Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How does one interpret persistently positive lambda light chains on serum immunofixation but without measurable serum monoclonal protein and a normal light chains and ratio?
I would probably also check a 24 hour urine protein electrophoresis with immunofixation to evaluate if any significant and measurable monoclonal proteinuria that would make me more worried about SMM, MGRS, or amyloidosis. Would check urine protein/creatinine ratio to evaluate protein excretion for t...
What is the role for consolidative ISRT for patients with stage III follicular lymphoma following a good response to systemic therapy?
Advanced (stage III-IV) follicular lymphoma is not considered "curable" with either chemotherapy or immunotherapy (or the combination). A complete response may be achieved but an eventual relapse is inevitable. For patients who are asymptomatic without bulky or threatening disease, current guideline...
What options are available for patients with relapsed/refractory AL amyloidosis after Dara-CyBorD, other than clinical trial?
No great answers, unfortunately. Lenalidomide still tends to make me a bit nervous in AL amyloidosis, as does carfilzomib in patients with known cardiac involvement. But pom-based regimens are an option, or carfilzomib-based in the appropriate population.If the patient's BMBx shows t(11;14) by FISH,...
For lymphoma, how long after chemotherapy can you wait to start consolidative radiation therapy?
My general practice is to have patients return 3 weeks after their last cycle of chemotherapy with labs and post-treatment imaging and then proceed with consolidation RT. Depending on the complexity of planning, I am generally starting RT ~4-5 weeks after their last cycle of chemotherapy. This is co...
What are your considerations for peri-operative anticoagulation in patients with a mechanical heart valve undergoing a major noncardiac surgery?
For a patient with a modern (e.g St Jude bi-leaflet) mechanical valve (with or without AF) and who does NOT have a h/o of stroke or TIA, the available evidence suggests that "bridging" may have more risk than benefit: See Kovacs et al., PMID 34108229 and Siegal et al., PMID 22912386. Based on this e...
What is your treatment of choice for triple class refractory multiple myeloma?
To define triple-class refractory means the patient is refractory to FDA-approved IMiDs (up to Pomalidomide), proteasome inhibitors (bortezomib and carfilzomib), and CD38 naked antibodies (e.g. daratumumab or isatuximab). Refractory is defined as progression or within 60 days of the last dose. I ag...
Does testing for elevated serum homocysteine have any relevance in thrombophilia management?
Homocystine levels is part of a DVT workup. Although rare, it is a factor in DVT risk. The gene mutation in MTHFR contributes to the elevation and the mutation frequency is extremely high. However, elevation is almost never seen due to added and natural folate in the diet.
What are contraindications for growth factors in patients with hematologic malignancies?
This is a challenging question where little data exist to support a good conclusion. In real world situations, patients with cytopenias and suggestion of TR-MN warrant aggressive antibodies find yourself deciding which is the "best of class" in its nature. John
Do you adjust the dose of ruxolitinib in primary myelofibrosis based on hemoglobin?
This is a tough question. It generally depends on how bad the anemia is. You can expect at least a gram (or more) drop in the hemoglobin when starting ruxolitinib, so baseline hemoglobin is important. Also, assuming that the patient is symptomatic, you would want to reduce the dose as little as poss...
How would you approach a resected solitary osseous plasmacytoma?
With a few exceptions, surgery is rarely pursued as a definitive modality in hematologic malignancies. I have never seen an orthopedic oncologist attempt an oncologic resection for a solitary plasmacytoma of bone, so my subsequent thoughts are theoretical. In the (very unusual) situation posed, if t...