Questions discussed in this category
Given the rarity of this diagnosis (5-7% of all AL amyloidosis cases), and the prognostic and clinical differences when compared to non IgM-AL am...
My experience has been that patients can be neurologically devastated years out from WBRT. In Medical Oncology practice at my institution, we do not r...
We know the longer we expose patients to lenalidomide, the harder collection will be. Would you collect now or switch to an alternative regimen to ach...
No evidence of palpable splenomegaly, normal hematocrit and platelet count
Do the results change your clinical practice?
The said patient has been on Imatinib for 2.5 years and is In MMR. Last rt-PCR was 0.04.
E.g. in a patient with tenuous cardiac function, would starting treatment several weeks earlier potentially improve outcomes?
How does graft function play into your decision making? How do you utilize post allogeneic transplant chimerism in clinical practice? Do you obta...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
Does the safety profile impact your choice significantly?
Does your first choice vary by disease histology?
eg. eGFR < 30 ml
It is understood that the trials experience was to keep on treatment indefinitely until progression or unacceptable toxicity. We are asking about real...
If not, what instructions do you give to patients regarding checking temperature at home/return precautions?
If so, what regimen do you utilize?
Does a progressing kappa/lambda ratio > 100 at any point in time warrant treatment, or does one wait to treat patients in the setting of a slowly i...
What agents would have sufficient efficacy overlap to treat both?
Would you give R-CHOP without knowing if there was use of prior anthracycline?
Do you have a preferred sequence of therapies for diffuse skin limited MF?
What would you consider as contra-indications to Cladribine?
Peripheral blood flow shows prominent NK cell population but marrow aspiration/bx shows normocellular marrow with trilineage hematopoiesis.
Would you avoid imid's given reported association with transplant rejection?
For pts w/ eGFR between 30-60
Frailty Index per Palumbo et al. PMID 25628469Is it practical to apply in clinics? Have you made decision changes based on it?
Are you more inclined to use non cytotoxic regimens such as R2 or PI3K inhibitors?
Venetoclax has demonstrated efficacy in patients harboring t(11;14) mutations but is not FDA approved for MM. Can you expand on what situations you ma...
i.e. treatment-refractory PV, prior to progression to PMF or AML
Are the early results of CASSIOPEIA (Abst 8003) from ASCO 2019 practice changing? What about the GRIFFIN results in 2020?
Do you modify the aspirin dose based off the lenalidomide dose? Do you ever use higher dose aspirin in lieu of an anticoagulant? The NCCN guidelines s...
For example: shorten IMiD duration each cycle, add scheduled G-CSF, add antibacterial prophylaxis, etc.
What about changing standard regimens for TCL with HLH?
e.g. IS < 0.002% by qPCR
How does your treatment approach vary depending on the underlying predisposition?
CAR-T (any specific preference of product?) vs bispecific antibodies vs any other specific agents not previously utilized?
Given the POLARIX study data presented at ASH 2021, will this replace R-CHOP as the standard of care therapy in your practice? If not, how will y...
Is a repeatedly abnormal serum immunofixation all it takes for MGUS?
Is there any role for radiation therapy alone?
If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-f...
Would you continue with daratumumab maintenance per ANDROMEDA or switch regimen?
After 3-4 cycles of RVD, would you automatically take the patient to transplant if he has achieved at least a partial response, or is there any benefi...
Ki67 = 90% with multiple small nodes on PET scan and normal CBC
If you do recommend resuming carfilzomib, what dose and frequency would you use?
Patient in mid-30s with no major medical history presented with isolated left neck swelling. Incisional biopsy w/ HTLV1/2 associated ATLL, Ki67 of >...
What about multiple anaplastic plasmacytoma without bone marrow involvement?
Can you expand on this by sharing exactly what this routine workup should include? What additional tests outside of evaluating for POEMS and amyloidos...
Are there other supportive care interventions that would otherwise be covered by hospice?
How much weight do you give to a hgb/hct threshold versus symptoms?
Insurance won't pay for harvesting if the transplant is not done within a year.
Are there specific clinical, patient, or disease factors you focus on?
Does this data change your preferred first line treatment regimens when considering other options such as mAb combos, cytotoxic chemotherapy?
Is the non-inferiority margin of 1.429 sufficient, how was this selected?
Is the open label (rather than blinded) study design of any concern?
Is th...
Can experts comment on fungal pneumonia risk with individual BTK inhibitors as seen in ELEVATE-RR and whether this impacts their management decisions?
Do you feel comfortable with BTK inhibitors in these patients?
In ELEVATE-RR patients on a/c were excluded, and rate of atrial fibrillation in the ac...
