemotherapy in borderline resectable MSI-H adenocarcinoma of pancreas?
This is definitely an area worth of trials. We know of the degree of efficacy and tolerability of chemotherapies in this setting. We also are aware of the potential for deep and prolonged response to PD-1 inhibition in patients with MSI-H + high TMB + MMR-d by IHC. I try to utilize immunotherapy in ...
How do you manage the wide array of emotions like anger and disappointment patients may have when they first learn of an incurable relapse of an early stage cancer?
This is a really tough question and there is no easy or straight-forward answer. When I consider situations like this, however, I try to follow these guidelines: I use initial diagnostic uncertainty to my advantage. A diagnosis of relapse is almost never made instantaneously (a suspicious lesion on...
Does a patient with known systemic mastocytosis need a bone biopsy of lytic vertebral lesions to rule out other etiologies?
Yes, as long as other etiologies have been ruled out, such as cancer, osteomyelitis, or other infections. Even though osteoporosis is more common in systemic mastocytosis patients, bone lytic lesions are not.
In which oropharynx patients would you recommend TORS vs upfront RT or chemo-RT?
With MC1675 and ORATOR2 coming out at ASTRO21, and ECOG3311 published shortly afterwards, this topic is now particularly germane. Due to the recent reports on these trials, I'll be writing in the context of possible post-op de-escalation.I think the first and most important question to ask is, "What...
How would you approach treatment for a pre-menopausal patient with PR-positive, ER-negative, HER2-negative cT1c N1 breast cancer?
The prevalence of ER- PR+ HER2- breast cancer is relatively low and probably ranges from about 0-8%, with concerns about technical errors in HR status determination by IHC often being expressed in this instance. Because of this, I would consider repeat receptor testing at some point (an additional b...
How would you approach adjuvant therapy for a patient with resected T4N1 high grade large cell neuroendocrine tumor of the cecum with adenocarcinoma component?
However the diagnosis of mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) requires that each component (NEC and adenocarcinoma) exceeds 30%, I will make sure with pathology again this case is not MiNEN. For most patients with apparently localized GEP NECs, or MiNEN we should proceed with adj...
What is your standard diagnostic workup to confirm GVHD in a patient post-BMT with skin rash and jaundice?
I assume there is no diarrhea, so sigmoidoscopy would not be helpful. Gut and liver pathology are useful. Skin biopsy is less helpful. It can be fairly nonspecific, but we do it to rule out other diagnoses that have more definitive pathology. Ultimately, it is a clinical diagnosis. Liver biopsy woul...
What is your standard diagnostic workup to confirm GVHD in a patient post-BMT with skin rash and jaundice?
I assume there is no diarrhea, so sigmoidoscopy would not be helpful. Gut and liver pathology are useful. Skin biopsy is less helpful. It can be fairly nonspecific, but we do it to rule out other diagnoses that have more definitive pathology. Ultimately, it is a clinical diagnosis. Liver biopsy woul...
In a patient with very advanced head and neck cancer treated with induction chemotherapy and then definitive radiation do you recommend adding concurrent chemotherapy with the radiation?
Sequential chemotherapy does not provide a survival benefit over definitive chemoradiation. [1], [2], [3]. Hence, reasons to consider induction chemotherapy are for local control of disease and to delay the onset of distant metastases. Additionally, there are concerns for increased toxicity and dela...