Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you determine the safety of anticoagulation in patients with evidence of cerebral microhemorrhages who present with acute stroke secondary to cardioembolism?
This question assumes that the patient already had an MRI showing microhemorrhages. The Boston criteria provide guidelines for the number of microbleeds, associated superficial siderosis, or major hemorrhage to make the diagnosis of cerebral amyloid angiopathy. I would also assume that at least some...
Do you perform a bone marrow biopsy in all patients with grade 5 anaphylaxis to stinging insects and negative workup for HAT, MCAS, c-KIT?
Before saying that bone marrow biopsy is the next step (which it is), we must be certain that we are correctly assessing the situation. Was there documented hypotensive shock (and not just subjective light-headedness or brief vasovagal syncope? Were there other objective signs like urticaria (althou...
What is your recommendation for patients who are on weight loss medications like GLP-1-based therapies while receiving chemoradiation for head and neck cancer?
I recommend immediate discontinuation of GLP-1-based therapies. Increased risk of nausea/vomiting and weight loss certainly aren't side effects we need during head and neck chemorads. Additionally, there is concern that these agents, even outside of cancer patients, contribute to sarcopenia, which h...
Is there a scenario in which you would consider observation for T4a SCC involving the mandible?
While PORT is well established, the scientific basis for it is relatively weak in the absence of a randomized trial, as all phase 3 trials have focused on adding something to radiation rather than the benefit of radiation alone. Further, the rationale for PORT historically is if there is a belief of...
What is the preferred neoadjuvant/adjuvant chemotherapy regimen for HPV-associated nasopharyngeal cancer?
Let me give more context: Had an interesting conversation with a med onc colleague regarding neoadjuvant or adjuvant gem/cis for HPV-associated NPC. I personally make a distinction between EBV-associated NPC and HPV-associated NPC. My interpretation of the data is that the benefit is only/mainly for...
For unresectable-appearing BRAF V600E papillary thyroid cancer involving the trachea and carotid artery, is neoadjuvant targeted therapy a viable path to surgery, or is definitive radiation the better option?
If the tumor is considered unresectable due to carotid encasement, as is likely in this case, then neoadjuvant targeted therapies should not be considered. Multikinase inhibitors (i.e., lenvatinib) or targeted therapies (dabrafenib and trametinib) will not produce great enough responses to make the ...
How do you approach a patient with indolent, small-volume, but slowly progressive lung mets from sarcoma?
If small volume without active extrapulmonary disease and amenable to addressing all lesions with SABR, surgery, or a combination of both, I would target all lesions with local therapy. If the above conditions are met, these can often be monitored closely with q3-6 month CT surveillance in the prese...
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In patients with inflammatory arthritis (RA, psoriatic arthritis) and a history of MGUS are there any concerns regarding use of biologics?
There is no absolute contraindication to any particular biologic used to manage active RA in a patient with MGUS. The literature does point out a small potential risk associated with tocilizumab in terms of development of myeloma influenced by the IL-6 pathway (and I would tend to extend that potent...
What do you recommend for patients with stage 3 MSI-H colorectal cancer who are ineligible for oxaliplatin-based adjuvant therapy?
I typically don’t offer adjuvant therapy to those patients. 5-Fu/Xeloda does not benefit as a single agent in this patient population. If Oxaliplatin-based treatments cannot be given, then there are practically no other options that are associated with a survival benefit.