clinical cases

[gutonc]

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For node-positive NSCLC on PET, do you always refer for EBUS or does it depend on how convincing the PET is?

Specifically, T1 primary tumor 2 cm with ipsilateral FDG-avid ipsilateral hilar node, SUV 3. Looks real.

NCCN guidelines say to do pathologic sampling for any stage II, but I'm wondering if that's done in the real world.

Yes. Especially because it's the difference between a IA2 (resection/SBRT only) and IIA/B (depending on AJCC 8/9) where you'd consider neoadjuvant chemo-IO (or Chemo-Osi) for appropriate patient.

I know that my thoracic surgeons wouldn't operate on this patient without a LN biopsy. I think you'd also be hard pressed to get neoadjuvant chemo-IO covered for a T1bN?.

Now, "back in the day" when it was just adjuvant chemo as your option, it would be totally OK to go to the OR with just the PET and do a mediastinoscopy prior to the resection. But in this day and age, a biopsy is mandatory unless there's other extenuating circumstances that prevent it.

I guess the other question I have is, how did you get path without a bronch in the first place? I can't get pulm to do a diagnostic bronch without a PET if I offer to pay a year of their kid's college tuition.

 

[gutonc]

1. Prayer and Ivermectin do not in fact cure NS-cHL.
2. I am batting .500 on Lorlatinib --> psychotic break patients.

 

[GUoncologist]

1. Prayer and Ivermectin do not in fact cure NS-cHL.
2. I am batting .500 on Lorlatinib --> psychotic break patients.

1. Show me randomized data you pharma mogul!
2. Have they tried ivermectin and prayer?

 

[gutonc]

1. Show me randomized data you pharma mogul!

We went through that already. They did 6 cycles of P+I and repeat PET showed Deauville 5. Starting 2nd line Nivo-AVD next week.

2. Have they tried ivermectin and prayer?

Mushrooms and meditation actually. Equally ineffective.

 

[gutonc]

83M, remote h/o Stage IIC prostate cancer treated with RT alone in Jan 2024(for some reason, felt to be "too frail for ADT" but never saw med onc).

Admitted to mothership hospital with L-spine compression fracture and underwent laminectomy. Pathology negative for malignancy. CT as inpatient notable for "multifocal blastic osseous lesions of spine, pelvis and bilateral ribs". PSA 3.2 (never got below 1.5 after RT). Labs otherwise unremarkable/baseline with mild anemia (Hg 11.5) and CKD (baseline SCr 1.8). Discharged to f/u with me with diagnosis of met prostate cancer despite PSA <4 and negative biopsy.

I see him in clinic, tell him we're going to start from scratch, repeat the PSA, do a myeloma lab workup and then a PET, deciding on FDG vs PSMA once the PSA came back. PSA comes back as 2.6 so I ordered FDG-PET. FDG-PET is negative except for the bone "mets" previously seen but no uptake. SPEP negative. Beta-2-MG 8.2, Kappa and Lambda LC both mildly elevated with K/L ratio 1.7 (just barely abnormal). Immunoglobulins normal. UPEP negative.

So...now what?
PSMA-PET? Hard to justify with a normal PSA.
Bone lesion biopsy? So unsatisfying but really the only abnormal thing.
Bone marrow biopsy? Will probably be negative, but we might get lucky.
Just watch? Also feels unsatisfying.

I think I need to convince IR to biopsy a bone lesion. But since we don't have a "CUP Tumor Board" and I'm basically solo practice, bouncing it around this room.

 

[HemeOncHopeful19]

I agree I would biopsy the bone lesion. I would message my IR colleague and ask them what they think too which lesion seems highest yield.

I also think this sounds like a board question and the answer is small cell prostate but the lack of FDG avidity really has me stumped.

 

[gutonc]

I agree I would biopsy the bone lesion. I would message my IR colleague and ask them what they think too which lesion seems highest yield.

I also think this sounds like a board question and the answer is small cell prostate but the lack of FDG avidity really has me stumped.

Me too. Low PSA and negative FDG-PET just makes no damn sense.

 

[gutonc]

On an unrelated note, and another one of my "what is in the water out here in the wilderness?" cases, In the last 2 months, I have had 3 JAK2 mutated ET patients transform to myelofibrosis. I've taken care of a ton of ET over the years and never once had one transform.

 

[GUoncologist]

Me too. Low PSA and negative FDG-PET just makes no damn sense.

What was the grade group at diagnosis? Are they on dutesteride? Saw a similar case recently and ended up biopsying it, which revealed prostate cancer. Turns out the patient was on dutesteride. If the patient was averse to being poked pet-psma may be helpful but of course it is not specific to prostate.

 

[gutonc]

What was the grade group at diagnosis? Are they on dutesteride? Saw a similar case recently and ended up biopsying it, which revealed prostate cancer. Turns out the patient was on dutesteride. If the patient was averse to being poked pet-psma may be helpful but of course it is not specific to prostate.

4+4 in 4 cores, 4+3 in 6 cores, 2 cores negative. Initial PSA was 13 or so. No dutasteride.

 

[EEtoPre-Med]

I’ve got an interesting case that I would love to hear some opinions about.

