Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Will you offer adjuvant BEP after orchiectomy to a patient with embryonal carcinoma, solely based on the size at presentation, such as a 6 cm testicular mass?
I would not consider adjuvant BEP in this setting. While the risk of relapse is likely higher than smaller non ECC predominant tumor, it likely does not exceed a 50% chance of recurrence. Our general stance is active surveillance for all CS 1 seminoma and non seminoma patients. Adjuvant anything imm...
What would be the treatment options for metastatic clear cell carcinoma of kidney who develops recurrent thrombosis despite therapeutic anticoagulant on cabozantinib in second line treatment after failing immunotherapy?
Any TKI will potentially increase the risk of thrombosis, so this is a bit of a challenge for the patient. However, cabozantinib, based on personal experience, is more likely to cause this complication and other TKIs may be better in this regard. If you need to completely avoid TKIs, everolimus mono...
How would you proceed for a patient with metastatic gastric-type adenocarcinoma, with vaginal and inguinofemoral disease only, who experiences complete response to her vaginal tumor but residual inguinal disease?
There is no ideal data to guide this. I would recommend surgical nodal excision of the residual inguinal disease, followed by pelvic and inguinal radiation (with or without platinum if the patient can tolerate further). Another approach would be with cisplatin-based chemoradiotherapy with treatment ...
How would you approach a pT2 nonseminomatous testicular cancer, embryonal caricnoma with +LVI with persistent b-hcg < 20 post-operatively?
If a patient has had an inguinal orchiectomy and has a persisting b-HCG in a reliable lab (remember that alpha-HCG can cross-react with the alpha chain of LH, so a "good" beta-HCG assay is important, especially as hypogonadal males often have an elevated LH), it suggests clearly that there is residu...
How would you treat a patient with newly diagnosed prostate cancer with low volume bone metastases and extensive lung metastases with a very low PSA (< 5) and no neuroendocrine differentiation on pathology?
Generally, I would treat such a patient with ADT plus abiraterone (or enzalutamide). A recent paper from our group suggested that patients who present with pulmonary mets, without concurrent liver mets, usually have a great prognosis with hormonal therapies. Another interesting phenomenon is that pa...
How would you manage a patient with MSS, KRAS mutated locally advanced rectal adenocarcinoma with a mixed response to neoadjuvant FOLFOX?
If there is new bone marrow involvement, I assume you confirmed this with a bone marrow biopsy? This would be a very unusual location for rectal cancer, so to speak. If you have not done a BMB, I would obtain pathologic proof of bone involvement. That would make this patient stage IV, in which case,...
Would you offer neoadjuvant chemotherapy for a large, but recurrent grade 1-2 myxoid chondrosarcoma of knee which is no longer amenable to limb salvage?
While not directly relevant for this patient, it is also important to keep in mind that RT is quite effective in decreasing LF in chondrosarcoma, particularly in anatomically challenging locations like joints/pelvis/spine where wide margins often cannot be achieved. The benefit of RT (HR 0.23 for LF...
In a patient who experienced less than 90% necrosis after neoadjuvant chemotherapy for localized, high-grade osteosarcoma, do you recommend adjuvant ifosfamide?
What is the best way to approach elevated liver enzymes in patients treated with combination TKI and immunotherapy?
We rely on clinical judgment in this case as both TKIs and immunotherapies can cause elevation of liver enzymes. Currently, the recommendations in case the attribution of the hepatitis is questionable is to hold both drugs and to check the liver enzymes daily; if it improves, then it is likely due t...
How would you treat high risk prostate adenocarcinoma who relapsed after RT and ADT with a very low PSA, widespread mets to bone and soft tissue who is progressing on ADT, docetaxel and carboplatin?
Difficult situation, this patient likely has neuroendocrine differentiation. I would check for markers like NSE, chromogranin if positive, then can make the case of treating as small cell ca progressed on platinum based chemotherapy and treat with lurbinectedin (Trigo et al., PMID 32224306).PSMA bas...