Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat newly diagnosed metastatic HER2 positive breast cancer with liquid NGS revealed ERBB2 L755S mutation (a marker for resistance against trastuzumab)?
Neratinib
How would you treat a patient with recurrent metastatic HCC 6 years after liver transplant for HCC?
Sadly, I have seen recurrence as far out as 10 years in these situations. Given the high risk of organ rejection (some literature report up to 40%) with immunotherapy and the lack of prospective data, I typically start patients with TKI such as lenvatinib or sorafenib depending on the provider's pre...
Should osimertinib be held prior to yttrium 90 liver directed therapy?
While not a common scenario and thus paucity of high level of incidence, I will, in principle, hold 1-2 days before the procedure and wait until a week post procedure ensuring LFTs are within acceptable range before restarting osimertinib.
Does recent COVID-19 infection result in elevated PSA?
A study from Turkey showed that PSA can increase sometimes dramatically in men with BPH (not necessarily with prostate cancer) during active COVID infection, from an average of 1.5 pre-COVID to 4.3 during active infection. (Cinislioglu et al., PMID 34626600). One can imagine a similar phenomenon may...
For cisplatin ineligible patients with locally advanced head and neck cancer, would you consider RT + immunotherapy rather than RT + cetuximab?
No. While the cited GORTEC trial showed pembrolizumab was no worse than cetuximab, the results from HN004 showed a significant reduction in PFS in the durvalumab arm. This plus emerging data from the lab of @Dr. First Last (Darragh et al., PMID 36385142) showing that elective nodal radiation signifi...
What "adjuvant" therapy would you consider in patients with gallbladder cancer with liver metastases that are resected upfront?
The scenario is that of already metastatic disease. Adjuvant therapy does not apply. The only choice is patience, hoping for no recurrence. While knowing recurrence is definite, would wait to treat when recurrence occurs. Close monitoring and support would be best!
How would you approach the primary treatment of a rapidly growing uterine carcinosarcoma with local extension through the anterior abdominal wall?
This patient needs multimodal therapy - surgical resection is a mainstay of treatment followed by adjuvant therapy (most likely chemotherapy +/- vaginal brachytherapy). In terms of chemotherapy agents - up front adjuvant treatment is usually carboplatin/paclitaxel or ifosfamide/paclitaxel. I would p...
What is your approach to BK hemorrhagic cystitis not responding to cidofovir?
BK hemorrhagic cystitis can range from completely asymptomatic infection (with positive BK viremia and viruria by PCR) or grade 0 to massive macroscopic hematuria requiring instrumentation for clot evacuation and urinary obstruction requiring bilateral nephrostomy tubes for urine diversion (grade 4)...
How would you treat a patient with bilateral synchronous breast cancers and evidence of metastatic disease on imaging when one breast has a triple negative cancer and the other breast has a ER/PR negative HER2+ cancer?
Herceptin, perjeta, and taxol
For a patient with PE undergoing procedures like port placement in the first month, how do you manage anticoagulation?
Due to their convenience, efficacy, and safety, I think direct oral anticoagulants (DOC) are the agents of choice for most cases of PE, DVT, or chronic prophylaxis. As per the package insert for Apixaban, for moderate or high risk invasive procedures, stop 48 hrs in advance, and for low risk, stop 2...