Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a patient with new isolated enlarged lymph node <6 months after RPLND with prior pT2NX non-seminoma treated with orchiectomy then RPLND within 1 year due to nodal metastases?
If the patient were marker negative and the node was relatively small, I would probably just repeat imaging in 8 weeks to see what was happening. If the markers were definitively rising, I probably would proceed with BEP X 3. I do not typically recommend a re-do primary RPLND. Also, a lot would depe...
What treatment would you consider for small cell neuroendocrine carcinoma of the bladder with a metastatic recurrence within 3 months of neoadjuvant cisplatin/etoposide followed by radical cystectomy (ypT0N0)?
Very poor prognosis with early recurrence in a very aggressive histology despite pCR in the primary tumor reflecting tumor heterogeneity and implying platinum resistance in the recurrence tissue. Would evaluate NGS for potential “actionable” genomic alterations and also consider clinical trials (e.g...
Would you consider SBRT and adjuvant therapy for a 4cm, node-negative, non-oncogene driven, NSCLC not amenable to surgical resection?
Ultimately, currently open clinical trials will address this question (i.e., SWOG-S1914, NCT04214262). In the absence of this, there have been several questions here on this topic ranging from the possible role for adjuvant chemotherapy, incorporating ctDNA testing, and how to follow these patients ...
What is your experience managing myelosuppression from busulfan, prescribed for PV?
I have no direct experience managing busulfan-induced myelosuppression in PV but I do have experience in managing busulfan-induced aplastic anemia. To begin with, busulfan is an alkylating agent and as such is a leukemogen and its use in a chronic myeloproliferative neoplasm should be restricted to ...
Would you send Oncotype Dx for a premenopausal patient with a pT2N0 ER/PR+ lobular breast cancer that was diagnosed during the first trimester of pregnancy?
This is a complicated question. I feel as though more information would be helpful. I will try to address specifics that I consider when managing such cases that I hope are helpful. Appreciate others' thoughts as well. First, how sure are we that this patient is N0? I cannot count the number of cli...
Do you give adjuvant chemotherapy to a patient with a completely resected mediastinal pure seminoma?
There will never be “evidence based medicine” to answer this query. If this was known to be a primary mediastinal seminoma, he would have initially received standard chemo for good risk disease, preferably BEP X 3 if under age 50. In my opinion, that would have been preferred over radiotherapy. Argu...
How does one interpret persistently positive lambda light chains on serum immunofixation but without measurable serum monoclonal protein and a normal light chains and ratio?
I would probably also check a 24 hour urine protein electrophoresis with immunofixation to evaluate if any significant and measurable monoclonal proteinuria that would make me more worried about SMM, MGRS, or amyloidosis. Would check urine protein/creatinine ratio to evaluate protein excretion for t...
Are there effective adjunct therapies to relieve tumor flare pain from tamoxifen in the metastatic setting?
The current understanding of tamoxifen flare - could be explained by two mechanisms. One simply induces the necrosis of the tumor by inducing a cytotoxic response. Two, it can actually induce the estrogen mimic phenomenon - which can enhance the metabolism of the tumor itself (or metastatic site). ...
How would you treat a young patient with classical intermediate-risk Hodgkin lymphoma who has an underlying DNA repair-deficiency disorder, such as congenital mismatch repair disorder or ataxia telangiectasia?
It depends on the DNA repair disorder.
Would you consider continuing a biologic for difficult to control autoimmune disease in a patient with a recent diagnosis of a surgically curable solid malignancy?
There continues to be relative uncertainty regarding the management of biologic therapy in these patients. As treating physicians, this scenario is not uncommon where a decision to continue or stop a biologic has to be made in face of solid malignancy. A detailed review of individual circumstances t...