Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When patients develop headaches from luspatercept, do they tend to improve over time?
I've seen two common scenarios with this. One is headaches related to hypertension as a result of luspatercept. By treating the hypertension, the headaches often improve. If the headaches are in the absence of hypertension, I do use a low dose beta blocker to see if it helps, and have had some resul...
How would you treat an elderly patient (ECOG 0-1) with locally advanced rectal cancer and synchronous Merkel cell cancer of the extremity requiring adjuvant RT?
Interesting - the flurry of activity came several months after I treated the patient. The patient was not going to get further surgery for either. I choose to treat with definitive CRT (Xeloda) to 54 Gy w VMAT. I treated the Merkel Cell with 30/10 at the same time, presuming the patient would have a...
What clinical or pathologic features would make you more concerned that a new skin SCC is from metastatic disease or a new cutaneous primary?
Histologic examination should reveal an epidermal connection in a primary SCC. If one cannot be found, the pathologist must raise the possibility of a metastatic lesion and state that alternatively could be a portion of primary SCC (epidermal connection may not be included in biopsy sampling). If th...
What chemotherapy backbone would you use with trastuzumab in patients with HER2+ esophagogastric cancer that relapse after perioperative FLOT4?
As with many of these head-scratchers, there's no right answer here. But, I would begin from the starting point that the current standard-of-care for 1st-line treatment of Her2 positive GEJ/gastric cancer is pembrolizumab/trastuzumab and a fluoropyrimidine/platinum doublet, as the question acknowled...
How would you approach a sarcoma that was initially diagnosed as UPS of the distal femur with groin lymph node spread, resected, and found to have an EWSR1-FLI1 fusion diagnostic of Ewing's on NGS?
If this is a primary bone tumor with EWSR1-FLI1 fusion, I would treat it as if it were Ewing sarcoma.
How do you approach patients with lymph node only recurrences in the setting of previously resected colon cancer that are not amenable to biopsy?
What is your preferred approach to third-line treatment of metastatic HER2 positive esophageal adenocarcinoma after progression on FOLFOX/CAPOX + trastuzumab, then T-DXd?
If the patient's disease is still HER2+, I would strongly consider a clinical trial. Outside of a trial, my preferred 3L therapy would be ramucirumab/paclitaxel. The phase 3 RAINBOW trial (Wilke et al., PMID 25240821) showed a survival benefit of ram/paclitaxel over paclitaxel alone. In this trial, ...
For T cell ALL treated in CR (without transplant), how often do you do BM biopsies as part of surveillance, and for how long?
The role of surveillance bone marrow exams in ALL (either B or T-lineage) is a matter of some debate. Thoughtful clinicians can disagree, but in my practice, I do NOT routinely perform these procedures, instead reserving them for signs or symptoms suspicious for relapse. This is analogous to how the...
How would you manage stable/slightly enlarged pulmonary metastasis from non-seminoma testicular cancer after receiving 3 cycles of BEP, which resulted in a mixed responses on chest CT but normalized AFP?
This is a patient with nonseminomatous germ cell tumor, with presumably pulmonary metastases at start of BEP X 3. I am also assuming that his abdominal CT scan was either normal baseline or it reverted to normal post BEP. The issue now is a mixed response in the lungs, implying some lesions are smal...
Would you consider 177Lu-PSMA-617 for a patient with mCRPC that has neuroendocrine features on biopsy but PSMA-positive disease on PET?
That depends somewhat on the extent of PSMA positive disease. mCRPC is a heterogeneous disease - if the majority of the disease is clearly PSMA positive, then I think it would be reasonable to use PSMA-directed therapy regardless of what the biopsy is demonstrating.