Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat ESRD patients on hemodialysis with recurrent AV fistula thrombosis found with low protein C activity?
I assume that the patient described in the vignette has a negative family and personal history of VTE. PC (and PS) deficiencies are relatively common in ESRD patients. The low levels are thoughts to reflect a combination of true (acquired) reduction and the assay interference rather than true defici...
Do you hold ADT before work up for prostate cancer when ordering advanced imaging such as PSMA PET?
The answer to this question is somewhat context dependent. The influence of ADT on a PSMA PET/CT is likely dependent on the clinical setting in which PSMA imaging is being considered, the duration of ADT prior to imaging, and how a provider plans to use the information to influence his or her treatm...
When do you consider preoperative chemoRT v. chemotherapy in unresectable thymoma or thymic carcinoma?
I believe that the best systemic therapy for thymoma is anthracycline-based (e.g. cisplatin, doxorubicin plus cyclophosphamide (PAC)) as these regimens have historically about a 20-30% higher response rate than non-anthracycline regimens. As such concurrent radiotherapy is not permissible because of...
How do you treat metastatic collecting duct carcinoma of the kidney in the first line setting?
As is the case with all extremely rare neoplams we operate in a nearly completely data free zone. This is a highly aggressive, lethal neoplasm. Cisplatin-based chemotherapy has some, albeit limited activity, thus gemcitabine/cisplatin is reasonable initial therapy if renal function is adequate. I wo...
What dose do you use to palliate multiple myeloma in a vertebral body?
For ISS Stage 1 MM patients who are going to have an OS of over 10 years, I generally prefer a more protracted regimen of 25 Gy in 10 fractions for improved durability of pain control. I typically only treat the symptomatic VB only and use inverse planning. If there is gross epidural disease or cord...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
Does plasma donation cause iron deficiency?
It really shouldn't but small amounts of blood are lost with the pheresis machine so it may occur with frequent donation. I would make sure to check from time to time. There are only marginal amounts of Fe in plasma so infrequent donations are unlike to cause iron deficiency.
How do you approach patients with partially occlusive thrombus in the splenic vein posterior to the pancreatic cancer lesion?
I am not a surgeon, but in the absence of other vessels affected, anticoagulation is not absolutely necessary. In these cases, patients can develop varices, specifically gastric varices and they can be at risk of bleeding. So that risk should be considered when/if offering anticoagulation. If bleedi...
How would you treat severe, symptomatic splenomegaly in a patient with ET/MF who has progressed through all approved JAK inhibitors and is not a candidate for alloSCT?
Refractory symptomatic splenomegaly to JAK inhibition is thankfully not common but does occur and requires consideration of both pharmacologic and non-pharmacologic strategies.Clinical trials should first be explored but if none are available or the patient is ineligible, then you can consider hypom...
How would you treat severe, symptomatic splenomegaly in a patient with ET/MF who has progressed through all approved JAK inhibitors and is not a candidate for alloSCT?
Refractory symptomatic splenomegaly to JAK inhibition is thankfully not common but does occur and requires consideration of both pharmacologic and non-pharmacologic strategies.Clinical trials should first be explored but if none are available or the patient is ineligible, then you can consider hypom...