Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage a patient with primary CNS lymphoma who is not a candidate for high-dose methotrexate?
This is a relatively rare situation in my experience, but I think WBRT is the second most active agent for PCNSL after high-dose MTX, so if MTX is not possible, I would strongly consider WBRT. Hypothetically, if patient has good PS and you are going for "curative intent", the standard WBRT alone app...
How do you manage classical early stage Hodgkin lymphoma patients when an ESR is not checked as part of their workup?
I personally don't think ESR plays a huge factor in the management of early stage Hodgkin Lymphoma now in the era of PET-adapted treatment selection. So, if a patient has very favorable stage I-IIA HL meeting all other criteria by the GHSH study and is interested to not have combined modality treatm...
With recent measles outbreaks occurring in the US, would you consider offering multiple myeloma patients s/p ASCT on maintenance treatment vaccination, or an alternate means of immunity?
Measles is on the rise and protection is appealing. The current guidelines for adult immunizations are not clear what patients with monoclonal gammopathy (MGUS), smoldering myeloma (SMM), or multiple myeloma should do. Are they all immunocompromised? Are they all immunocompromised to the same amount...
What stage is bilateral orbital/conjunctival NHL (limited only to the bilateral orbit/conjunctiva)?
By the Ann Arbor staging system, this is stage IV disease because more than one extranodal site is involved at initial presentation. However, NCCN and other guidelines acknowledge that MALT lymphoma involving both paired organs (e.g., bilateral orbital/conjunctiva) is often best treated with RT alon...
How do you approach CNS prophylaxis in patients with DLBCL?
I think the NCCN-CNS-IPI based on the German data is a reasonable place to start when it comes to making decisions regarding CNS prophylaxis. We typically do IT MTX for patients on the lower end of the risk spectrum and high-dose IV MTX for patients on the higher end of the risk spectrum.
How would you manage a patient with a MALT lymphoma (H. Pylori negative) found incidentally in the surgical specimen at the time of sleeve gastrectomy?
MALT lymphoma tends to be a multifocal disease. Furthermore, imaging is often suboptimal in delineating the true extent of disease within many extranodal sites, including the stomach. For these reasons, the entire organ is typically treated during a course of radiation therapy. Historically, radical...
Why are hypomethylating agents as single agents not approved yet by FDA for treatment of AML (technically off-label)?
DNA hypo methylation gets agents are not approved as single agents for treatment of AML as Phase 3 studies with both azacitidine and decitabine vs treating physician choice of best alternative regimens failed to meet their primary end-point of statistically significant improvement over-all survival ...
What dosing schedule of cladribine do you use for newly diagnosed hairy cell leukemia in need of treatment?
Great question. For patients who meet criteria for treatment and have classic hairy cell leukemia, both the 7-day continuous infusion of cladribine and the 5-day daily dosing seem to have equal efficacy and toxicity. I think either is fine and patient preference can be considered. The 5-day scheme s...
How would you manage a patient with minimal residual disease (<1% of CD25 positive cells) six months after completing therapy with 2-CDA for Hairy Cell Leukemia?
This is a challenging question. Patients with HCL who have MRD after treatment with cladribine or pentostatin have shorter remissions than those who have pathologic remissions. Several studies have shown eradication of MRD with subsequent treatment with rituximab. Thus, utilization of rituximab afte...
How would you treat low grade follicular lymphoma with diffuse epidural involvement? Would you give intratheracal or high dose systemic methotrexate in addition to systemic chemoimmunotherapy?
This is a rare presentation of follicular lymphoma especially if its primary epidural lymphoma without presentation outside the epidural space. This entity was traditionally treated with combined chemotherapy and radiotherapy and associated with a poor prognosis of less than a year. I would conside...