Such as patients with specific underlying cardiovascular risk factors or other medical comorbidities?
Would you use MRD status to guide your decision making?
Is leukocytosis and thrombocytosis alone an indication for treatment?
Is the therapeutic purpose of the proteasome inhibitor to maximize total dosage per week or number of infusions per week?
In the case of subtle single lineage dysplasia with normal cytogenetics, do you routinely perform NGS testing for CHIP-type clonal mutations?
Do you ...
Recommendations in guidelines are discordant (ASCO vs NCCN vs UptoDate).
Do next generation sequencing results influence diagnostic and therapeutic decisions for patients with MDS?
Do your recommendations differ between those who receive ABVD and escalated BEACOPP?
Do you recommend consultation with fertility specialists for all...
Especially with the current drug shortage of nelarabine.
Is it safe to challenge with other CD20 monoclonal antibodies such as obinutuzumab?
If yes would you delay initiation of antineoplastic therapy to allow time for the vaccine to start acting?
When do you start treatment in this case?
Would this change with someone who has a history of thrombosis (e.g. DVT/PE, MI, CVA)?
Would this change with someone who is more fit vs more frail?
Results of AHOD1331 are not yet known, but adults have started using Brentuximab upfront for high risk patients
How does age play a role in this decision? If you do intensify therapy, how do you explain the negative results of CALGB/Alliance 50303?
How is this impacted by patient features, cytogenetics/disease biology, depth of response, or other factors? What would compel you to continue 3 drugs...
How do you factor in patient age, frailty, patients with underlying organ dysfunction, or other clinical features?
Do you still consider CyBorD or R...
Do you opt for VRd, DaraRD, CyBorD or another regimen?
How would this change for a patient with high risk cytogenetics?
In your experience, do certain regimens have more cumulative toxicity, financial impact, or patient convenience factors?
If given both options, which donor would one prefer: haploidentical related donor or 7/8 mismatched unrelated donor using post transplant cyclophospha...
Are there scenarios where you would use a higher dose of lenalidomide in a novel doublet or triplet (eg. relapse on lenalidomide maintenance)?
Does the rate of progression of IgM influence your decision?
Would you change your radiation therapy treatment dose or volume if you needed to treat a chloroma? If a patient had a separate cancer (e.g. skin canc...
When would you consider utilizing autologous SCT in those with a PR or SD?
Is there a potential role for BCMA-directed CAR-T or bispecific therapy in...
Would you use ALK inhibitors such as crizotinib based on recent phase II data?
Are there any research efforts to combine ALK inhibitors with current ...
How do you distinguish this entity from other plasma cell disorders (eg. MGUS, MM, etc.)?
Review of literature suggests that most of these pa...
Are there any subsets of patients that you're more inclined to offer maintenance?
In particular, for frail patients to avoid toxicity or for those that do not want chemotherapy
What regimens would you consider combining it with?
Any specific combinations to avoid or special considerations?
Are there other regimens you employ for patients unsuitable for standard chemotherapy?
Do you always treat with the full 21-day treatment course, or can defibrotide be stopped if certain criteria are met sooner?
Is Ommaya placement with CNS-directed therapy preferred to intrathecal or cranial irradiation? How do you interweave this therapy with systemic therap...
Excluding clinical trials
Do you prefer a cHL chemotherapy backbone or PMBL chemotherapy backbone?
Given nationwide shortage in vinblastine, several of my patients under active therapy are facing delays in their therapies. Is it appropriate to subst...
Would you use R-CHOP or a more intensive chemotherapy regimen? Would you consolidate with radiation therapy after 3 cycles or use systemic thera...
The current NCCN guideline version 2.2021 is a little confusing. On page HODG-2, the clinical staging/risk classification did not include ESR, b...
Does your recommendation differ between autologous and allogeneic transplants?
Does your recommendation differ in allogeneic transplant recipients wh...
Would you offer refractory doses (40-50 Gy) to the RPnodes and send for splenectomy? Or would you offer refractory doses to both RP nodes and spleen?&...
Does your management change based on the type of end-organ involvement at the time of diagnosis?
Are there any reports of CNS involvement with non-se...
When do you consider splenectomy? Is there a role for splenic radiation in non-surgical candidates?
Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?
Do you use specific tools or take into account certain factors when considering treatment options for older adults?
Are there particular mutations (eg SF3B1) or syndromes (eg MDS/MPN overlaps such as MDS/MPN-RS-T) where you are more apt to using lenalidomide?
Would you utilize radiation along with systemic therapy?
If so, what is your time threshold for when you'll start PCP prophylaxis--when you anticipate steroid courses greater than 1 week? 1 month? 3 months?&...
