Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you start anticoagulation in a patient with a history of CVA 1 year ago and high risk APL profile who was never started on anticoagulation, but is now presenting for follow up and without recurrent thrombotic events?
This is a difficult question. The details here are important. Therapeutically, you can go either way in my opinion. Were the positive antiphospholipid antibodies checked again later? Did the patient have an infection when the APS labs were first done? Does the patient have diabetes or other CV risk ...
In what scenario would you prefer weekly vs every 3 week carboplatin/paclitaxel for high grade serous ovarian cancer?
This is a great question without a simple answer. Let’s briefly review the pertinent data, followed by a discussion on how to use the information to consider weekly chemotherapy vs. a standard q 3-week (wk) chemotherapy regimen for primary advanced ovarian cancer.There has been increasing interest i...
What additional testing besides LAC/APLS, factor V Leiden, prothrombin gene mutation, JAK 2 do you draw for unprovoked cerebral venous sinus thrombosis?
Cerebral venous sinus thromboses (CVST) are often put into the category of "thromboses of unusual sites,"--as opposed to the more common lower extremity thromboses or pulmonary emboli.Provoked causes of CVST include pregnancy or exogenous estrogen use, infection of the head/neck or CNS, head trauma,...
How do you approach a patient with recurrent chest wall BRAF(+) mutated melanoma who developed multiple metastatic axillary nodes while on immunotherapy, now post axillary dissection for adjuvant radiation?
This is a patient with recurrent BRAF+ metastatic melanoma who has undergone definitive resection for metastatic lymph nodes. I think it's important to clarify whether this patient progressed after single-agent immune checkpoint therapy (i.e., pembrolizumab or nivolumab) vs dual-immune checkpoint th...
How should a contralateral breast cancer be treated when found during a prophylactic mastectomy?
Whenever a contralateral prophylactic mastectomy is planned, diagnostic imaging of that breast and nodal basin is recommended pre-operatively if not done within the last month or so. Any abnormality should be resolved diagnostically and treated accordingly. Even with this process, incidental cancers...
How do you approach autologous stem cell transplant in T-cell lymphomas/PTCL after induction chemotherapy with achievement of CR1?
Autologous SCT can be considered in PTCL in CR1 especially if the patient is MRD negative by PET and molecular testing (by checking for the persistence of clonal T cells, for example). Schmitz et al., PMID 33512419 If MRD positive CR or PR/SD, would consider allogeneic SCT instead. The main concern ...
How do you approach autologous stem cell transplant in T-cell lymphomas/PTCL after induction chemotherapy with achievement of CR1?
Autologous SCT can be considered in PTCL in CR1 especially if the patient is MRD negative by PET and molecular testing (by checking for the persistence of clonal T cells, for example). Schmitz et al., PMID 33512419 If MRD positive CR or PR/SD, would consider allogeneic SCT instead. The main concern ...
Would you drop carboplatin/paclitaxel weeks or considering shortening duration of treatment in a BRCA1+ patient with synchronous TNBC (left 2.4 cm tumor, right 9 mm tumor) who has complete response on interim breast ultrasound?
From a medical oncology perspective, the short answer would be no. The ability of imaging to predict pathologic complete response is not good enough. For example, here is one looking at MRI: Weber et al., PMID 28919579. Imaging isn't good enough to spot a true path CR. Certainly, if there is toxicit...
How do you approach patients with SDH deficient advanced GIST tumor for systemic treatment?
For SDHB mutant GIST (the most common SDH mutation), I try to observe them for as long as possible and resect the enlarging lesions when possible (NF1 and SDH mutant GIST tend to grow slowly compared with their KIT/PDGFR mutant counterparts). If no surgical resection options are available, the les...
Is pembrolizumab-carboplatin-pemetrexed an acceptable initial therapy for metastatic non-squamous NSCLC regardless of PD-L1 status?
In my opinion, the approval of Pembro-chemo for 1st line therapy of non-squam NSCLC, based on the small randomized Phase II KEYNOTE 021 trial, with no link to PD-L1 expression, was premature. The implications are so great that waiting a few months for the Phase III results is warranted. Afterall, th...