Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you give 3 or 4 cycles of HiDAC during consolidation for good/intermediate-risk AML without an available allotransplant donor?
This is a complicated question because risk stratification of AML has rapidly transitioned from including clinical presenting features (age, WBC, co-morbid diseases) with cytogenetics/select mutations to now multiple mutations and other biologic features. An example is core binding factor AML with a...
How would you approach a patient with smoldering myeloma that has a quickly rising and very high M-spike (6 g/dL range)?
The level is very high and worrisome for tumor lysis syndrome and cytokines related symptoms. I would do a bone marrow biopsy first and check free light chain assay. This may confirm the diagnosis of symptomatic myeloma. Also bone imaging study to find any lesions. Once you decide to treat I would ...
Would you treat a patient with definitive local XRT without systemic therapy if he/she presents with pathology showing a PTCL NOS from a small (1.5 cm) lesion of the skin of the chin?
For background, there are several T-cell primary cutaneous lymphomas. Several are treated routinely with radiation therapy alone, including primary cutaneous anaplastic large cell lymphoma (ALCL) and primary cutaneous CD4 positive small/medium T-cell lymphoma. Other T-cell primary cutaneous lymphoma...
What are your radiotherapy recommendations for a unilateral primary intraocular large B-cell lymphoma following high-dose methotrexate and rituximab?
Primary intraocular lymphoma is quite rare without standard treatment guidelines. As PCNSL often involves the globe, at initial diagnosis and/or at relapse, I view isolated intraocular disease as a subset of primary CNS lymphoma. HD-MTX regimens are typically utilized. As the disease is localized, c...
How do you approach previously treated grade 1 follicular lymphoma now with transformation to a large cell lymphoma?
I believe the question is an important one that has not been addressed by an adequately powered prospective study. These patients are often folded into studies of relapsed and refractory disease. The consensus is that these patients have a poorer prognosis than those with de novo diffuse large B-cel...
Would you use Ibrutinib plus Venetoclax as second line therapy in relapsed/refractory mantle cell lymphoma?
I may consider this for the right patient with Mantle cell lymphoma that has relapsed with TP53 and high risk prognostic score. Even though the data is very exciting it is a single arm study with a small patient cohort, I would want to see a randomized data to make a definitive switch. The CR rates ...
Is there a situation where you would use a purine analogue in combination with rituximab for the frontline line treatment of normal variant Hairy Cell Leukemia?
This is an excellent question, and I was assisted in this answer by Drs. @Dr. First Last and @Dr. First Last who are both hairy cell leukemia experts since there is really not a lot of trial data to guide this answer. There is limited data for the addition of rituximab in the frontline setting in vH...
When would you consider treating a testicular relapse with definitive radiation in a child with ALL?
I would strongly advise against treating with testicular radiotherapy alone at relapse given that testicular relapse is often a harbinger for systemic relapse (depending on the length of first clinical remission) which radiotherapy alone strategies will fail to address (PMID: 8275428). Radiotherapy ...
Do you have a preferred strategy for front line induction therapy in DLBCL patients who have asymptomatic depressed ejection fraction and thus concern about anthracycline dosing?
I generally replace the anthracycline in RCHOP with etoposide 50 mg/m2 IVPB Days 1-3 based on an ASH abstract #408 in 2009 by Sehn L et al. If the day 2 and 3 doses of etoposide are given orally rather than IV the dose would be 100 mg/ m2.
What is your preferred approach to the treatment of transplant ineligible multiple myeloma that has been treated with a triplet regimen and reached a plateau phase?
The depth of response translate into better PFS and OS. Partial response is not appropriate today. We have better combinations that can lead to that. We need to get our patients into CR as soon as possible. After we are there we can talk about maintenance.