Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How does your approach differ when managing a "triple hit" versus a "double hit" or "double expressor" lymphoma?
Double-hit lymphoma and double-expressing lymphoma are biologically and clinically distinct entities. DHL is now classified within the WHO as high-grade lymphoma, and the majority are of germinal center immunophenotype, whereas DEL is most typically of non-germinal center immunophenotype and classif...
How do you approach fit patients with quickly relapsed Hodgkin lymphoma (disease-free interval less than or equal to one year) after 6 cycles of ABVD and radiation therapy?
As of this point in 2018 such patients are curable only with high-dose chemotherapy with stem cell transplant and then only if they are in chemosensitive relapse. Accordingly, I would have the transplanters see the patient at once and follow their recommendation regarding the pre-transplant regimen ...
How do you approach incidentally diagnosed mantle cell lymphoma found on a routine screening colonoscopy?
Stage IE MCL would be very rare; this is probably disseminated disease with extra nodal GI involvement which is seen in the majority of such patients. I would treat as disseminated disease, PS and comorbidity permitting per NCCN guidelines.
How would you treat an elderly fit patient with stage IE DLBCL (single skin lesion)?
Is this a primary cutaneous large B-cell lymphoma, leg type? I suspect so. This is a rare and aggressive disease. I would carefully stage the patient ( to include bone marrow ) and treat as per any localised DLBCL with 3-4 cycles R-CHOP and XRT. Even with this regimen 50% of patients relapse so I'd ...
How would you manage a primary dural low-grade lymphoma?
Primary dural low grade lymphoma is a rare presentation, usually marginal zone lymphoma, mostly scattered case reports in the literature but one recent series from Memorial Sloan Kettering (de la Fuente et al., PMID 27649904). I would rx similarly for other marginal zone sites. Local rx only, usuall...
What dosing regimen of carfilzomib do you use in the front line setting for high risk transplant-eligible multiple myeloma?
I almost never use carfilzomib in the front line setting, as there is almost no evidence to support its use over bortezomib in this setting. When I do give carfilzomib in combination with lenalidomide, I generally extrapolate from the twice weekly 36 mg/m2 dosing and combine those into a single week...
How long after high-dose IV methothrexate for chemo-refractory CNS lymphoma do you wait before giving brain radiation?
As was taught by my mentor- "As long as possible!". Of course, the prognosis is extremely poor if the patient is chemo-refractory to IV MTX and longer-term risks of WBRT may be less relevant than present-day symptoms requiring palliation. While I do recommend WBRT, as what is visualized on MRI is ju...
Would you offer RT to a patient with a stage I low grade follicular lymphoma in the groin/upper thigh (7 cm) s/p complete excision with negative margins?
An abstract presented at the 2017 ASTRO from MD Anderson Cancer Center by Andraos and colleagues (last author Dabaja) addressed this question in a retrospective analysis. Of the 39 patients who underwent complete resection of their nodal low grade FL, "those treated with adjuvant therapy experienced...
Do you offer adjuvant chemoimmunotherapy after IFRT for Stage I to II low grade follicular lymphoma?
I do not. Absent overall survival benefit, which is not seen or reported, this strategy overtreats the subset of patients who are cured with RT alone, and prematurely exposes the other group to the toxicity of chemotherapy.
What is your standard dose for total skin irradiation in a mycosis fungoides patient?
Our standard has been to do the low-dose 12 Gy TSE regimen as it still has good overall response rates with low toxicity.https://www.ncbi.nlm.nih.gov/pubmed/25476993https://www.ncbi.nlm.nih.gov/pubmed/28843374I asked @Dr. First Last to weigh in on this and he agrees that 12 Gy is the standard.