Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When should a biopsy be obtained to rule out small cell transformation in a patient with stage IV NSCLC and an EGFR mutation?
Histologic transformation is a well-described but poorly understood - and under-diagnosed - mechanism of resistance to TKIs. The best known is small cell transformation in EGFR mutant NSCLC but transformation, to either small cell or squamous cell, has been seen with multiple different TKIs. Biopsy ...
For patients with Stage IIIB or IV HD flowing Bv-AVEPC with initial large mediastinal adenopathy, how can we avoid ISRT?
It is true that on the clinical trial AHOD1331, patients who presented with large mediastinal adenopathy received radiation therapy as did patients who were slow early responders (Deauville 4 or 5 after two cycles of therapy). It is noteworthy that 3-year event-free survival was extremely high for a...
Do you recommend adjuvant capecitabine for a very small amount (2 mm, ypT1a) of residual invasive disease in TNBC patients following neoadjuvant chemotherapy and lumpectomy?
The data regarding TNBC neoadjuvant cases who attain an RCB1 response suggests they do almost as well as RCB0 pCR patients. (Symmans et al JCO) so the absolute impact of adjuvant xeloda will probably be minimal and not worth the toxicity. It is of more benefit in those with RCB2 disease. The CREATEX...
How do you sequence Ra-223 and Lu-177 in patients with mCRPC with predominantly bony disease?
The RALU study (Rahbar et al., PMID 36302656) really is quite a small 49-patient cohort study looking at the one-way question of the safety of PSMA-Lu177 in carefully selected patients who had adequate marrow function after both an ARSI, taxane chemo, and radium-223. While these selected patients to...
Is there a role for CRS prophylaxis with tocilizumab during bispecific T cell engager initiation for myeloma?
I would not use Toci prophylactically. I see more problems with ICANS/confusion in MM bispecifics, and this responds to steroids, not Toci, or resolves on its own.
Is there a role for CRS prophylaxis with tocilizumab during bispecific T cell engager initiation for myeloma?
I would not use Toci prophylactically. I see more problems with ICANS/confusion in MM bispecifics, and this responds to steroids, not Toci, or resolves on its own.
At what age do you stop LDCT chest for lung cancer screening?
One of Medicine's three priority-ordered duties is to postpone death. This also pertains to persons who have reached age 81. Lung cancer can occur longer than 15 years after cessation of smoking. Even if surgery can't be done, primary radiation of Stage 1 squamous cell lung carcinoma can result in p...
How would you approach a patient with metastatic ER/PR+, HER2- breast cancer with linear leptomeningeal enhancement on MRI but negative CSF protein and cytology?
First, it is important to note that the sensitivity of CSF cytology depends on both the number of LPs and the volume of LP. For example, one LP has a sensitivity of only ~70%, while doing more than 3 LPs takes the sensitivity up to 98%. Similarly, withdrawing at least 10 ml of CSF improves sensitivi...
How, if at all, does your systemic therapy management differ between HER2+ breast cancer patients with active CNS metastases compared to those with stable/treated CNS metastases?
For HER2+ breast cancer patients with active CNS metastases, the focus is on using systemic therapies with proven CNS penetration, such as tucatinib combined with trastuzumab and capecitabine or T-DXd, to address both systemic and CNS disease. In contrast, for those with stable or treated CNS metast...
What experience have you had with familial clustering of polycythemia vera?
JAK2 V617F is a somatic mutation that can be acquired as early as in utero based on elegant work by Williams et al., PMID 35058638.There is some data available regarding familial MPN predisposition syndromes and this review very nicely summarizes much of the available data (Lim et al., PMID 39316992...