Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to treating early stage EBV-positive diffuse large B-cell lymphoma of the elderly after a CR to systemic therapy?
EBV+ diffuse large B-cell lymphoma of the elderly, which typically affects apparently immunocompetant individuals > 50 y/o, was a provisional diagnosis in the 2008 edition of the WHO classification system. EBV+ DLBCL has been recognized in younger patients which led to a revision in the 2016 classif...
Do you use absolute WBC count or doubling time to determine whether to start treatment for early stage CLL?
In my view, the pace of disease is a more relevant indicator of the need for treatment than any absolute WBC count. Observations over time usually make it clear when treatment is needed. Several studies have shown that early intervention is not associated with improved survival, though it must be ac...
When treating a patient with multiple myeloma with bortezomib, how do you decide between subcutaneous vs intravenous dosing?
Due to the markedly increased risk of of peripheral neuropathy, the standard of care worldwide is to utilize subcutaneous bortezomib. There really is no medical indication to prefer IV over SQ. The issue of weekly versus biweekly bortezomib is controversial. The FDA indication is for biweekly on day...
Would you consider aggressive presentation of multiple squamous cell carcinomas of the skin an indication for treatment of CLL?
In general, no. The reason is that the many squamous cell carcinomas are a manifestation of immune dysfunction. Historically, when all the treatments were chemo-based, immunity would be if anything, temporarily worsened. Then, even in people in CR, immunity wasn't always restored. For example, patie...
What is the best strategy after initial treatment with hypomethylating agents for high grade myelodysplatic syndromes, mainly for responders who became transfusion independent?
The hypomethylating agents (HMA’s, 5-azacitidine & decitabine) have important disease modifying properties in addition to relieving cytopenias for patients with high-risk MDS. They decrease the risk of progression to leukemia and improve overall survival. The randomized phase III Aza-001 study dem...
How would you treat a diffuse CNS myeloid sarcoma (aka chloroma/granulocytic sarcoma) without evidence of blood or bone marrow involvement?
Careful pathology review is essential in confirming this entity given the unusual presentation (make sure this is not ALL). In addition, I would recommend FISH, cytogenetics, and a next gen sequencing for myeloid molecular panel for mutations that could be used to monitor disease progression or poss...
What growth factor would you use with A+AVD, if any at all?
When treating patients with Hodgkin lymphoma with either ABVD or A-AVD I decide if their risk of febrile neutropenia is likely to be more than 20%, which, therefore, includes some patients on ABVD and most patients on A-AVD. For such patients I give GCSF (filgrastim, grastophil) on days 6-11 after e...
How do you treat a young woman of child bearing age group diagnosed with primary CNS lymphoma?
The first step is to check HIV serology to ensure that the patient is HIV negative as HIV+ve patients would need to antiretroviral therapy promptly along with chemotherapy or the prognosis is dismal. If patient is young and fit the initial approach is similar in both HIV +ve and -ve patients. Assumi...
How would you approach a Follicular grade 1-2 NHL found on a terminal ileum biopsy with otherwise negative EGD and colonoscopy and contrast enhanced CT scan?
At our facility, we have treated a significant number of patients with low grade lymphoma isolated to a single fixed site within the GI tract with excellent long term results. It is worth considering a dose of 2400 rads to the involved site.
What is your threshold for transfusing platelets in an asymptomatic patient after autologous stem cell transplant?
My thresold for transfusing platelets in an asymptomatic patient after autologous stem cell transplant is the same as with other patients - transfuse for plts<10 unless febrile or if any bleeding complications, at which time the threshold would be higher.