Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In transplant-eligible, fit patients with multiple myeloma who have an inadequate response to front-line therapy, what regimen would you choose for second-line?
for transplant eligible patients who you want to get to transplant but have not achieved an adequate response for stem cell collection, there are 3 senarios: 1: if no response at all to front line therapy (VRd) say <PR: would do VDPACE x 2-3 cycles, using the last cycle as chemo mobilization with co...
In staging Hodgkin's lymphoma, would you identify a PET+ bony focus as disease when there are no associated bone changes on CT and a biopsy was not obtained?
PET is generally the most sensitive indicator for-involvement with HL, so I would not let the absence of CT findings deter one from diagnosing bone disease if the PET is convincingly positive. One should also weigh the clinical circumstances and consider how likely the pt is to have bone involvement...
How do you approach front line treatment for TP53 mutated mantle cell lymphoma?
For patients with TP53 mutations based on the information presented by Eskelund et al. and previous experience. Given the knowledge that the mutation is a dominant negative which eliminates and functional activity of the tumor suppressor it stands to reason that an durable response with chemotherapy...
In a patient with Waldenstrom's macroglobulinemia doing well and feeling better on ibrutinib & rituximab, but with a rising IgM, do you switch treatment or continue?
A lot depends on the pace of increase of the IgM and the line of therapy. If the pace is rapid, I would think about changing therapy. If the pace of increase is small and the patient is asymptomatic, you could continue a little longer. If planning to changing therapy, it may be reasonable to restage...
Do you routinely order double-hit assessment in cutaneous DLBCL?
There are certainly reported cases of primary cutaneous DLBCL that harbor double-hit mutations. Guidelines do not distinguish the workup of cutaneous DLBCL from other sites, and if a skin DLBCL were to be of germinal center immunophenotype with IHC expression of myc and bcl2 and/or bcl6, FISH would ...
Would detection of an adverse cytogenetic marker such as dup(1q) alone in the setting of MGUS satisfy criteria for a diagnosis of multiple myeloma?
Short answer, no.Longer answer -The important transition between MGUS/SMM to MM is CRAB criteria (hypercalcemia, renal disease, anemia, bone lesions), OR the development of a myeloma defining events -- >60% clonal plasma cells on bone marrow, multiple lesions on MRI, or FLC ratio > 100. These myelom...
What is your preferred chemotherapy regimen for a fit younger patient with mantle cell lymphoma?
For a young fit patient with mantle cell lymphoma not suitable for observation and in need of treatment, without contraindications to intensive therapy, my preferred approach is to use the MCL Younger strategy of alternating RCHOP and cytarabine-based therapy as induction. I will routinely substitut...
What recommendations do you make regarding the use of biologics for uncontrolled Crohn's disease in patient's who have a history of DLBCL that developed while on infliximab and azathioprine and whose lymphoma is essentially cured?
This is a frequent question without a clear answer. There has not been a randomized study of anti-auto-immune therapy strategies to define the risk of a relapse or secondary lymphoma in patients with a clear need for treatment. I recommend the patient work with their rheumatologist to start a low i...
How would you manage CML first-line second generation TKI with a best response of MMR 4, but now with a loss of MMR with more than one log response loss but still in complete cytogenetic remission and mutation panel negative?
The easiest would be to repeat the test in 1 month or so. If the results show persistently increased levels, then I would monitor the patient closely. I would also review any new medications for possible drug to drug interactions. I would also review the patient's adherence, does the patient still h...
Is there currently a role for adding venetoclax to a hypomethylating agent (HMA) after failure of single-agent HMA therapy in MDS?
For patients with MDS who have failed single-agent HMAs, there is an intriguing small retrospective series suggesting that adding on Venetoclax at the time of HMA failure can lead to responses (Ball et al., PMID 32589727). Because of the retrospective nature of this publication and the small numbers...