Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you follow up a patient with esophageal adenocarcinoma who is not a surgical candidate after finishing chemoradiation?
I am assuming that this patient has adenocarcinoma and also had definitive dosing radiation (50.4 Gy +) and not neoadjuvant dosing as was used in the CROSS trial (41.4 Gy). If that is the case, you would use the same surveillance as you would after surgery which is H&P every 3-6 mo with labs and sca...
How should you work up calvarium or other osseous lesions when found during the initial staging of a patient with a new diagnosis of NSCLC otherwise non-metastatic?
In general, I try to "prove" metastatic disease to ensure appropriate staging. I have had several situations where a skull or other osseous lesion is suspicious on CT and have tried to assess by PET or NM bone scan - ultimately though, have referred for biopsy and have actually diagnosed several int...
Which chemo regimen, if any, would you use as adjuvant treatment in a young patient with primary malignant thyroid teratoma?
There is no evidence base to guide you here. The term "malignant teratoma" is not particularly helpful here and does not distinguish between benign teratoma, somatic transformation, or active germ cell malignancies. If classic markers AFP and HCG are significantly elevated, that would favor a malign...
What is the best treatment for pT2 cN1 seminoma with mild elevation of B-HCG (~100)?
I would recommend making sure that the pathology is seminoma (with either review of the orchiectomy specimen and making sure there are trophoblastic elements or a biopsy of the retroperitoneal lymph node) as the beta hCG level is getting close to the upper end of what I would expect from a seminoma....
Is there any role for ascertaining somatostatin-receptor status with a DOTATATE PET scan in prostatic adenocarcinoma with neuroendocrine features to consider lanreotide along with chemotherapy?
Great question! The easy answer is no--regarding current standard of care treatments. This is not an FDA-approved treatment. However, this touches on the larger issue of we don't really know/understand what it means 'neuroendocrine' prostate cancer is. Ongoing work is better defining the molecular c...
Is there a role of everolimus or capecitabine and temozolomide in diffuse idiopathic pulmonary neuroendocrine cell hyperplasia in patients already on octreotide?
The key question is why there is a reason to change the treatment... Is it for worsening symptoms or progressive disease with overt lung NET development or progression of known lung NET?In a retrospective study of 55 patients with DIPNECH, only 18% had a progression to a lung NET (typical carcinoid)...
How do you utilize p53 NGS testing in your treatment planning for patients with CLL?
When I approach consideration of treatment, it is clear that TP53 mutation or del(17)(p13) chromosome region on interphase cytogenetics identifies a group of patients at risk for progression after treatment with a venetoclax containing regimen and also to a lesser extent BTKi (ibrutinib/acalabrutini...
What is your treatment approach for a recurrent brainstem glioma?
Recurrent brainstem glioma is a very challenging situation. One could consider participating in a clinical trial if available, especially one that targets some of the known mutations in the tumor (such as histone h3, TP53, ATRX, ACVR1, and others). We have previously re-irradiated a few patients at ...
Do you routinely obtain next generation sequencing for patients with metastatic renal cell carcinoma and if so, what is your approach to incorporating these results into treatment decision making?
Currently, I do not routinely send NGS for patients with metastatic clear cell RCC as we do not have level 1 evidence that these results should guide treatment decisions. We do not have "actionable mutations" that would change or guide our treatment of choice. IMDC still remains our best risk strati...
What clinical and pathological features do you consider when deciding which androgen receptor targeted agent to combine with ADT for a patient with newly diagnosed castrate sensitive metastatic prostate cancer?
Regarding which novel hormonal agent I use with ADT, there are no specific pathologic features which suggest that any one agent is better than any others as far as I know, so I do not consider that in the decision. The primary reasons why I choose an agent are based on adverse events and side effect...