Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the utility of immunotherapy in management of malignant peripheral nerve sheath tumors?
The correct answer would be "unknown" or "TBD". Enrollment on clinical trials, even broad phase 1 trials, would be encouraged in cases where SOC therapy has failed.
How do you approach unresectable or borderline resectable symptomatic nasal/paranasal Rosai-Dorfman disease?
Sinus/nasal/paranasal RDD can be difficult to treat in many cases, with numerous recurrences. There is no one size fits all strategy for these cases, and most recommendations are based on case reports/series or anecdotal experience. If surgical resection is not feasible easily and refractory/recurre...
For a patient on dialysis with metastatic clear cell renal cancer, what regimen would you use after front line immunotherapy?
For patients with ESRD on dialysis, prior data showed that pharmacokinetics of VEGF-TKIs in subjects with severe renal impairment were similar to those with normal renal function (Khosravan et al. 2010, Chen et al, 2016, Nguyen et al, 2016). Also, other retrospective studies showed safety of VEGF-TK...
How do you treat patients with newly diagnosed metastatic MiT Family Translocation Renal Cell Carcinoma?
The AREN1721 clinical trial is accepting patients of all ages with unresectable or metastatic TFE/translocation renal cell carcinoma (RCC). The tumors must have either TFE3 expression by immunohistochemical staining or evidence of a TFE3 or TFEB translocation. The three arm trial compares nivolumab,...
When would you offer adjuvant chemotherapy after axillary dissection and RT for an isolated squamous cell carcinoma of an axillary node with unknown primary?
This is a conundrum that is rare but real. Here are my recommendations: Make sure an extensive medical history is taken about potential lesions that were frozen, excised, etc. Speak with your pathologist to make sure the SCC is not originating from a pilar tumor, or similar adnexal skin appendage t...
What treatment regimen would you choose for a patient with gastric adenocarcinoma who is found to have peritoneal and omental implants at the time of surgery after receiving preoperative FLOT?
I think there are 2 ways to answer this question. The more straightforward scenario is if the patient had a diagnostic laparoscopy prior to starting pre-operative chemotherapy and did not have either gross peritoneal disease or positive peritoneal cytology. In this case, this would be clear progress...
Assuming an absolute contraindication to immunotherapy and good PS, what is your preferred first line for metastatic squamous cell carcinoma of the lung?
As with many situations we face, there is likely no definite "one" answer to this question. That being said, I tend to like gemcitabine + platinum (usually carboplatin) since it is generally well tolerated and, for those who feel strongly about retaining hair, usually does not lead to hair loss. In ...
In what situations would you offer systemic therapy for HER2+ microinvasive invasive ductal carcinoma?
I usually do not treat microinvasive HER2+ ductal cancer as most screen-detected cases still have a good prognosis and there is limited data for therapy benefit. A review by Padmore et al. (PMID 10717623) and a Chinese series (Si et al. Front Oncol 2020) suggested a higher risk of recurrence in youn...
How do you advise patients on duration of first line maintenance PARPi and the potential risk of MDS or AML?
For patients, who could derive significant survival benefit from first line maintenance PARP-inhibition (BRCA+ and HRD tumors), we advise them to take PARP-inhibitors up to 2 years (olaparib) or up to 3 years (niraparib) if no disease progression or unacceptable toxicity. I counsel patients that dev...
Why are autoantibodies not often detected on monoclonal gammopathy assays (SPEP/IFE, quantitiative immunoglobulins)?
Autoantibodies do not cause a false positive M protein. Even though autoantibodies may target a specific antigen, they are polyclonal. Rarely, a very high rheumatoid factor titer can produce a broad-based (polyclonal) peak in the electrophoretic pattern. UpToDate