Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Are cavitary lung lesions a contraindication to TKIs/VEGF inhibitor use in renal cell carcinoma?
There is a potential risk of neutropenia or leukopenia with TKI use in RCC patients. Nevertheless, none of the clinical trial data showed increased infection with their use (Reinwald et al., PMID 27127405). However, a cavitary lung lesion can be due to serious infection caused by aggressive or oppor...
Would you give EP to a patient with Stage I testicular nonseminoma with risk factors (LVI and 90% embryonal), who is not a candidate for bleomycin?
Personally, I would not and there are no strong clinical data supporting that approach in CSI NS. First if given, adjuvant chemotherapy for CSI NS with high risk features is BEP X1 if you ask what approach has the largest database, most mature results, and reporting of relapse and toxicity. (SWENOTE...
How would you treat an isolated ipsilateral axillary recurrence in a BRCA+ HR+ HER2+ breast cancer?
I would use olaparib for 12 months (OlympiA trial) in combination with endocrine therapy after surgery and radiation. Then continue the endocrine therapy with abemaciclib times 24 months and TDM1 for 12 months. Then only endocrine therapy for a total duration of 5-10 years. This is the most comprehe...
When a patient with a preexisting rheumatic disease and on immunotherapy begins to flare, how do you decide if this is an underlying rheumatic disease activity versus an immunotherapy related adverse event?
If the symptoms/signs are similar to their prior flares of their rheumatic disease, then it is likely a flare. Over 50% of patients with autoimmune diseases flare on immune checkpoint inhibitor therapy if you look at systematic literature reviews of the limited published data. If symptoms are unrela...
How would one alter therapy in a transplant-ineligible AL amyloidosis with less than a complete response to six cycles of Dara-CyBorD?
If the patient has achieved deep VGPR (but perhaps not CR due to interference of dara), it is probably reasonable to continue dara maintenance as per ANDROMEDA as long as the patient is also clinically improving. If the response has not reached this level or the patient has not had evidence of impro...
How would you treat a patient with new isolated enlarged lymph node <6 months after RPLND with prior pT2NX non-seminoma treated with orchiectomy then RPLND within 1 year due to nodal metastases?
If the patient were marker negative and the node was relatively small, I would probably just repeat imaging in 8 weeks to see what was happening. If the markers were definitively rising, I probably would proceed with BEP X 3. I do not typically recommend a re-do primary RPLND. Also, a lot would depe...
What treatment would you consider for small cell neuroendocrine carcinoma of the bladder with a metastatic recurrence within 3 months of neoadjuvant cisplatin/etoposide followed by radical cystectomy (ypT0N0)?
Very poor prognosis with early recurrence in a very aggressive histology despite pCR in the primary tumor reflecting tumor heterogeneity and implying platinum resistance in the recurrence tissue. Would evaluate NGS for potential “actionable” genomic alterations and also consider clinical trials (e.g...
Would you consider SBRT and adjuvant therapy for a 4cm, node-negative, non-oncogene driven, NSCLC not amenable to surgical resection?
Ultimately, currently open clinical trials will address this question (i.e., SWOG-S1914, NCT04214262). In the absence of this, there have been several questions here on this topic ranging from the possible role for adjuvant chemotherapy, incorporating ctDNA testing, and how to follow these patients ...
What is your experience managing myelosuppression from busulfan, prescribed for PV?
I have no direct experience managing busulfan-induced myelosuppression in PV but I do have experience in managing busulfan-induced aplastic anemia. To begin with, busulfan is an alkylating agent and as such is a leukemogen and its use in a chronic myeloproliferative neoplasm should be restricted to ...
Would you send Oncotype Dx for a premenopausal patient with a pT2N0 ER/PR+ lobular breast cancer that was diagnosed during the first trimester of pregnancy?
This is a complicated question. I feel as though more information would be helpful. I will try to address specifics that I consider when managing such cases that I hope are helpful. Appreciate others' thoughts as well. First, how sure are we that this patient is N0? I cannot count the number of cli...