Male in mid 70’s with history of MIBC who previously received ddMVAC x 2 cycles (then developed renal failure) and CKDV (not on dialysis) so cystectomy was scrapped and patient received definitive radiation. Then he developed non-MIBC cancer 9 months after completing XRT. Surgeon is not excited about cystectomy given the prior irradiation. Sent them to us for neoadjuvant EV-Pembro. It seems EV-Pembro is not approved in the non MIBC setting. There is data for pembro in patients who are refractory to BCG and Durva+BCG in high risk NMIBC but it seems this may be an urology call? Thoughts? He has not received BCG yet.

 

[GUoncologist]

I’ve got an interesting case that I would love to hear some opinions about.

Male in mid 70’s with history of MIBC who previously received ddMVAC x 2 cycles (then developed renal failure) and CKDV (not on dialysis) so cystectomy was scrapped and patient received definitive radiation. Then he developed non-MIBC cancer 9 months after completing XRT. Surgeon is not excited about cystectomy given the prior irradiation. Sent them to us for neoadjuvant EV-Pembro. It seems EV-Pembro is not approved in the non MIBC setting. There is data for pembro in patients who are refractory to BCG and Durva+BCG in high risk NMIBC but it seems this may be an urology call? Thoughts? He has not received BCG yet.

Unless there is concern for undersampling, I would not do EV P

 

[EEtoPre-Med]

Unless there is concern for undersampling, I would not do EV P

The cTDNA is positive probably from the initial lesion, but given that we only have proven NMIBC recurrence, we are doing single agent pembro. He also has squamous cell and sarcomatoid features.

 

[ONC2023]

A) 60 year old. Smoker, poor lungs, but otherwise fine.

Has a stage III ccRCC resected two months ago with positive ctDNA.

I got a PET, and he had positive right axillary nodes that I biopsied - it showed melanoma, BRAFV600E.

He has two skin lesions that were biopsied that showed basal cell, so no primary has been found. (Whole body PET and brain MRI negative).

I’m planning on doing neoadjuvant ipi/nivo and have his nodes removed and then continue nivo. This will cover the RCC and melanoma. Technically only pembro is approved for adjuvant RCC, but close enough.

But since he’s BRAFV600E, would anyone add BRAF therapy? That’s the biggest issue because the NADINA trial gave BRAFV600E melanomas BRAF-directed therapy after surgery instead of IO.

2) I have two lung SCC, unreaectable, planned for concurrent chemoRT. But both have neuropathy that’s pretty significant.

Any thoughts on cis/etop versus carbo/taxol? I know taxol has higher risk, but I’ve read cisplatin is more likely to be permanently worse (not sure if that’s something people believe).

I’m guessing there are no good options here, but maybe weekly carbo/taxol is my best best? I’ve heard weekly carbo/taxol may not be as bad.

 

[gutonc]

A) 60 year old. Smoker, poor lungs, but otherwise fine.

Has a stage III ccRCC resected two months ago with positive ctDNA.

I got a PET, and he had positive right axillary nodes that I biopsied - it showed melanoma, BRAFV600E.

He has two skin lesions that were biopsied that showed basal cell, so no primary has been found. (Whole body PET and brain MRI negative).

I’m planning on doing neoadjuvant ipi/nivo and have his nodes removed and then continue nivo. This will cover the RCC and melanoma. Technically only pembro is approved for adjuvant RCC, but close enough.

But since he’s BRAFV600E, would anyone add BRAF therapy? That’s the biggest issue because the NADINA trial gave BRAFV600E melanomas BRAF-directed therapy after surgery instead of IO.

I'd personally use pembro, but ipi/nivo isn't wrong either. The data for IO in BRAF V600E is as good as it is for targeted therapy. I regularly use IO first in BRAF mutated melanoma (neo/adjuvant or met) and only use targeted when IO isn't tolerated (or stops working in metastatic disease).

2) I have two lung SCC, unreaectable, planned for concurrent chemoRT. But both have neuropathy that’s pretty significant.

Any thoughts on cis/etop versus carbo/taxol? I know taxol has higher risk, but I’ve read cisplatin is more likely to be permanently worse (not sure if that’s something people believe).

This is more or less my experience. More common with taxol, more severe, when it happens, with cisplatin.

I’m guessing there are no good options here, but maybe weekly carbo/taxol is my best best? I’ve heard weekly carbo/taxol may not be as bad.

I'd try that and see if you can sneak 4 or 5 weeks of it in before they give up. I've also started with carbo/taxol before and had to stop after 2-3 weeks for either anaphylaxis or neuropathy and then just given one dose of cis/etop and gotten away with it.

 

[ShuperNewbie]

Don't feel obligated to use adjuvant BRAF MEK. Most people in NADINA got adjuvant Nivo, with only really path non-responders getting BRAF MEK which is how most people practice. You're fine with just adjuvant IO following neoadjuvant Ipi/Nivo especially if path shows any semblance of IO response

 

[Plutarch02]

Do yall have a age cutoff for HMA in transfusion dependent MDS? Reasonable to give dose reduced HMA 3 day course >90?

 

[HemeOncHopeful19]

Do yall have an age cutoff for HMA in transfusion dependent MDS? Reasonable to give dose reduced HMA 3 day course >90?

Not much else you can do other than hospice, I’d probably at least offer it if they wanted to

 

[gutonc]

Not much else you can do other than hospice, I’d probably at least offer it if they wanted to

As would I. Assuming you've gone through ESAs and luspatercept already and not 5q-.

 

[ShuperNewbie]

Go hard and yolo it. FLAG-Ida-Ven

 

[BRCA123]

For people on TRANSMET trials, do you continue chemotherapy after liver transplant until the first interim scan?