Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage concurrent non-life-threatening hemoptysis and acute pulmonary embolism?
Hemoptysis can occur with PE when there is pulmonary infarction. However, the majority of pulm embolism cases have pleuritic chest pain without infarction. Significant hemoptysis is very rare in these cases and anticoagulation is nearly always safe. When hemoptysis continues or the volume is concern...
What is your strategy for breakthrough chemotherapy induced N&V in patients receiving highly emetogenic chemotherapy and already received a NK-1 antagonist, 5-HT3 antagonist, dexamethasone, and olanzapine?
I find the MASCC anti-emetic guidelines to be very well written Davis et al., PMID 34398289.Very few randomized clinical trials in cancer for antiemetics (with positive trials associated with metoclopramide (D2 receptor antagonist) and olanzapine).So - most are based on trial and error + clinician p...
What is your protocol for transitioning to oral anticoagulation post-thrombolysis for pulmonary embolism?
My answer has multiple parts."Thrombolysis" is not all the same. As studied in stroke treatment, alteplase causes marked fibrinogen depletion and coagulopathy (prolonged PT, aPTT), whereas tenecteplase doesn't so much (Huang et al., PMID 26514192).So, if alteplase was used (systemic or reduced cathe...
Do you routinely check Pulmonary function testing prior to each cycle of BEP for young patients with testicular cancer with no pulmonary risk factors?
A few comments: I do not check DLCO or PFTs in general in patients under age 50 getting just 3 courses of BEP. We tend to avoid bleo if over age 50. If a patient is getting 12 weeks of bleo, I check DLCO just prior to the start of the 4th course, and if DLCO < 60%, I give VIP for the 4th course. Ad...
Do you always biopsy suspicious liver lesions if you have a biopsy from the pancreatic mass showing PDAC?
I don’t always biopsy especially if the tumor marker is very high. I start with treatment and reassess. I do think a good liver MRI with contrast can be helpful here as well. One important caveat: I do biopsy if there is scant tissue from the pancreas biopsy so I can send the NGS panel.
Is there ever a role for adjuvant chemotherapy and/or immunotherapy for early stage, N0 non-small cell lung cancer treated with SBRT alone?
Excellent question. There is certainly a need! If we step back and take an honest look at our control rates with SBRT, while primary tumor control rates are high, we suffer the same viciousness of lung cancer that surgeons do - local control is trumped by a 2-3x rate of regional and distant failure....
For newly diagnosed ALK or EGFR + NSCLC with oligometastases to brain only and otherwise cN0-1 thoracic disease, would you offer targeted therapy alone or SRS to brain + concurrent chemoradiation/surgery to chest?
For asymptomatic patients with smaller lesions, I would offer initial osimerinib or alectinib and get MRI with SRS planning sequences at 1month. We would then SRS any non-responding lesions
When would you initiate chronic therapeutic phlebotomy in a patient with erythrocytosis secondary to a high hemoglobin-oxygen affinity hemoglobinopathy?
The large majority of patients with high oxygen affinity hemoglobinopathy do not require therapeutic phlebotomy. There is a subset of patients who develop symptoms (generally these are non-specific such as headache) or complications such as thrombosis. There seems to be no correlation between hemato...
Do you recommend lifelong antibiotic prophylaxis, or do you prefer a more selective approach based on risk factors in asplenic patients without a history of severe infections?
The advice is limited by the fact that there are no randomized controlled trials in adults on daily antibiotic prophylaxis post-splenectomy. There are trials in children with sickle-cell disease that do show a benefit, but it is not clear that these can be extrapolated to splenectomized adults. Furt...
Would you consider elective neck nodal irradiation for a large >5 cm head and neck extramedullary solitary plasmacytoma arising from the nasal cavity?
A plasmocytoma in the nasal cavity may bear a higher risk for nodal involvement if it involves Waldeyer's ring or nasopharynx.Adding ENI to the neck will certainly increase the risk of toxicity and only lead to a modest benefit in terms of isolated regional recurrence. I would thus not perform elect...