Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you substitute carfilzomib in place of bortezomib in a transplant-eligible AL amyloidosis patient with baseline amyloid neuropathy and worsening neuropathy on bortezomib despite maximal dose reduction?
I never give carfilzomib as part of first line therapy on Al amyloidosis. These patients already have some form of cardiac involvement (based on troponin and NT proBNP). 56% of AL amyloid patients have 2 or more organ involvements with cardiac being one of them. Always take into consideration cardia...
How, if at all, does your approach to adjuvant chemoradiation differ with proton beam radiation vs. conventional photon radiation for H&N Cancers?
As there is no prospective data for protons over photons in head and neck cancer, despite the proliferation in utilization, I would not feel comfortable treating this way unless it was the only option.In addition, recent reports indicate a relatively high risk of mandibular ORN, which is hardly seen...
How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?
Our hematologist/oncologist referred just such a patient. No evidence of malignancy, but elevated CRP &ESR. I did an “internist’s” workup as I would for dermatomyositis, starting with the most important and therefore most thorough aspect: taking a full and very “invasive” history, followed by a comp...
For patients with IgG kappa multiple myeloma receiving an IgG kappa mAb (i.e., daratumumab), how important is it clinically to use an interference assay if they're in a VGPR to see if their M-spike might actually be 0?
I always try to perform an assay to distinguish an IgG kappa monoclonal protein from the therapeutic antibody of interest. For daratumumab, the ‘hydra shift’ assay has been used for a while. Now, with Mass spectrometry available, it is the perfect way to assess very sensitively for a residual protei...
Would repeat MMR/HER-2 or NGS testing be beneficial during progression of gastric cancer in patients who have already received first line chemotherapy?
There are really no good data one way or another, as far as I know, so any views expressed here are purely anecdotal and personal opinions.As a group and speaking for myself, I rarely repeat NGS. The bigger picture is that we identify actionable alterations in esophagogastric cancer no more than 5% ...
What criteria do you use to determine the resectability of mucosal melanoma of the H&N region?
Obviously, the best specialist to answer the posted question would be a H&N surgeon. As a Rad Onc enthusiast who conducted a retrospective study about the subject long ago (Lee et al., PMID 8302112), I’ll provide my own 2-cents here:Mucosal melanoma (MucMlnm) of the H&N is a relatively uncommon mali...
What is the treatment approach if an AML patient receiving azacitidine/venetoclax is later found to have FLT3 and IDH2 mutations?
This is solely an opinion as there is little data. Since FLT3 inhibitors are not approved for use with azacitidine and venetoclax and data is just emerging about triplet therapy with the addition of these inhibitors, I would just keep going with azacitidine and venetoclax and reserve FLT3 and IDH2 i...
How do you approach hormone replacement therapy for premenopausal patients following pelvic radiation therapy?
Most patients who undergo pelvic radiation will become menopausal. Physiologically, the outcome is similar to surgical menopause because sufficient doses of radiation result in complete loss of ovarian function. In contrast, after natural menopause, the ovaries continue some types of endocrine funct...
What is the role of local control +/- whole lung irradiation in a patient with relapsed/refractory Ewing sarcoma to the hilum plus multiple lung nodules?
I would boost residual thoracic disease to at least the usual Ewings gross disease dose of 55.8 (total, including WLI dose). Doses in this range are well known to be safe in the thorax and this multiply relapsed disease is likely to be more treatment refractory than primary disease. SBRT boost seems...
Is there any reason to hold fulvestrant during SBRT to an oligoprogressive nodule?
No.