Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Are there contraindications to giving radium-223 concurrently with palliative radiotherapy or systemic chemotherapy for mCRPC?
These combinations have not been approved, but studies of radium-223 with taxane therapy have been conducted in concert with docetaxel and have been presented in 2017 at GU ASCO by Michael Morris. These studies show that the combination is promising but myelosuppresive. The response rates to combine...
What is the preferred regimen for testicular lymphoma with de novo symptomatic CNS involvement and systemic disease at the time of presentation ?
I often consider treating with high dose methotrexate alternating with R-CHOP in such cases. At the end of treatment, I consider radiation to the contralateral testicle. Others have treated similar patients with Hyper-CVAD (Park et al. Am J Hematology 2007)
Is there an effective treatment for multiple appearances of cutaneous Kaposi's lesions besides radiation?
Unfortunately, there is no established effective treatment for multiple appearances of cutaneous Kaposi's lesions. Radiation therapy seems to work if the dose is adjusted well. Radiologists are very familiar with this. However, there are often out-of field recurrences which are difficult to treat. ...
What surveillance strategy do you use for patients after resection of localized renal cell cancer?
Surveillance depends on the pathological stage of the patient. For T1a disease I follow annually. For T1b disease and higher I follow q 6 mos with MRI imaging if abdimen and low dose Ct of chest. I do not perform imaging of bones or brain without a clinical indication. For LN positive disease i star...
For untreated patients with minimal complaints and good PS with metastatic adenocarcinoma positive for Exon 21 L858R mutation, how do you choose among the available first line EGFR directed therapies?
Based on the secondary analyses of Lux-Lung 3 and Lux-Lung 6, which showed a survival advantage for afatinib vs platinum-based chemo in patients with exon 19 deletions, I've generally turned to afatinib in this group, while reserving erlotinib for those with exon 21 mutaitons. Lux-Lung 7 has had onl...
How do you manage adjuvant therapy for patients with locally advanced ER positive breast cancer with no response to neoadjuvant endocrine therapy?
For patients with ER+ locally advanced disease and no response to neoadjuvant chemotherapy (assuming an optimal chemo regimen was given -anthracycline and taxane based, my preferred regimen in this setting would be AC dose dense X4 with pegfligrastim followed by paclitaxel weekly X12) , then the tum...
How do you treat HER2-equivocal breast cancer in the neoadjuvant setting?
If there is no response to AC alone, and the Her2 is equivocal, I would treat with an anti-Her2 regimen such as THP. One could also simply give traztuzumab (possibly with pertuzumab, given the new data from APHINITY to be presented at ASCO 2017) for a year after surgery similar to the HERA trial des...
How do you treat a locally-invasive, keratin-positive gastrointestinal spindle-cell neoplasm?
Treating sarcomatoid neoplasms is a clinical challenge. Approaches include treating with sarcoma-like regimens vs. treating with regimens appropriate for the site of origin. I don't think there is high level data to support a general approach but these malignancies are generally quite aggresssive an...
Is there a preferential approach for systemic therapy for triple negative breast cancer patients with leptomeningeal disease?
There are very few data on effective systemic therapies for triple negative leptomeningeal disease (LMD), mostly from case reports and small series. Much of the larger series are from unselected solid tumors and have focused on intrathecal therapy. However, it is generally recognized that systemic t...
How would you manage HER2+ GEJ adenocarcinoma that recurs as a single 1.6cm lung nodule a year after completing primary chemoradiation and esophagectomy?
It is always best with upper GI cancers to assume that there is more disease than meets the eye. Despite the presence of a single lesion on imaging, I would favor systemic chemotherapy with FOLFOX + trasutuzmab (or clinical trial) upfront. If, after 6 months of treatment, no other disease emerges, t...