Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach risk-stratification/staging of a extra-gonadal germ cell tumor with both mediastinal and retroperitoneal lymphadenopathy?
Actually there is zero chance a primary mediastinal germ cell tumor would ever have retrograde adenopathy to the RPLN's. Thus this is a primary retroperitoneal germ cell tumor. Assuming no non-pulm visceral mets and markers at good risk level, would treat with BEP x 3. You did not mention pathology,...
Would you consider neoadjuvant endocrine therapy in a postmenopausal patient with ER + locally advanced breast cancer with nodal disease who wants to avoid chemotherapy?
While neoadjuvant endocrine therapy should not be presented to patients as a standard-of-care, it may be an appropriate option for certain carefully counseled patients. I would consider it reasonable in a patient for whom chemotherapy would NOT be an option (e.g. too frail, too unhealthy, or patient...
What is the role of Braftovi (encorafenib) and Mektovi (binimetinib) in combination for unresectable or metastatic melanoma?
This is a very timely question with the FDA approval of the encorafenib/binimetinib regimen. There are no randomized head-to-head trials comparing BRAF/MEK inhibitors so there are no clear data to guide which regimen is the most effective. The COLUMBUS trial reported the longest OS, PFS with the enc...
Do you ever recommend PORT or chemoRT rather than chemotherapy alone for NSCLC with adverse features other than positive margins or N2 disease?
Despite the numerous limitations of the PORT meta-analysis, and subsequent non-randomized studies of postoperative RT in NSCLC, one message seems clear (at least to me)- radiation therapy can cause harm. In patients with resected lung cancer (who often have many co-morbidities), prudence seems a wis...
How do you manage a patient with multiple similar appearing ground glass opacities (~8-9) on Chest CT where one has been surgically removed and confirmed to be adenocarcinoma in situ?
This is a common scenario. Determining the stage of lung cancer can be challenging. Many patients, especially those with chronic lung disease, will have multiple non-specific abnormalities seen on CT scans. The patient with multiple GGO's on CT can be especially challenging. GGO's can represent canc...
Is there any data available regarding the benefit of adjuvant chemotherapy in patients with early stage, lymph node negative, triple negative adenosquamous breast cancers?
Except for a rare low-grade adenosquamous carcinoma, which, according to UpToDate (Taqhian A, Merajver S. Overview of the treatment of newly diagnosed, non-metastatic breast cancer - Rare histologies — Certain very rare subtypes of metaplastic carcinoma (eg, low-grade adenosquamous and low-grade fib...
How do you manage a patient with decreased but residual PET activity following concurrent chemoRT and PCI for limited stage SCLC?
I agree with @Dr. First Last. There are too many false positive PET scans in the mediastinum. There is no effective second line therapy. Only under the rarest of situations would we consider biopsy to prove this is persistent SCLC and consider surgical resection. The best advice I could give would b...
How do you manage patients with HER2 positive breast cancer who have progressive CNS metastases after prior exposure to pertuzumab, trastuzumab, TDM1, and lapatinib?
At our institution we have 3 clinical trials that could be considered but would need more information to match against eligibility criteria. 1. HER2-CLIMB with Tucatanib excludes prior capecitabone. Lapatanib is a relative contraindication depending on duration. This is an exciting drug unless inel...
What is your approach to metastatic choroidal melanoma with systemic metastases outside of a clinical trial?
I often consider local therapy for systemic mets with radiation (Mostly SBRT), embolization, ablation, Y-90 etc. In very selected patients surgery. If widespread disease or not a candidate for local therapy then I favor PD-1 inhibitors over ipi to start due to toxicity. Both agents have limited acti...
What is your routine workup and treatment approach to patients with NSCLC NOS discovered in mediastinal nodes but without obvious primary lung lesions or metastatic disease?
Aside from PET/CT and MRI? Depends on smoking history but would strongly consider NGS for mNSCLC