Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What adjuvant therapy would you offer following adjuvant chemotherapy for a patient with Stage III lung adenocarcinoma with an atypical EGFR mutation such as EGFR L861R?
Mutations at position 861 (most commonly L861Q) have been described, occurring in approximately 2% of all EGFR-mutant patients [Mitsudomi and Yatabe, PMID 19922469]. These mutations are considered partially sensitizing to afatinib based on a post-hoc analysis of LUX-Lung 2, LUX-Lung 3, and LUX-Lung ...
Would you offer local therapy to a patient with GEJ adenocarcinoma with FDG-avid para-aortic node oligometastasis?
I have favored induction systemic therapy and interval re-assessment. If responsive or at least stable disease, I have offered extended field CRT as long as the treatment volume seems reasonable and my perception is that it would be tolerable when assessed in the context of a patient’s performance s...
Do you offer anticoagulation to patients with prior antiphospholipid antibodies detected in pregnancy without a history of pregnancy loss or thrombosis?
I do not know what the risk of pregnancy loss is in a woman without a prior history of VTE or pregnancy loss. I am sure the risk is affected by whether the woman has an underlying rheumatological disease (SLE) and whether she has single positive vs. triple positive LAC. I recommend a baby aspirin on...
For a rectal cancer with questionable T3 or questionable N+ by MRI, can short course radiation be given followed by surgery and the pathology still be interpreted to guide adjuvant chemotherapy?
This is a somewhat common scenario. In these situations, I have strongly favored short course RT followed by immediate surgery such that there is not a sufficient time interval between RT and surgery to allow any significant pathologic response. I think you can be confident in that the pathology aft...
How do you manage grade 3 enterocolitis from 5FU mitomycin and pelvic radiotherapy?
With infection ruled out and CT showing diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field, presumably, it is due to the 5FU/mitomycin. In the few cases I have had, it generally heals 2-3 weeks after counts nadir. Besides supportive care (Imodium, Lomotil, Gas-X, ti...
How would you approach cytopenias 5 weeks after initial dosing in a young patient with MDS treated with Azacitadine as a bridge to transplant?
Bridging with HMA to transplant in MDS patients is a common practice although it did not show improved outcomes. You will definitely have to r/o other potential causes of pancytopenia (i.e., infections, etc). I would repeat a BM A/Bx to make sure that blasts are not increasing (< 20% and preferably ...
Do you recommend adjuvant chemotherapy in a patient with node positive gastric adenocarcinoma with mixed dMMR/MSI histology?
Well, this is certainly a situation where treatment decisions are completely unburdened by data and one could do virtually anything, from observation to immunotherapy plus chemotherapy.A more straightforward version of this scenario is if the patient has a fully resected node-positive dMMR/MSI gastr...
How would you approach second line treatment for prostate adenocarcinoma with diffuse neuroendocrine features?
Men with NEPC (histologic evidence of small cell carcinoma) face a poor prognosis and are typically refractory to all hormonal interventions, and in fact transformed NEPC much more typically evolves after potent AR inhibition than present de novo at diagnosis. Autopsy series and biopsy series sugges...
What are your takeaways from the GPRC5D-Targeted CAR-T trial (Mailankody et al. NEJM Sept 2022) and any key differences compared to the BCMA directed products?
I think it is hard to draw too many conclusions given that this is a first in human phase I study with only a small number of patients. What is promising here is that GPRC5D seems to be a good target for myeloma, even among patients with prior exposure to BCMA-targeted therapy. The population in thi...
How do you manage a Ta pure squamous cell carcinoma of the urinary bladder?
The ideal management of non-muscle invasive bladder cancer (NMIBC) with histologic variants remains controversial. The American Urological Association and the National Comprehensive Cancer Network guidelines recommend radical cystectomy for T1 patients with variant histology based on expert opinion ...