An otherwise healthy patient with spleen only diffuse large B cell lymphoma with mild spleenomegaly, Spleenectomy plus Rchop or Rchop plus RT?
Can results from emerging AML data be extrapolated to high risk MDS populations?
Is there data to guide the choice of continuing the HMA in combinati...
Relapsed disease occurred 3.5 years after initial treatment
Bulky adenopathy compressed bilateral ureters, CrCl < 30, post stent placement, but renal function has plateaued
Do you only give intrathecal chemotherapy or systemic therapy?
What are the scenarios in which a rebiopsy is warranted for follicular lymphoma?
Does the absence of an OS benefit in the AG221-AML-005 presented at ASCO 2020 deter you from this strategy?
CT scans show omental and pelvic disease.
Would you consider “bridging” therapy with something like an HMA?
Is it at neutrophil recovery, at documentation of CR on bone marrow biopsy, or is there a different point in time?
Does acute leukemia sub-type affect your decision?
Do you offer adjuvant chemoimmunotherapy after IFRT for Stage I to II low grade follicular lymphoma?
TROG 99.03 showed nearly 20% improved PFS at 10 years with chemoimmunotherapy despite 31/75 patients assigned R-CVP vs 44/75 assigned CVP without ritu...
For example, for joing replacement surgery? Do you hold the revlimid for certain about of time before and after?
Is there a preference for obinutuzumab over rituximab in early relapsed DLBCL, or in primary refractory disease?
For instance, would you discontinue when there is resolution of adenopathy and normalization of counts? If so, do you overlap ibrutinib with other the...
The NCCN recommends both regimens.
At what age would you treat an early stage hodgkins lymphoma patient with ABVD + RT (adult treatment) vs OEPA x 2 or AV-PC x 3 (pediatric paradigm)?&n...
How do you decide between WBRT, maintenance chemotherapy, or stem cell transplantation?
Risk of CNS relapse in a reported series is less than 5%.
Given the rarity of DLBCL with MYC/BCL2/BCL6 rearrangements, do you approach this disease differently than DLBCL with MYC/BCL2 or BCL6 rearrangement, ...
Or do you consider addition of this agent in the re-induction setting for refractory disease?
Do the potential late effects offset any benefit of mediastinal XRT in a young patient with bulky disease?
To me, the recent NEJM study is flawed in that the control arm did not have maintenance treatment while the experimental arm used maintenance Dar...
Would you proceed to autologous transplant, or switch to an alternate regimen (eg. daratumumab-based) first?
Would the type or degree of organ involv...
If so, what is your approach to laboratory and clinical testing?
In a patient with no evidence of bleeding, do you use a platelet cutoff? Do you utilize genomic testing (eg CALR, MPL, JAK2, etc.) to decide on cytore...
Once a tissue biopsy has confirmed light chain amyloid, what additional tests do you perform as part of a standard workup?
In whom should treatment b...
Do these events mandate discontinuation of lenalidomide therapy or switching to a different agent? Can appropriate therapy for these skin cancers be r...
(ie Deuvelle criteria 1-3) Is it appropriate to discontinue brentuximab like you would with bleomycin?
Specifically, do you consider repeating maintenance therapy after second line therapy if a patient had already received 2 years of maintenance rituxim...
If a young and otherwise healthy patient with normal echocardiogram and no other cardiac risk factors needs treatment for DLBCL, but has previously re...
Would you still proceed to high-dose therapy and autologous SCT?
Would you incorporate radiation pre- or post- transplant? Or offer additional salvag...
If the patient has not experienced significant infectious complications? If so, what agent?
Specifically, do you utilize 3 cycles of chemo with ISRT or 6 cycles? Do you use R-EPOCH or R-CHOP in these cases?
For instance, do you ever start with dasatinib 50 mg daily? Are there any titration schedules that you follow?
Given the PFS benefit seen in the most recent ECOG-ACRIN, and the prior study of Rd showing an OS benefit, is your practice to put any high-risk SMM p...
e.g. mixed indolent/aggressive NHL, mixed NHL/HL? Is there a definitive way to discern composite from transformation? NCCN does not list recommendatio...
if so, are there specific cytogenetic, molecular, clinical, or hematologic factors that you take into consideration?
Have you changed your practice based off the FLYER trial presented at ASH 2018?
How would you handle high risk features (eg double hit) with the limitations of dialysis?
Although not approved, for example, are you every using AVD-nivolumab?
Would you give 3 cycles of RCHOP followed by consolidative IFRT or 6 cycles of R-mini CHOP? Is there a role for 3 cycles of R-mini CHOP followed by IF...
