Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer curative intent therapy to a patient with a new diagnosis of breast cancer with multiple small lung nodules (<1cm not amenable to biopsy) as the only possible site of metastatic disease?
I will typically give the benefit of the doubt to the patient in planning treatment for a potentially curative treatment. Finding small lung nodules on CT scans can be related to benign, granulomatous, or an old infection and not necessarily due to malignancy. It is important to understand the conte...
Would you prescribe ADT or AR inhibitors for a patient with moderate to severe dementia who has biochemical recurrent, non-metastatic prostate cancer, but otherwise good physical performance status and prognosis >5 years?
I would discuss with their caregivers. They are the ones who have to manage the patient's moderate to severe dementia daily and presumably are acting as the patient's medical power of attorney. Practical consequences to typically routine therapies can be serious. Substantial declines in cognition, m...
How do you approach a cervical node biopsy-proven follicular lymphoma in situ in a symptomatic patient with night sweats and PET findings of low SUV uptake throughout the body?
Follicular lymphoma in situ, aka in situ follicular neoplasm (ISFN) is an uncommon entity, representing an early precursor lesion and better conceived of as premalignant as opposed to a true malignancy, and a pathologic diagnosis of ISFN is not an indication for therapy. Most patients with ISFN will...
How would you approach the adjuvant treatment of a stage IVA adenosarcoma of the ovary?
Adenosarcomas have a benign/low grade epithelial component, unlike carcinosarcoma/sarcomatoid carcinoma. The sarcomatous component is the high grade element driving prognosis, so therapy should be directed a'la sarcoma based on usual predictive factors of age, PS, organ function, etc.
Would you recommend adding a TKI to a pediatric regimen for a AYA B-ALL patient with IKZF1 mutation?
I would not add a TKI to standard chemotherapy in this situation. Background/Rationale: IKZF1 mutations (specifically deletions) are associated with inferior prognosis. Specifically, the prognosis appears to be worst with mutations that lead to loss-of-function (e.g., focal deletions [Beldjord et al...
What advice do you have for the management of nail toxicity associated with pemigatinib and other FGFR inhibitors?
Pan-FGFR inhibitors as a class can cause significant dermatologic toxic effects (including alopecia, dry skin, nail changes, and stomatitis) anywhere in the range of 20% to 45%, depending on the specific agents (Lacouture et al., PMID 33021006, Bétrian et al., PMID 28538953).Lacouture and colleagues...
How do you mitigate 6-MP-induced GI toxicity in pediatric and AYA patients with leukemia?
This is a great question as GI toxicities are commonly encountered in children, adolescents, and young adults being treated with 6MP including elevated transaminases, pancreatitis, and hypoglycemia. These GI toxicities are likely due to a skewing of 6MP metabolites with an accumulation of the GI tox...
Do you consider the duration of lung/lobar atelectasis in your decision making while offering airway stents for malignant central airway obstruction?
Yes, always. We review old imaging to determine when there is a post obstructive pneumonia or collapsed lobe/lung secondary to endobronchial obstruction (extrinsic or intrinsic). The old teaching was that, if a lobe is down for more than two months, it is unlikely to be salvaged, even after the endo...
How would you manage a transplant-eligible patient with DLBCL who relapsed 6-12 months following a CR1 to R-CHOP and then attained a CR2 to platinum-based salvage chemoimmunotherapy?
In this case, given that the patient obtained a CR2 to salvage therapy, I would, if they are otherwise eligible, take this patient to transplant given the data presented by Shadman et al., PMID 34570879 which indicates that those with at least a PR from salvage chemotherapy appeared to benefit as mu...
What gene mutations do you always test for prior to starting EGFR inhibitor therapy in metastatic colon cancer?
At a minimum, I operate with pan-RAS, BRAF (yes, even for left sided tumors), MMR/MSI, RNA fusion/rearrangement, and HER2 testing prior to anti-EGFR therapy. Obviously, you would not want to give an EGFR inhibitor to a RAS mutated cancer, but similarly, I need to know the BRAF (particularly V600E) u...