Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a mixed neuroendocrine/adenocarcinoma appendiceal tumor with metastasis to the liver?
I find it helpful to ask pathology to comment on the individual tumor components. If there is a substantial adenocarcinoma component in the tumor, I worry that platinum/etoposide may be inadequate as therapy. For a predominantly high-grade, poorly differentiated neuroendocrine carcinoma with a minor...
Would you hold rituximab for newly diagnosed B-cell lymphoma if the patient is COVID-19 positive?
The question of how best to manage ongoing lymphoma therapy in the face of SARS-CoV-2 infection remains unanswered. That said, centers are developing guidance for clinicians based upon available and emerging data. Newer data from MSKCC suggest that recent treatment (within the last 30 days) is not a...
What is your approach to unresectable metastatic rhabdomyosarcoma transformed from an embryonal cell germ cell tumor?
More information would be helpful. I infer this is a patient who underwent an orchiectomy for a more typical histology of germ cell cancer, probably with elements of teratoma. He may or may not have had elevated hCG or AFP. He may or may not have received BEP or similar chemotherapy. Perhaps he had ...
How would you approach adjuvant therapy for resected spindle cell rhabdosarcoma of the tongue?
From a practical management and chemo-sensitivity standpoint, I would think of this as a UPS and not the conventional embryonal/alveolar RMS. I would favor completing the SOC local control with XRT and re-stage a month later. If still with NED and the patient wants to be aggressive, reasonable to co...
What frontline treatment would you offer a patient with AITL who is not a candidate for an anthracycline due to baseline cardiomyopathy?
I would probably offer this patient CEOP. No data to back this up, however. Incorporation of etoposide in addition to CHOP confers a progression-free survival advantage in younger patients with PTCL, so it's reasonable to assume the etoposide would have activity.
What radiation sensitizer do you recommend for early stage poorly differentiated squamous cell carcinoma of the anus, in a patient with stage IV chronic kidney disease?
I have used carboplatin (AUC 2 weekly) + 5-fluorouracil in this setting with good tolerance. I acknowledge that the substitution of carboplatin for cisplatin is largely an extrapolation from the approach to squamous cell carcinomas of other primary sites. However, I feel very comfortable with this s...
What is your preferred second line treatment for advanced hepatocellular carcinoma after progression on atezolizumab and bevacizumab?
Atezolizumab plus bevacizumab and other potential combination therapies will become what I have been calling line minus 1. This will help provide the proven value of sorafenib followed by regorafenib; lenvatinib as first line; ramicirumab as second line if AFP is >400mg/mL; and cabozantinib as secon...
What adjuvant treatment would you offer after repeat surgery for a locally recurrent, lymph node positive small bowel adenocarcinoma with residual neuropathy after prior FOLFOX?
There is no good data for small bowel adenocarcinoma and a lot of treatment is extrapolated from colon cancer literature. If the patient had recurrent disease after initial surgery and adjuvant FOLFOX, the benefit of further chemotherapy as adjuvant treatment is questionable. I would not recommend c...
With the approval of capmatinib, how would you approach a newly diagnosed metastatic NSCLC with MET Exon 14 skipping mutation?
Somatic MET mutations leading to splicing-mediated loss of exon 14 and subsequent MET overexpression are an emerging therapeutic target present in 2-4% of lung adenocarcinomas (1, 2). MET tyrosine kinase inhibitor (TKI) treatment was associated with improved overall survival in a retrospective study...
Would you treat a patient with Radium 223 for prostate cancer with mainly bone metastasis if he has a history of osteonecrosis of the jaw bone from bisphosphonate/Denosumab?
This is a good question, and one that has very little evidence to answer. Certainly there is some risk of ONJ due to radium 223 from case reports in the literature. There have also been successful palliative treatments with radium in men with bone mCRPC, despite ongoing ONJ due to bisphosphonates:Us...