Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to a patient with an advanced stage diffuse large B-cell lymphoma treated with chemotherapy alone (with a PET CR) who then develops an isolated CNS relapse?
This is a challenging albeit relatively rare situation. First, I would make sure to complete systemic workup, including MRI of brain/spine, CSF cytology, and PET/CT. I would not consider radiosurgery even for a single brain lesion, as this is ultimately a more diffuse disease process. If patient has...
What chemotherapy regimen would you recommend for a patient with symptomatic cutaneous B cell lymphoma?
This would depend on the subtype and stage. If only cutaneous disease and marignal or follicle center histology then single agent rituximab is best studied. The literature is variable on the # cycles to give, but there is nearly a 100% RR with high CR with follicle center. PCDLBC-LT requires multiag...
Given the sensitivity and prognostic value of the serum free light chain ratio for light chain multiple myeloma, do you continue to check urine studies?
This is a very pertinent and timely question. In fact, there is finally data. Dr. Dejoie et al published in Blood a study comparing the performance of serum and urine measurements in 113 newly diagnosed light chain myeloma patients. Interestingly only 64% of these patients had a measurable urine pro...
What is your next step in management for a patient with immunotherapy induced pneumonitis that does not improve on high dose steroids for 48 hours?
There is an excellent answer to this question from my colleague Dr. @Dr. First Last that can be found here. She provides an overview of the data as well as multiple references.
Is sentinel lymph node biopsy several weeks after partial mastectomy as reliable as sentinel lymph node biopsy done at the time of partial mastectomy?
Great question! We do it all the time in the setting of invasion found after lumpectomy for DCIS or after a surgical biopsy finds an invasive cancer but the question is whether it's as accurate in this scenario? Does a previous surgery alter the lymphatic drainage pattern to a degree that renders se...
How do you decide between re-irradiation, chemotherapy, and alternating electric field therapy in patients with relapsed GBM post chemoradiation with TMZ?
The best care for patients with glioblastoma is multi-disciplinary. For that reason, we review these patients in our tumor board. The critical questions are - 1) Is this truly disease progression or could it be radiation necrosis/ pseudoprogression? 2) What functions are located in the area of recur...
Is there utility in molecular or proteomic testing (e.g., Foundation or Caris) for metastatic clear cell renal cell carcinoma when several lines have failed?
The role of genomics is not well-defined in mRCC. In my personal experience there are very few truly actionable mutations that will be discovered. I would generally favor alternative FDA-approved agents of novl clinical trials.
How would you approach metastatic hepatocellular cancer with neuroendocrine features?
I would consider having both specimens reviewed by an expert GI pathologist to determine the histology and apply additional IHC stains as indicated. Misdiagnosis of NETs is not all that uncommon and I have seen both HCC and cholangiocarcinoma called NETs and the other way around too. For a tumor tha...
In multiple myeloma patients on bortezomib and dexamethasone, who develop HZV reactivation while on HZV prophylaxis, do you stop bortezomib/dexamethasone permanently?
It is important to make sure compliance with the drug is good. If it is drug resistance may play a role and alternative approaches can be used. Permanent discontinuation is not really an option as many drugs used for myeloma carries the same risk of zoster and if the patient needs the treatment, the...
What is your preferred dosing and schedule for interferon in pregnant CML patients?
The ideal starting dose for interferon in pregnant patients is a bit of a challenge because of gaps in the evidence base. In the IRIS study, interferon alfa at a dose of 5 million units/m2 was administered on a daily basis (along with cytarabine) and the toxicities of this regimen are well known but...