Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you recommend adjuvant radiotherapy with concurrent Ado-trastuzumab emtansine (T-DM1) in your breast cancer patients?
In the Katherine trial (von Minckwitz et al. NEJM 2018) 1486 patients with non-metastatic invasive residual HER2+ breast cancer after preoperative chemotherapy were randomized to 14 cycles of trastuzumab or trastuzumab emtasine (T-DM1), an antibody-drug conjugate of trastuzumab and the cytotoxic age...
How would you modify therapy for a metastatic HER2+ breast CA who develops persistent cardiomyopathy after dual HER2 blockade with trastuzumab + pertuzumab?
The clinical data suggests that dual blockade is not associated with significantly increased cardiomyopathy over trastuzumab based therapy alone. In significant cases holding anti-HER2 therapy for 4-8 weeks can allow the dysfunction to reverse while medical therapy for CHF is optimized. After recove...
How would you manage a patient simultaneously diagnosed with T2N1M0 triple negative breast cancer and T3N2M0 rectal adenocarcinoma?
That is a tough one. I would do the breast surgery first then shortly after do short course radiation to the rectal cancer. Then 1-2 weeks later start 4-6 cycles of dose dense FAC or FEC + Neulasta (to get some 5fu in) followed by the rectal cancer surgery. Then I would do radiation to the breast re...
Would you consider adding IO therapy to 1st-line platinum/etoposide in a patient with metastatic extrapulmonary small cell carcinoma?
The use of platinum based chemotherapy for extra pulmonary small cell is a tradition that has some data to support its use, but the majority of enthusiasm stems from its efficacy in pulmonary small cell. The use of IOs in small cell is now reshaping the field and thus brings this type of question fo...
How do you approach front line treatment for TP53 mutated mantle cell lymphoma?
For patients with TP53 mutations based on the information presented by Eskelund et al. and previous experience. Given the knowledge that the mutation is a dominant negative which eliminates and functional activity of the tumor suppressor it stands to reason that an durable response with chemotherapy...
How would you treat someone with unknown primary metastatic SMARCA4 deficient tumor (high-grade tumor with rhabdoid morphology)?
Ponatinib might be useful. You might also see if a clinical trial is available.http://clincancerres.aacrjournals.org/content/24/8/1932
In a patient with Waldenstrom's macroglobulinemia doing well and feeling better on ibrutinib & rituximab, but with a rising IgM, do you switch treatment or continue?
A lot depends on the pace of increase of the IgM and the line of therapy. If the pace is rapid, I would think about changing therapy. If the pace of increase is small and the patient is asymptomatic, you could continue a little longer. If planning to changing therapy, it may be reasonable to restage...
Is it safe to continue/re-challenge oxaliplatin in patients with oxaliplatin-induced hepatic sinusoidal injury and splenomegaly?
Typically, if there is documented hepatic injury, I will not revisit oxaliplatin as continued therapy will result in continued injury that may limit future therapeutic options. Given that many GI oncology patients will receive multiple agents that are metabolized through the liver and/or have hepati...
Do you routinely order double-hit assessment in cutaneous DLBCL?
There are certainly reported cases of primary cutaneous DLBCL that harbor double-hit mutations. Guidelines do not distinguish the workup of cutaneous DLBCL from other sites, and if a skin DLBCL were to be of germinal center immunophenotype with IHC expression of myc and bcl2 and/or bcl6, FISH would ...
Are you categorically using lenvatinib over sorafenib for unresectable HCC in the absence of contraindications?
I have done that is recent patients, yes. I am doing it because "on paper" I see better PFS and better ORR, of course in addition to the non-inferiority when compared to sorafenib in the randomized trial that is now published. However, I am building experience with respect to tolerance in my particu...