Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer empiric lung SBRT for two growing FDG-avid lung lesions in a patient with severe COPD on oxygen?
This is a good question! The short answer is yes, most likely. Many patients are too high-risk to receive biopsies; this is decided by surgery/pulm/IR. Unless the patient has contraindications to RT or something like severe IPF (where treatment may be worse than the disease), I would likely offer th...
Would you recommend sentinel lymph node biopsy at the time of wide excision for a 3 mm Merkel cell carcinoma of the cheek/lateral canthus?
Unlike melanoma and certainly NMSC, MCC is highly unpredictable in nature, with clinical lesion size having little clinical prognostic value. As such, it appears that SLNB is valuable in many cases for the purposes of prognosis and in determining the need for adjuvant systemic therapy and radiation....
In ES-SCLC presenting with limited asymptomatic brain metastases and treated upfront with systemic therapy alone (carbo/etop/atezo), how would you approach the brain if MRI shows PR after a few cycles?
In our practice, we would typically watch such a patient on systemic therapy. However, we would stress the need for vigilant monitoring and likely administration of RT (SRS ideally) at the carbo/etop/atezo transition to atezo monotherapy, given the poor intracranial efficacy of the maintenance syste...
How do you manage a cytology-negative pleural effusion that develops after lung RT?
I think most times you can just watch them as long as they are stable and not symptomatic. I see them not infrequently after RT, especially lung SBRT, and find they often find a size they feel comfortable with and don't change much over time. I wonder about their physiology... my impression is there...
How do you manage perioperative anticoagulation for a patient with a history of recent, surgically provoked VTE?
In most cases, bridging is rarely indicated because the bleeding risk usually outweighs the risk of VTE recurrence during a short (1–2 day) interruption of anticoagulation. However, after a recent VTE (defined as <3 months), the estimated risk of VTE recurrence is high (>15–20% per year) (still low ...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
Does stage of resected EGFRm NSCLC impact your treatment decisions for use of adjuvant osimertinib?
Yes, to some degree; it informs the risk/benefit ratio when I discuss adjuvant osimertinb with patients. The benefit of adjuvant osimertinib was seen in stages 1B, 2 and 3 but the magnitude of the benefit increased with higher stages. This makes sense because the risk of recurrence increases with in...
What is your preferred first-line treatment for metastatic melanoma in a patient with a class 2/non-V600 BRAF mutation?
Class II BRAF mutations have intermediate kinase activity and are much less likely than V600E or V600K mutations to respond to traditional BRAF+MEK inhibitor therapy. Targeted therapy should not be used as a front-line therapy in these patients. Immunotherapy (and immunotherapy-based front-line clin...
How would you approach a patient with vitreoretinal lymphoma without CNS or systemic involvement?
The optimal treatment approach for primary intraocular lymphoma is debated. This is a rare disease with only small retrospective series guiding therapy. There is no clear superior treatment approach in the literature. In clinical practice, younger patients are often treated initially with high-dose ...
How should you manage a coronavirus infected/suspected patient who is receiving radiotherapy and cannot interrupt or delay their cancer treatment?
Hi Everyone, I agree with all the comments—this is certainly a fluid situation. We have not had a confirmed COVID-19 case, but we have developed a plan. If it is deemed a known COVID-19 patient, and it is elected to continue treatment by the treating physician, the treatment will happen at the end o...