Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you interpret isolated PSMA-avid sites in a patient with prostate cancer with no pelvic or RP LN uptake?
The issue of false-positive PSMA scans is a vexed one, and we are still learning how to handle this optimally. My general approach is to think about the clinical context, level of risk, and whether an early diagnostic pick-up will actually make a clinical difference. For example, in a patient with ...
For a patient with large volume glioblastoma, what do you do if they are found to have a subdural infection in the middle of chemoRT requiring repeat surgery?
In this scenario, the patient will likely stop the daily treatments for a variable period of time that I would estimate to be measured in weeks while recuperating from surgery and receiving IV antibiotics. When cleared for radiation, I would start by doing a new Simulation using an updated MRI to ac...
What is the expected timeframe for the development of radiation myelitis and therapies that have helped with neurologic symptoms?
The incidence and the timeframe of the development of radiation myelopathy are influenced by total radiation dose, radiation dose per fraction, time between courses of radiation, and associated chemotherapy or immunotherapy. Older age, the presence of diabetes, and previous exposure to radiation are...
How would you empirically manage a large sellar/suprasellar mass with encasement of the right cavernous and terminal internal carotid arteries?
Knowing the histology of the mass would really help in creating more accurate treatment recommendations. A biopsy of a sellar mass is usually accomplished by an endonasal-endoscopic transsphenoidal approach utilizing the expertise of an ENT surgeon and a skull-base neurosurgeon. However, in this cas...
What is your treatment approach for a pediatric patient with H3K27M-mutant diffuse midline glioma following progression after radiation therapy?
First, if the patient is at least six months from initial radiation and has had a reasonable initial response, reirradiation is the best proven treatment for recurrence. We would also encourage enrollment on a clinical trial (the DMG National Tumor Board is a helpful resource for determining for whi...
How, if at all, will you incorporate durvalumab + FLOT in patients with HER2+ resectable gastric/GEJ adenocarcinoma?
Currently, there are no approved biomarker-driven targeted therapies for patients with locally advanced resectable gastric/GEJ adenocarcinoma. While data from the metastatic setting have consistently demonstrated improved outcomes with the addition of HER2-targeted therapies to chemotherapy in HER2-...
How do you manage a cytology-negative pleural effusion that develops after lung RT?
I think most times you can just watch them as long as they are stable and not symptomatic. I see them not infrequently after RT, especially lung SBRT, and find they often find a size they feel comfortable with and don't change much over time. I wonder about their physiology... my impression is there...
How do you manage a nodal recurrence of an early stage glottic laryngeal cancer previously treated with definitive radiotherapy?
As a general rule, patients with post-RT recurrences that are resectable should undergo surgery rather than re-irradiation, unless surgery is expected to be associated with substantial risk or functional deficit (in which case the patient should be consulted about the risks of each modality). In the...
How do you counsel eligible patients on lung cancer screening who are hesitant because of the cancer risk from CT scans?
This is simple. The risk of lung cancer in patients who have smoked for >20 years is orders of magnitude higher than the theoretical risk of medical X-ray-induced cancers from low-dose CT (LDCT) screening. A typical LDCT scan exposes patients to approximately 1.5 mSv of radiation, equivalent to abou...
In a patient with pancreatic carcinoid s/p resection with positive margins do you recommend surveillance or adjuvant therapy?
Well-diff and by small size (<1 cm), NCCN guidelines would have said watch this from the start, so certainly wouldn't recommend any adjuvant therapy at this time for positive margin resection. Margin status has been shown not to be associated with overall survival outcomes, particularly for low-grad...