Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What induction combination(s) would be appropriate for newly diagnosed standard cytogenetic risk multiple myeloma who have a transplanted kidney?
This is a tough question! On one hand, the risk of allograft rejection with IMiDs is a real concern. On the other hand, one must consider that the evidence for this is limited to case reports/series (ex Walavalkar et al., PMID 29661456; Lum et al., PMID 28189378; Nguyen et al., Blood (2019) 134 (Sup...
In young patients with essential thrombocythemia and early significant atherosclerotic disease but no thrombotic history, would you consider the addition of cytoreductive therapy?
This is a good question without an evidence-based answer. It's important to understand why this person has early atherosclerotic disease, have other modifiable risk factors been identified and addressed? For example, familial conditions that lead to hyperlipidemia, or smoking, obesity, etc. If the p...
How do you manage a patient with transfusion-dependent MDS with concurrent hemochromatosis requiring phlebotomy?
I actually have a couple patients like this. If the ferritin is >1500, I add deferasirox. However, if MDS is responsive to ESAs, you might be able to manage with occasional phlebotomies. It's a tough problem.
How would you manage an asymptomatic elderly frail patient with newly diagnosed mantle cell lymphoma with TP53 mutation?
While p53 mutations are known to impact clinical outcome after administration of cytotoxic chemotherapy in frontline MCL (Eskelund et al., PMID 29794145, Elhassadi E et al. Presented at: 2019 European Hematology Association Congress; June 13-16, 2019; Amsterdam, The Netherlands. Abstract PF493, Ferr...
How do you manage a patient with superficial venous thrombosis with close proximity (<3 cm) to deep veins and an inherited thrombophilia ?
I would treat the patient for 3 months with a DOAC and then repeat the scan. If the clot is resolved, I would order a d-dimer and Factor VIII level on anticoagulation. If the tests are negative, I would stop the DOAC and retest at 30, 90, and 180 days. If tests remain negative then stay off anticoag...
What is your typical workup for a patient with a spontaneous renal infarct?
Broadly speaking, in the setting of a renal infarct, consider a thromboembolic event (venous thrombosis with paradoxical embolism or an arterial source) or a local vascular event such as dissection. The latter can be easily missed because the appropriate imaging is generally not performed. Once a va...
How do you approach transplant eligible myeloma patients with a partial or minimal response to treatment with 3-4 cycles of RVD?
This is something that occurs more often than is reported. Put another way, what to do when a patient's response plateaus after achieving a partial response? Evidence suggests that achieving at least a PR during induction is associated with better post-autologous transplant outcomes. What about VGP...
How would you approach a patient with gastric MALT lymphoma who has CREST syndrome?
The quick answer is, very carefully. To elaborate - I first had to look up what CREST syndrome is - the short answer is limited extent scleroderma, usually the distal upper and lower extremities, but occasionally the head and neck region and most relevant to this question, the esophagus. The literat...
How would one alter therapy in a transplant-ineligible AL amyloidosis with less than a complete response to six cycles of Dara-CyBorD?
If the patient has achieved deep VGPR (but perhaps not CR due to interference of dara), it is probably reasonable to continue dara maintenance as per ANDROMEDA as long as the patient is also clinically improving. If the response has not reached this level or the patient has not had evidence of impro...
What is your experience managing myelosuppression from busulfan, prescribed for PV?
I have no direct experience managing busulfan-induced myelosuppression in PV but I do have experience in managing busulfan-induced aplastic anemia. To begin with, busulfan is an alkylating agent and as such is a leukemogen and its use in a chronic myeloproliferative neoplasm should be restricted to ...