Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How often do you follow ferritin and organ iron-deposition in a patient who has known hereditary hemochromatosis, but no current evidence of iron overload?
Once diagnosis is made, I stress blood donation or less optimally, therapeutic phlebotomy. If donation every 56 days until ferritin <100 and TSAT <30. This assumes asymptomatic without LFT abnormality. Thereafter the intervals can be adjusted to keep parameters in the desired range. I never follow o...
How long do you continue caplacizumab in relapsed refractory TTP?
While there are no data from studies to guide our answer, general practice is to continue caplacizumab until the ADAMTS13 activity is at least 20% on two occasions, or greater than 30% assuming it was measured at least 4-5 days after the last plasma exchange procedure. The goal is to have stable rec...
Would you consider the use of ctDNA as part of surveillance in high risk TNBC patients?
Patients with significant residual TNBC following NAC have an increased risk of recurrence and death within 3 years, despite SOC adjuvant capecitabine (EA1131). The presence of ctDNA following initial active treatment (using Signatera or other platforms) has reliably shown to predict risk of recurre...
Would you offer a RET inhibitor for a RET-mutated medullary thyroid carcinoma after R1 resection in a patient with elevated calcitonin?
RET inhibitors have not yet been studied in the adjuvant setting in MTC (or in other RET-driven cancers for that matter). Thus, it is not considered SOC to start a RET specific inhibitor in the adjuvant setting following surgery for MTC, even when calcitonin and/or CEA are elevated. In the post-oper...
Will you offer adjuvant BEP after orchiectomy to a patient with embryonal carcinoma, solely based on the size at presentation, such as a 6 cm testicular mass?
I would not consider adjuvant BEP in this setting. While the risk of relapse is likely higher than smaller non ECC predominant tumor, it likely does not exceed a 50% chance of recurrence. Our general stance is active surveillance for all CS 1 seminoma and non seminoma patients. Adjuvant anything imm...
What would be the treatment options for metastatic clear cell carcinoma of kidney who develops recurrent thrombosis despite therapeutic anticoagulant on cabozantinib in second line treatment after failing immunotherapy?
Any TKI will potentially increase the risk of thrombosis, so this is a bit of a challenge for the patient. However, cabozantinib, based on personal experience, is more likely to cause this complication and other TKIs may be better in this regard. If you need to completely avoid TKIs, everolimus mono...
How would you proceed for a patient with metastatic gastric-type adenocarcinoma, with vaginal and inguinofemoral disease only, who experiences complete response to her vaginal tumor but residual inguinal disease?
There is no ideal data to guide this. I would recommend surgical nodal excision of the residual inguinal disease, followed by pelvic and inguinal radiation (with or without platinum if the patient can tolerate further). Another approach would be with cisplatin-based chemoradiotherapy with treatment ...
How would you approach a pT2 nonseminomatous testicular cancer, embryonal caricnoma with +LVI with persistent b-hcg < 20 post-operatively?
If a patient has had an inguinal orchiectomy and has a persisting b-HCG in a reliable lab (remember that alpha-HCG can cross-react with the alpha chain of LH, so a "good" beta-HCG assay is important, especially as hypogonadal males often have an elevated LH), it suggests clearly that there is residu...
How would you treat a patient with newly diagnosed prostate cancer with low volume bone metastases and extensive lung metastases with a very low PSA (< 5) and no neuroendocrine differentiation on pathology?
Generally, I would treat such a patient with ADT plus abiraterone (or enzalutamide). A recent paper from our group suggested that patients who present with pulmonary mets, without concurrent liver mets, usually have a great prognosis with hormonal therapies. Another interesting phenomenon is that pa...
How would you manage a patient with MSS, KRAS mutated locally advanced rectal adenocarcinoma with a mixed response to neoadjuvant FOLFOX?
If there is new bone marrow involvement, I assume you confirmed this with a bone marrow biopsy? This would be a very unusual location for rectal cancer, so to speak. If you have not done a BMB, I would obtain pathologic proof of bone involvement. That would make this patient stage IV, in which case,...