Assuming the patient has an indication for treatment.
Thrombosis was ruled out and no etiology was found. Would you start ponatinib back at a lower dose, transition to omacetaxine or begin transplan...
Assuming there are no other indications at the moment.
Some specific questions:
Would you recommend repeat biopsy to confirm residual disease?
How would your recommendations vary if the patient had pre...
Would this affect your decision regardless of the stage and symptoms?
Do you await molecular and cytogenetic results prior to initiating therapy, or does age and function status primarily drive your choice?
NCCN does not list any preferences for the TKIs in their guidelines.
I.e., Can day 2 Rituximab (RCHOP) or day 6 Rituximab (DA-EPOCH, Hyper CVAD) be given? Or should only Day 1 Rituximab be used with chemoimmunotherapy i...
Since some prior studies (eg. Eskelund et al. Blood 2017 130:1903-10.) have shown intensive chemoimmunotherapy does not overcome the ad...
Since ECHELON-1 trial showed an improvement in PFS (but not OS), are there any situations where you would replace bleomycin with brentuximab...
For example - Would you offer tandem transplantation in a young, fit patient in a CR after first transplant, but with MRD detectable?
Would you follow an algorithm such as the one proposed by Hall et al?
How do you decide between intrathecal chemotherapy vs systemic therapy with HD-...
Pathology is clear this is not a concurrent DLBCL and is indeed transformed CLL
FDA package insert lists posaconazole as strong cyp3A4 inhibitor and states to consider other therapies.
Can it be added after 2 or 3 cycles of HMA?
How do you assess chemosensitive vs chemorefractory disease?
Given the results of ZUMA-7, TRANSFORM, and BELINDA - will you be altering your current ...
Does presenting total white blood cell count affect your decision? Does myeloid subtype affect your decision?
How might your decision change if the patient had a suitable 10/10 donor? How about if the patient had a targetable molecular mutation such as IDH2?
Although the MMR vaccine is contraindicated in immunosuppressed patients on anticancer treatment according to CDC/ACIP and IDSA guidelines, data on sa...
Is there a specific Ki67 percentage? P53-negativity?
I have received inquiry from a patient's gastroenterologist regarding use of Entyvio or Stelara in such a situation.
Given the recent results presented from the Griffin trial, would you choose a daratumumab-based regimen (eg. D-VRd) over other salvage options (V...
Would the site of disease relapse play a role in your decision (i.e. isolated lymph node recurrence versus failure at primary site of disease)?
Has the recent data presented at ASH affected your choice of regimen?
Would your choice differ between transplant-eligible and transplant-ineligible ...
Shanafelt et al. recently presented results from the phase III E1912 study at ASH 2018. Will you still utilize FCR as first-line or now use Ritux...
Would MRD assessments affect your clinical decision making for MM patients outside of a clinical trial?
Do you use etoposide-based regimens such as R-CEPP? How about substitution with liposomal doxorubicin?
Specifically, what regimen would you choose in a patient with new renal failure but not requiring dialysis?
What factors influence your decision (patient/disease characteristics, additional agents added to induction chemotherapy, CR1 or later, etc)?
How would your choice of therapy differ (if at all) for high vs low risk disease?
Would the specific anti-platelet agents used influence your choice ...
If a patient obtains a PR or less to front line cladribine, what factors help you chose between a second course of cladribine, an alternative pur...
How about if disease is found in the CSF?
When is it warranted to utilize targeted therapies for known mutations (eg. midostaurin or an alternative TKI for FLT3 mutations, ivosidenib for ...
Does the choice of initial induction regimen affect your decision for when to employ lenalidomide maintenance?
Are there situations where you would c...
Are you routinely using letermovir as CMV prophylaxis in high-risk patients?
Any special considerations with its use versus other antiviral agents?
...
Would you consider switching regimens?
Would you treat differently for de novo disease vs disease arising from large cell transformation of an indolent NHL?
Given the rarity of this in MF, is it still predictive of response to lenalidomide therapy?
Does their candidacy for autologous HSCT affect your decision to use maintenance lenalidomide?
How do you determine whether to add intrathecal chemotherapy in patients with +CSF? Would your approach change for primary vs secondary CNS lymphoma?
Would you change to an alternative triplet therapy, or switch to maintenance therapy?
Are there variations in depth of response short of CR that woul...
Does the more recent data regarding the continued utility of brentuximab vedotin and the utility of PD-1 inhibitors factor in to your reasoning at all...
Do you have experience administering these agents in the outpatient setting?
Could one make a case for addition of Rituxinab frontline to increase the chances of a complete remission and even maybe achieve MRD-negative status ?
