Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the transfusion management of a sickle cell patient during pregnancy?
Prophylaxis: There is an ongoing trial in transfusion management in pregnancy, comparing prophylactic red cell exchange to a target HbS or SC < 30% compared to transfusion only when clinically indicated. Interestingly, it does not specify a Hct target. Until that trial is done, I would follow the AS...
How would you approach the treatment of patients with von Willebrand disease or hemophilia A previously managed with intranasal DDAVP during the recall?
There are two separate questions here, one is easy and one complicated. Desmopressin challenges can be performed with intravenous desmopressin, 0.3 mcg/kg. It is not necessary to challenge a patient with IV who previously responded well to the nasal preparation, in my view. How to approach treatme...
Is antiplatelet or anticoagulant therapy preferred for the secondary prophylaxis of cryptogenic stroke in a patient with underlying malignancy?
Will look at the stroke radiographically. If appears embolic and the patient is low risk for bleeding, with respect to their cancer regimen, co-morbidities, and labs, I will discuss off-label anticoagulation with eliquis. If there are additional, chronic embolic appearing strokes - that will also sw...
For a patient with previously relapsed TTP but in clinical remission, what is the role of rituximab in treating asymptomatic ADAMTS13 deficiency to prevent relapse?
A very good and interesting question. In remission, there is no question that severely deficient ADAMTS13 activity (<10%) is a strong risk factor for relapse. In patients with a chronic relapsing TTP history (at least 2 episodes), the approach most commonly has been to treat them preemptively with r...
How would you treat an adult patient with T-cell lymphoblastic lymphoma with FGFR1 rearrangement and co-exisiting myeloproliferative neoplasm?
This is a rare condition only recently recognized as its own diagnostic entity by the WHO as part of a larger family of disorders referred to not-concisely as "myeloid/lymphoid neoplasms associated with eosinophilia and rearrangement of PDGFRA, PDGFRB, or FGFR1 or with PCM1-JAK2" (Arber et al., PMID...
When would you perform a thrombophilia workup in a pediatric patient presenting with VTE?
I was trained to do workup in cases of unprovoked VTE and still practice that way mainly to guide the length of anticoagulation therapy as well as prophylaxis. I must admit though, in pediatrics I have come to realize there is more practice based on experience and extrapolation from adult data than ...
Are there any special considerations when evaluating patients with non-malignant hematologic or immunodeficiency disorders for allogeneic transplant?
In most malignant diseases, we prefer to take patients to allogenic transplant either in complete or partial remission as it will take few months before post-transplant immune-reconstitution results in effective graft-versus-disease response. In non-malignant diseases, we take patients to transplant...
What is the role of hydroxyurea in variant sickle cell genotypes?
I have had little success using hydroxyurea in my patients with hgb SC disease and at this point in patients with two or more acute visits over 12 months for pain, I am using crizanlizumab as some of the subjects in the phase 2 study on which the drug received FDA approval had SC disease (Ataga et a...
How do you treat a low-grade B-cell lymphoma with plasmacytic differentiation (Waldenstrom's) confined to the CNS?
This is a rare complication of WM called Bing Neelapu syndrome. It is hard to find a standard of care. Patients tend to have shorter responses to standard therapies such as HD MTX based regimens. Ibrutinib has shown long-term responses (Castillo et al., PMID 30523119).
Do you offer iron supplementation to a non-anemic adolescent athlete with a low ferritin?
I prefer having a TSAT on an overnight fast. Extreme athletes have increased hepcidin. If ferritin is greater than 30, my cut-off, no. If TSAT is 19 or less, yes. I would not criticize someone who gave iron, but PO iron is pretty tough to take. I would prefer staying within the current parameters of...