Rheumatology
Clinical discussions on autoimmune diseases, biologic therapies, vasculitis, and musculoskeletal conditions.
Recent Discussions
Do you consider APBI a reasonable alternative to mastectomy for women with early stage breast cancer and collagen vascular diseases?
As to the appropriateness of using APBI via a balloon catheter system for patients with CVD, data are limited to just small case series and individual case reports (e.g., Brachytherapy 10:121-127,2011; Brachytherapy 10:486-490,2011). Further, most patients reported in these series have been classifi...
Is hypofractionation ever appropriate in women with early stage breast cancer and latent lupus who have never experienced skin symptoms in their lifetime?
Short answer: Yes. I do offer HFRT to such patients. No. I would not advise a "wait-and-see" approach. Long answer: There are actually two categories of considerations here: First, are you comfortable treating patients with autoimmune/collagen vascular disease (CVD)? If so, are you a "lumper" or a ...
In which patients with stage IV NSCLC and PD-L1 TPS >50% plus concomitant autoimmune disease is it considered safe to give immune checkpoint blockers?
Given the adverse events of special interest noted with immune checkpoint blockers - specifically immune related AEs (or irAEs), the safety (and efficacy) of using these drugs in patients with pre-existing autoimmune disorders is not entirely clear. To date, most (if not all) studies have excluded p...
How would the presence of active rheumatoid arthritis on methotrexate impact your choice of fractionation for a patient with prostate cancer?
It depends on the dose of MTX. For 7.5-10 mg weekly doses have not changed volume or dose but if on a higher dose of MTX then I would discuss with rhematologist for possible holding or decreasing dose of MTX (as in that range has known radiosensitizing effect)
How do you identify immunotherapy-related pneumonitis vs. radiation pneumonitis in a patient status post chemoradiation receiving consolidation immunotherapy?
Unfortunately, it can be quite difficult to discern the two. Radiation pneumonitis is classically more focal within the treatment field, however, it is absolutely possible to get a more diffuse pneumonitis even with focal RT (albeit uncommon).https://www.ncbi.nlm.nih.gov/pubmed/15256622Immunotherapy...
How does the presence of active rheumatoid arthritis on rituxan impact your decision to proceed with prostate radiation?
I am always concerned about irradiating a patient with an active chronic inflammatory condition, as these people may be more prone to toxicity, both acute and late. In the case of a patient with both prostate cancer and rheumatoid arthritis, the latter being treated with rituximab, the fact that he ...
Would you resume biologic treatments such as TNF blockers in patients with symptomatic autoimmune conditions who are in remission from their cancers?
Most guidelines in rheumatology recommend use in patients who have been in remission for 5 years or more, there is data for safety for these patients. However, we do not know yet whether TNFi are safe in patients who have been NED for shorter periods and who may be at higher risk of recurrence given...
How do you approach post operative radiation therapy to someone with head and neck cancer who has high risk of local recurrence who also has scleroderma?
While the risk of morphea (skin and subcutaneous damage ) after radiotherapy to breast ca is well documented, there are very few data about the risk in HNC. Searching Pubmed for: scleroderma, radiotherapy, and head neck, I get only 2 references, one of which is a case report of a severe late toxicit...
How do you approach further treatment of patients who develop grade 2-3 immune colitis from nivolumab/ipilimumab prior to completion of the 4 ipilimumab doses?
If the colitis completely resolves, I would consider a colonoscopy to be sure that subclinical microscopic lymphocytic colitis has completely resolved. If not, I would consider 3 dose of infliximab to reduce recurrence of colitis. Then once off steroids, I would restart single agent anti-PD1.
When do you stop immunosuppressants in patients with GPA?
It depends on the severity of the initial presenting symptoms and which organs were involved. However, generally, I don't stop all treatments and maintain the patient on at least MTX or azathioprine, potentially for life, even if these were not part of the initial remission-inducing regimen, such as...