Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What genetic testing would you consider for recurrent arterial events (cryptogenic strokes, MI) in patients with limited risk factors?
This would be a case-by-case evaluation with additional history, examination and imaging features. I would take a multidisciplinary approach and also consult with hematology and cardiology. I am assuming all other workups are negative. I would probably repeat APLS labs in 6 weeks with lupus anticoa...
In patients with cholangiocarcinoma who qualify for HAIP therapy, would you recommend treating with chemotherapy and immunotherapy?
While HAIP is considered promising (again - 20 years later), no appropriate phase III trial has shown benefit in any diagnosis. Since phase III trials support immunotherapy, that is preferred.
What is the recommended initial treatment for spinal cord compression due to non-Hodgkin lymphoma (e.g. diffuse large B-cell lymphoma)?
The answer depends greatly on clinical circumstances, such as stage of disease, degree of neurological impairment, prior treatment if any, etc. First, I would argue there is seldom a role for surgical intervention ( other then biopsy to establish diagnosis) since lymphomas are uniquely radiosensitiv...
What is your approach to treatment of infection-triggered HLH that does not respond to treatment of the underlying infection?
The algorithm our center follows is to Recognize hyperinflammation (see answer to question above -- in addition to baseline labs, we obtain an infectious disease consult) Look for and treat the trigger. A concern, if the patient is responding, is that we are missing a trigger (HLH does not occur sp...
Do you offer ultra-hypofractionated 5-fraction RT regimens for DCIS s/p lumpectomy?
The premise of this question attempts to "split" DCIS from early-stage invasive disease. When we live in an eternal present-tense, we naturally repeat the mistakes of the past. Again, as for modest hypofractionation, we are not going to see a "separate" clinical trial for pure DCIS in this space. In...
Do you use the same criteria for offering neoadjuvant chemotherapy in a lobular breast cancer as you would in ductal?
HER2+ ILC is uncommon but can be seen in about 5% of ILC cancer cases. A retrospective review by MD Anderson suggested similar outcomes for HER2+ ILC vs IDC. (JCO 2012, ASCO Absract 612) I would confirm the HER2+ and low grade in this case, as that is discordant. As for regular ILC which is usually ...
Would you anticoagulate an SMV thrombosis caused by malignant obstruction in the setting of metastatic colorectal cancer?
Superior Mesenteric Vein Thrombosis is a rare phenomenon, within the category of Splanchnic thrombosis. While portal vein thrombosis is most often associated with cirrhosis (though also seen in many patients without cirrhosis), SMV thrombosis is more commonly seen in the context of either local prov...
Would you anticoagulate an SMV thrombosis caused by malignant obstruction in the setting of metastatic colorectal cancer?
Superior Mesenteric Vein Thrombosis is a rare phenomenon, within the category of Splanchnic thrombosis. While portal vein thrombosis is most often associated with cirrhosis (though also seen in many patients without cirrhosis), SMV thrombosis is more commonly seen in the context of either local prov...
Is there a concern for the potential of future congenital malformations in offspring when preservation of eggs and sperm is done AFTER cyclophosphamide treatment given that it is an alkylating agent?
No, there is not a significant risk of congenital malformations in embryos created with cryopreserved gametes or unassisted pregnancies AFTER cyclophosphamide use. While alkylating agents lead to both male and female infertility, congenital malformations from cyclophosphamide occur when conception h...
How would you approach a patient with symptomatic anal cancer and oligometastatic lesion to the lung?
Systemic treatment is the standard approach for metastatic anal squamous cell cancer. Carboplatin plus paclitaxel or 5FU plus cisplatin are reasonable choices. Recently, the InterAACT trial (Rao et al. JCO 2020) involving 91 patients comparing carboplatin/paclitaxel to 5FU/cisplatin showed similar O...