Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Are you now using luspatercept as your first choice for anemia management in patients with low-risk MDS otherwise appropriate for EPO initiation, regardless of presence of SF3B1 or ringed sideroblasts?
Only use luspatercept if the patient is transfusion-dependent. FDA approves luspatercept as first-line treatment of anemia in adults with lower-risk MDS (aabb.org). In patients with MDS who are candidates for epo and transfusion independent then epo is still my first choice.
What is your preferred third-line therapy for a fit patient with symptomatic, relapsed follicular lymphoma who has failed bendamustine-rituximab and lenalidomide-rituximab?
This sounds like the patient where a CART may make sense. If that's not an option for whatever reason, I may go to bi-specific over say, copanlisib at this point. I suppose if EZH2 mutated, tazamezostat might be an option, but less appealing in a young otherwise healthy person.
What is your approach to bridging anticoagulation in patients with history of recent HIT?
One should not re-expose patients with past HIT to heparins. Even with remote HIT, there is a high rate of serologic recurrence (eg, Warkentin and Anderson, PMID 27114458) and while the rate of overt HIT relapse may be low with proper precautions, I have seen and published a couple of fatal HIT recu...
How would approach the management of a patient with significantly positive anticardiolopin and beta 2 glycoprotein antibodies in the absence of any clotting (including obstetric) history but with significant thrombocytopenia (but no other features of active connective tissue disease)?
I would first evaluate for other causes of thrombocytopenia (most of them can also result in positive APL antibodies): CTD, medications, liver disease, pregnancy, malignancy, splenomegaly, etc.I would not treat stable asymptomatic thrombocytopenia.If worsening/symptomatic, I would treat like any oth...
What is the preferred treatment for a patient with an EBV+ monomorphic PTLD (DLBCL) not currently on immunosuppressive therapy?
For patients who are candidates for an anthracycline-based regimen, R-CHOP is usually given if CD20+ PTLD. Patients whose tumors do not express CD20 are treated with CHOP chemotherapy alone. R-CHOP can lead to ~ 65% of CR (Trappe et al., PMID 22173060).
How do you interpret a low VWF activity/antigen ratio, when both activity and antigen levels are above 50%?
This discrepancy is most likely caused by heterozygosity for a VWF variant that either causes VWD type 2M, with defective binding to GPIbalpha, or interferes with the binding of ristocetin, assuming that the activity represents ristocetin cofactor activity. The presence of a bleeding history suggest...
How will you manage a patient with symptomatic secondary CNS involvement from DLBCL not eligible for HD-MTX?
Patients with secondary CNS lymphoma have historically had a very poor prognosis. Depending upon circumstances, many patients today are treated with a chemotherapy regimen that penetrates the blood-brain barrier (e.g., MATRix). If the patient responds favorably and is fit, high-dose chemotherapy fol...
Would you still recommend bone marrow biopsy in an elderly non-transplant eligible patient with mild cytopenias if NGS from peripheral blood indicates MDS mutations?
Yes. The presence of mutations in peripheral blood is not diagnostic of MDS. The elderly can have CHIP mutations and mild cytopenias which qualify for CCUS rather than MDS. CCUS has a higher risk for progression to MDS but is not MDS by itself. Would get a bone marrow prior to diagnosing MDS and sta...
How do you manage drug-drug interactions between oral anticoagulants and the ARSI agents such as apalutamide and enzalutamide?
Commonly used oral anticoagulants, such as apixaban, rivaroxaban, and warfarin are substrates of hepatic cytochrome P450 enzymes (CYP). Co-administration of an AR signaling inhibitor (ARSI) variably affects the concentration of those drugs depending on the effect on the type of CYP enzymes. For exam...
How would you approach the treatment of an elderly patient with multiple myeloma and CALR+ myelofibrosis with elevated platelets?
Thank you! This is a great question and a very complicated case. Generally, I would be less concerned about thrombocytosis. I would focus more on the symptoms and splenomegaly that the patient may be experiencing. If they are not having significant MF-related symptoms or splenomegaly, then observati...