Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Why do we immediately perform CNS staging with a LP at diagnosis of ALL when the risk of seeding is highest with a high lymphoblast count?
We wait until circulating blasts are cleared from PB before doing LP.
How do you approach a patient with IgM monoclonal gammopathy associated with severe neuropathy of unclear etiology?
I usually confirm if the patient does not have AL Amyloidosis or POEMS, and as part of work up for IgM MGUS, I order MYD 88 mutation. If all are negative and I still believe that neuropathy is caused from his/her MGUS, you can try IVIG for the neuropathy as a trial (of course after using gabapentin,...
What dose and volume would you treat in a patient with diffuse large B-cell lymphoma confined to the stomach after complete response to R-CHOP?
In a patient with stage IE gastric DLBCL in a complete response (Deauville 1-3) after R-CHOP, I would consolidate with 30 Gy of RT. The volume would depend upon the size of the original tumor and how defined the original disease was on PET-CT and upper endoscopy. In a patient with a smaller lesion i...
Would you offer consolidative RT to a patient with early stage, non-bulky, high-grade non-Hodgkin's lymphoma of the orbit after 6 cycles of RCHOP + IT chemotherapy?
Yes I would. The high grade nature of disease and the location would be enough to convince me. There are now several large, single institution series that show that the pattern of failure is the same in patients with unfavorable DLBCL (non GCB type, DH/DL, Ki-67> 90, CD5+, Burkitt’s type DLBCL etc.)...
How would you treat a stage IE diffuse large B-cell lymphoma of the adrenal gland in an elderly patient who is not a candidate for systemic therapy?
This is an extremely tough situation if the patient cannot get systemic therapy. These tend to be non-GCB subtype with a generally poor prognosis even with R-CHOP based chemotherapy regimen with high rates of systemic and CNS relapses. Typically, I would recommend R-da-EPOCH, CNS directed chemothera...
What would you recommend for a patient with bilateral conjunctival MALT (without systemic disease)?
While technically this patient is stage IVAE (>1 extranodal site is categorized as stage IV), these patients do as well as those with unilateral conjunctival MALT NHL. Bilaterality is not unusual in this disease. This is a situation where definitive treatment (24 Gy in 12) is appropriate for stage I...
Do you consider discontinuing brentuximab in stage III-IV classical Hodgkin lymphoma patients on AVD+brentuximab who have a good response to 2 cycles?
Now that the 4 year progression free survival results are available (Bartlett, 2019 ASH abstracts, #4026: 4-y PFS A-AVD 82%, ABVD 75%), the evidence for superiority of A-AVD is clear. This better outcome with A-AVD was achieved when the brentuximab was kept included through all 6 cycles of chemother...
How do you manage patients who develop de novo or recurrent skin cancers (SCC or BCC) while on lenalidomide?
The most common hematologic malignancies in patients who have undergone stem cell transplantation and then lenalidomide maintenance are acute myeloid leukemia, myelodysplastic syndrome, and rarely acute lymphocytic leukemia (Palumbo A, Lancet Oncol, 2014, PMID 24525202 & Aldoss I, Leukemia, 2019).Le...
What is the preferred approach for giving high dose methotrexate in double or triple hit lymphomas being treated with dA-EPOCH-R?
I do not usually offer HD IV methotrexate for DHL without documented CNS disease. Instead, I use 4 cycles of IT methotrexate in addition to DA R-EPOCH (Blood 2017). For patients with documented CNS involvement, you can place an Ommaya reservoir for an intensive intrathecal therapy and I recommend us...
What would you recommend for a stage I follicular lymphoma of the bone?
Definitive treatment would be 24 Gy/12 to area of disease with margin (not entire bone). See ILROG guidelines for extranodal lymphoma (Yahalom et al., PMID 25863750).