Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What recommendations do you have for a transgender female patient with history of prothrombin gene mutation who is interested in starting gender affirming hormone therapy?
A review of the literature suggests that the risk of VTE associated with hormone therapy in this setting is quite low, even in the presence of other risk factors for clotting (see, for example, Mullins et al., PMID 33753543). Furthermore, the presence of an asymptomatic prothrombotic genotype is rar...
Do you consider discontinuing maintenance therapy in transplant-ineligible patients with Multiple Myeloma?
In absence of side-effects or relapse/progression, I continue maintenance in a dose-attenuated fashion for TI-NDMM based on available evidence in literature. I do encourage patients with standard risk disease to participate in trials asking the MRD-driven duration of maintenance question.
Do you routinely send NGS testing from bone marrow samples in patients with unexplained cytopenia or cytoses?
For patients with unexplained cytopenias in whom I suspect MDS or MDS/MPN, I will often obtain a broad NGS panel for myeloid malignancy gene mutations. The goal is to aid in diagnosis (and prognosis once the diagnosis is made), but I do not rely on the NGS panel alone to make the diagnosis. A bone m...
Do you recommend IVIg and/or cytoreduction for patients with IgM MGUS with reciprocal depression in IgG and recurrent infections?
Treating MGUS due to immune suppression is not a common practice. If IgG level is severely depressed below 200 mg/dl with recurrent bacterial infection, I would administer IVIG.
What is your simulation setup and dose fractionation for DLBCL of the hand with Deauville 4 residual disease following R-CHOP?
This is a difficult question which I will break into 2 parts: 1) Rx of primary refractory (i.e. chemotherapy resistant) localized DLBCL and 2) special considerations for a hand site. I presume the recurrent/persistent disease is still localized.Treatment of primary refractory DLBCL is a very difficu...
How do you manage and/or prevent ruxolitinib withdrawal syndrome?
Generally, tapering over a week or two is the best way to prevent it. If immediate discontinuation is needed, can consider using steroids.
Is there a role for IL2-receptor antagonists and TNF-alpha inhibitors in cytokine release syndrome as a complication of CAR-T or immunotherapy?
I came across a report from China regarding 3 patients who received BCMA CAR-T therapy, developed CRS, and were treated successfully with Etanercept based on elevated TNF-alpha. 2 of these patients did not receive tocilizumab before Etanercept which is not a standard practice. I'm not recommending u...
Would you continue ruxolitinib in combination with HMA plus venetoclax in myelofibrosis at the time of transformation to AML?
That is a good question. It would be difficult to give these three agents together as cytopenias would be very difficult to manage. In addition, it’s worth mentioning there are no data for this triplet and these drugs are not approved to be used together. That being said, there are some scenarios we...
Will you use or have you been using the IPSS-M as the primary way to risk-stratify patients with MDS to determine use of hypomethylating agents?
For the last 10 years, the IPSS-R has been the gold standard for risk stratification of patients with MDS. It is used by the NCCN guidelines to split patients into lower or higher risk groups, each with its own distinct treatment recommendations. The IPSS-R has been used to select patients for clini...
What would your radiation field be for a 7.5 cm DLBCL involving the tibia (with pretibial soft tissue involvement) after CR to R-CHOP x6?
Modern radiation fields in this setting would follow principles of involved-site radiotherapy (Yahalom et al., PMID 25863750). In the context of combined-modality therapy, radiation therapy is directed at original sites of involvement only. In this case, I would utilize pre-chemotherapy imaging (PET...