Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In a patient with stage 1 mixed germ cell tumor who cleared tumor markers post-orchiectomy but with subsequent rise to borderline abnormal within 6 weeks, would you treat with 3 cycles BEP as for S1 disease?
Several points to begin with. My strong preference is to recommend active surveillance for all well documented clinical stage 1 nonseminoma whether or not there is embryonal predominance or lymphovascular invasion present. Second, I do not make treatment decisions based on borderline abnormal normal...
What systemic therapy, if any, would you offer a patient after WBRT for an isolated CNS relapse of initially limited stage SCLC that received chemoRT without PCI?
Since the patient has not progressed outside the CNS, I would hold off on any further therapy till there is evidence of extracranial progression.
How do you manage patients with small, asymptomatic well differentiated PNETs?
Based on available data, nonfunctional low grade PNETs < 1 cm can be monitored with imaging (preferably MRI or triple phase CT). Tumors 1-2 cm are a gray area and consideration of surgery depends on the patient's age, comorbidities, and location of tumor. Tumors > 2 cm should have surgery if possibl...
For a patient with concurrent diagnoses of Hodgkin Lymphoma and Light Chain Myeloma complicated by Myeloma Kidney, how would you approach treatment?
I have seen this once, just once. Two separate but newly diagnosed hematologic malignancies that require treatment simultaneously are rare. More common is a passenger MBL in a myeloma older than 70 y.o., MGUS in the setting of another lymphoid malignancy is not unheard of, and a T-cell gene rearrang...
Would you recommend adjuvant chemotherapy for a patient who achieved a CR after TNT for stage III rectal adenocarcinoma but underwent no initial surgery, and now has a local recurrence >12 months later with plans to undergo low-anterior resection?
I wavered in my response to the poll, which tells me there is no clear "right" answer. The patient has had exposure to FOLFOX already, and assuming margins are negative, it is unclear if there is benefit to more chemo in this resection setting. I think you could apply the data we have for the lack o...
How does urinary obstruction impact your choice of therapy for metastatic or locally advanced prostate cancer?
Bladder outlet obstruction due to locally advanced prostate cancer is typically due to bladder wall and ureteral orifice invasion and T4 disease. These patients can suffer from pain and urinary obstructive symptoms for long periods of time despite the use of ADT, ADT plus AR inhibition, or ADT plus ...
How do you manage patients with chemotherapy-induced paronychia?
I manage patients with chemotherapy-induced paronychia with a few tricks: First, ensure that there is no infection (active drainage, especially purulent) is more indicative of infection, as well as appropriate hygiene. Topical steroids and soothing soaks (such as Domeboro or diluted distilled white ...
Do you routinely offer antiviral prophylaxis for patients receiving chemoimmunotherapy?
Yes, with R-CHOP and similar therapies for anyone who may have had chickenpox. I have seen shingles during treatment. I have not been doing routinely for younger patients who had VZV vaccines. Yes also for anyone with a history of HSV. Usually acyclovir BID.
In light of ALK-directed therapy, what is the role of chemotherapy for patients with newly diagnosed ALK+ DLBCL?
I haven’t seen any data on ALK inhibitors in DLBCL, I’m assuming partly since it’s a small subset of DLBCL. Presumably, toxicity would be similar to, say, a BTKi + R-CHOP? Maybe would consider off label in the R/R setting, but would not use upfront.Those with ALK+ ALCL typically do well. In that sce...
Would you continue adjuvant FOLFOX for a patient with stage III colon cancer and triple-vessel coronary artery disease who developed NSTEMI after the first cycle?
This is a challenging scenario where the patient has existing triple vessel CAD and developed NSTEMI after 1st cycle. We all agree that 5-FU based therapy is the backbone for adjuvant therapy of stage III colon cancers. There are no clear cut guidelines in this case and management is per expert reco...