Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In an elderly transplant ineligible IDH1-mutated patient with AML, who is in remission after 6 cycles of azacitidine and ivosidenib, would you discontinue azacitidine after cycle 6 and continue maintenance ivosidenib until progression/toxicity or continue both azacitidine and ivosidenib?
Our practice is to typically continue azacitidine + ivosidenib per the AGILE study (Montesinos et al., PMID 35443108) as long as the patient is not having excessive myelosuppression/toxicity and doesn't feel strongly about coming off azacitidine. That being said, there are data to support ivosidenib...
Do you recommend postoperative radiation for spinal cord compression DLBCL?
I would recommend postoperative RT, following completion of systemic therapy. I would restage with PET-CT prior to RT. If CR: 30 Gy would suffice.
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
How would you approach management of a patient with ESRD on the transplant list who is found to have high titer APS labs (ACL, B2GP1, LAC)?
This is an excellent but rather complex question. Management of patients with ESRD on the transplant list who are found to have high titer APS labs (ACL, B2GP1, LAC) depend on the renal histology, underlying autoimmune disease history, and comorbidities. Patients with thrombotic manifestations resul...
Would you recommend post operative radiation in an adult patient with a thoracic spine osteosarcoma?
The following answer is extrapolated from AOST2032 which is a pediatric clinical trial but is relevant to the question at hand. This case touches upon the concepts outlined in the AOST2032 research protocol for osteosarcoma radiation therapy. While acknowledging this is just one protocol and not a ...
In the post Covid era, could the ILROG hypofractionated regimens (published as "emergency guidelines" for lymphoma) be considered as standard of care for ISRT?
In palliative settings, we have utilized hypofractionated regimens in hematologic malignancies for decades. Examples include 4 Gy X 1 for follicular lymphoma, 4 Gy X 5 for myeloma, 3 Gy X 10 for DLBCL, and 4 Gy X 2 for mycosis fungoides. In select circumstances (both before and after COVID-19), I ha...
What second-line therapy would you offer a patient with metastatic colon cancer with HER2 IHC 3+ amplification and KRAS G12D mutation whose disease progressed on FOLFOX?
This is a rare but interesting situation since HER2 IHC 3+ is only found in <3% metastatic colorectal cancer (mCRC) while KRAS G12D mutation is about 12% in the mCRC population. This combination is quite uncommon. The best evidence would be from the DESTINY-CRC02 (Raghav et al., PMID 39116902), whic...
Do you check the Duffy-null phenotype before starting azathioprine and in which patients?
I personally do not check the Duffy antigen prior to starting azathioprine. I do check TMPT levels on all patients prior to starting it to help determine initial dosing.
How would you manage a patient with HbSS and severe pulmonary hypertension on home oxygen?
This patient should be referred to a specialist in pulmonary hypertension in sickle cell disease for right heart catheterization and aggressive management of the pulmonary hypertension. As described, the patient is not a good candidate for lung transplant or gene therapy.
Do you recommend trilaciclib as primary prophylaxis for myelosuppression in certain patients with ES-SCLC treated with first line chemo-immunotherapy?
I do not routinely use growth factor support nor trilaciclib with chemotherapy or chemo-immunotherapy for people with ES-SCLC. My starting doses of chemo are usually carboplatin AUC 5 day 1 + etoposide 100 mg/m2 days 1-3, and the degree of myelosuppression and incidence of neutropenic fever with thi...