Does it differ from the treatment of other relapsed peripheral T-cell lymphomas?
Are there any clinical trials or case series focused on SPTCL?
Is t...
Do we continue the hypomethylating agent indefinitely?
Technically, you can have up to 55% of larger cells circulating and still be called CLL.
Would you observe until progression or would you place the patient on maintenance?
Once you decide to begin treatment, any special precautions you would use for protein levels starting that high.
Assuming that the involved area is too widespread for RT. Would you try single agent rituximab first? Or obinutuzumab? What if rituximab alone gave on...
The recent NEJM phase II trial http://www.nejm.org/doi/full/10.1056/NEJMoa1715519?query=featured_home looked at a small cohort of 24 patients and show...
How do you choose between 3 and 4?
the MZL was untreated in the past prior to transformation.
Do these patients have a higher risk of recurrence post CR as opposed to patients with de ...
How do you get 17p testing on someone with only lymphadenopathy
Specifically, in patients that had progression or developed toxicity on ibrutinib? Idelalisib is very toxic and venetoclax a labor-intensive drug to g...
Even though Venetoclax is not FDA-approved yet, assuming you can get it off label?
1. Gemtuzumab: What dose/schedule and which HMA?
2. Venetoclax: W...
Would you consider resection? Or maybe anti-CD20 monoclonal antibody?
My practice had always been to transfuse for plts < 10, but the recent ASCO guideline change suggests that in the post-autoSCT setting it is ...
In the absence of any other classic CLL indications for treatment.
The CALGB regimen is quite complicated.
If filgrastim, how many days would you give? Pegfilgrastim is often not covered by payers if given less than 14 days before chemotherapy.
The patient has no medical problems and no history of leukemia/MDS. Biopsy of the filum terminale and arachnoid confirmed a myeloid sarcoma and MRI sh...
Subq has been shown to have lower risk of neuropathy. Is there any reason to use weekly IV still?
Would it change your management if patient if IgVH mutated?
This is a recently described entity with poor prognosis, so even with a CR after RCHOPx6 cycles, is your bias to push for ISRT due to EBV being poor p...
In a patient with multiple poor risk features including TP53 mutation, 1q amplification, stage III, and circulating plasma cells, would you consider a...
For example, how significant does the M protein have to increase for you to begin a conversation about new therapy?
Specifically, to you lean towards elotuzumab or a daratumumab-based regimen?
If a patient will receive a total of 4 cycles ABVD and has a CR by PET/CT after cycle 2, can RT be omitted to non-bulky sites to avoid toxicity?
Specifically I am thinking if a PET scan shows complete response, would it be reasonable to stop bleomycin and continue AVD?
What dose and volumes would you use?
Drug information indicates a patient may need 3-4 months off TKI. This seems like a long time off drug. Would a MMR of a certain duration make it less...
Would you ever give another IMiD?
Specifically when given as a single agent. Any role for G-CSF?
PET/CT/bone marrow biopsy negative for evidence of distant disease. Following 4 cycles of combination chemotherapy with no evidence of progressive dis...
With the advent of many new agents, any thought to initial therapy different from CHOP or CHOEP?
At what point is the neuropathy a contraindication to further bortezomib therapy?
Although bendamustine + rituximab is a standard option for advanced follicular lymphoma when treatment is required, does the regimen rituximab + lenal...
Specifically, can you rechallenge after the effusion has resolved (e.g. therapeutic thoracentesis)? If so, how long do you wait to rechallenge (especi...
Imatinib, or a second-generation TKI? Are there specific factors that make you choose one over the other?
If so, do you use antivirals and/or antibiotics? Does it matter if the patient has mantle cell lymphoma, CLL, or Waldenstrom's macroglobulinemia?
Specifically, do you just wait for count recovery? Do you check for morphologic or molecular remission at all during this time?
Do you re-challenge them? If so, what pre-medications do you give? Do you dose reduce the cytarabine? Or do you switch another regimen?
Specifically, is there still a role for dd RCHOP followed by ICE, or do you recommend DA-R-EPOCH for all patients?
NCCN guidelines suggest XRT as standard of care for this stage of disease. However, occasionally patients have their tumors completely excised when un...
Would you continue ibrutinib even if they are placed on anti-platelet therapy such as clopidogrel or ticagrelor?
What re-induction regimen without cytarabine or an anthracycline is likely to be most effective?
What is the utility of repeating FISH studies to evaluate for clonal evolution if FISH studies were done at diagnosis?
What dose do you recommend?
If a patient with stage I, low grade follicular lymphoma achieves a complete response after rituxan and treanda is there any role for consolidative ra...
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