Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your typical workup for a patient with a spontaneous renal infarct?
Broadly speaking, in the setting of a renal infarct, consider a thromboembolic event (venous thrombosis with paradoxical embolism or an arterial source) or a local vascular event such as dissection. The latter can be easily missed because the appropriate imaging is generally not performed. Once a va...
How do you approach transplant eligible myeloma patients with a partial or minimal response to treatment with 3-4 cycles of RVD?
This is something that occurs more often than is reported. Put another way, what to do when a patient's response plateaus after achieving a partial response? Evidence suggests that achieving at least a PR during induction is associated with better post-autologous transplant outcomes. What about VGP...
Would you offer gemcitabine-based chemoradiation for a resected node positive cholangiocarcinoma with negative margins that has tolerated adjuvant capecitabine?
For resected cholangiocarcinoma, adjuvant capecitabine is considered standard of care based on the BILCAP trial (Primrose et al., PMID 30922733). This is typically administered up to 6 months following surgery. Based on intention to treat analysis median OS was 51.1 months vs 36.4 months (HR 0.81, P...
What chemotherapy would you consider to treat platinum resistant high grade serous ovarian cancer in patients with a low grade MDS from prior platinum/PARPi?
Before making a recommendation to this patient, a basic understanding of treatment related MDS/AML is needed, along with a clarification of the meaning of “low risk of progression to acute myeloid leukemia (AML)”. My main goal would be to avoid therapy with a demonstrated risk of treatment related M...
What is the optimal prophylaxis regimen to use prior to a selinexor based regimen in the treatment of multiple myeloma for nausea and electrolyte abnormalities?
The official Karyopharm guidelines for nausea are as follows: NK-1R antagonist OR a combination of 5-HT3 antagonist AND olanzapine. So the details are:a) All patients should receive ondansetron 8 mg or equivalent, unless contraindicated, orally 1 hour before each dose of selinexor and q 8 hours for ...
Are cavitary lung lesions a contraindication to TKIs/VEGF inhibitor use in renal cell carcinoma?
There is a potential risk of neutropenia or leukopenia with TKI use in RCC patients. Nevertheless, none of the clinical trial data showed increased infection with their use (Reinwald et al., PMID 27127405). However, a cavitary lung lesion can be due to serious infection caused by aggressive or oppor...
Would you give EP to a patient with Stage I testicular nonseminoma with risk factors (LVI and 90% embryonal), who is not a candidate for bleomycin?
Personally, I would not and there are no strong clinical data supporting that approach in CSI NS. First if given, adjuvant chemotherapy for CSI NS with high risk features is BEP X1 if you ask what approach has the largest database, most mature results, and reporting of relapse and toxicity. (SWENOTE...
How would you treat an isolated ipsilateral axillary recurrence in a BRCA+ HR+ HER2+ breast cancer?
I would use olaparib for 12 months (OlympiA trial) in combination with endocrine therapy after surgery and radiation. Then continue the endocrine therapy with abemaciclib times 24 months and TDM1 for 12 months. Then only endocrine therapy for a total duration of 5-10 years. This is the most comprehe...
When a patient with a preexisting rheumatic disease and on immunotherapy begins to flare, how do you decide if this is an underlying rheumatic disease activity versus an immunotherapy related adverse event?
If the symptoms/signs are similar to their prior flares of their rheumatic disease, then it is likely a flare. Over 50% of patients with autoimmune diseases flare on immune checkpoint inhibitor therapy if you look at systematic literature reviews of the limited published data. If symptoms are unrela...
How would one alter therapy in a transplant-ineligible AL amyloidosis with less than a complete response to six cycles of Dara-CyBorD?
If the patient has achieved deep VGPR (but perhaps not CR due to interference of dara), it is probably reasonable to continue dara maintenance as per ANDROMEDA as long as the patient is also clinically improving. If the response has not reached this level or the patient has not had evidence of impro...