Clinical advances in hematology & oncology : H&O
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Clin Adv Hematol Oncol · Oct 2019
ReviewDelaying the use of high-dose melphalan with stem cell rescue in multiple myeloma is ready for prime time.
The significant advances made in the treatment of multiple myeloma (MM) have allowed for a paradigm shift away from the early use of high-dose melphalan with autologous stem cell transplant (HDM-ASCT). In 2015 alone, the US Food and Drug Administration (FDA) approved 4 novel drugs for MM. Novel drugs and regimens have shown unprecedented efficacy, which has increased the tempo of new drug development. ⋯ This article discusses the historic context of HDM-ASCT, the modern role of HDM-ASCT given the availability of highly sensitive MRD testing, and the likely future of quadruplet treatment. In summary, patients who attain deep responses using IMiD- and PI-based regimens may not require early HDM-ASCT. A delayed approach to this treatment is acceptable, and might be preferred by patients.
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Clin Adv Hematol Oncol · Jul 2019
ReviewRisk factors for and clinical management of venous thromboembolism during pregnancy.
Venous thromboembolism (VTE), which comprises deep vein thrombosis and pulmonary embolism, is one of the leading causes of non-obstetric maternal death in the United States. Physiologic and anatomic changes associated with pregnancy set the stage for a hypercoagulable state. In addition, other risk factors-including those associated with certain fetal characteristics such as low birth weight or stillbirth-have been correlated with an increased risk for VTE. ⋯ The choice of anticoagulant therapy for either treatment or prophylaxis in most cases is heparin, most commonly low-molecular-weight heparin. This is owing to the fact that vitamin K antagonists and the direct oral anticoagulants are contraindicated in pregnancy because of potential teratogenicity. With careful management and vigilant monitoring, appropriate anticoagulation can be used safely and effectively to improve patient outcomes.
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The care of patients with breast cancer in the modern era involves a multimodal approach to treating locoregional and distant disease. Recent studies have demonstrated that the extent of surgical intervention in both the breast and axilla can be minimized through a personalized approach based on breast cancer stage, subtype, and planned adjuvant therapies. The older approach focused on complete removal of the axillary contents for appropriate staging and to determine the need for adjuvant systemic therapy and radiation. ⋯ Further studies are needed in patients undergoing mastectomy to determine the optimal strategy for axillary management in the setting of limited disease in the sentinel nodes. The use of neoadjuvant chemotherapy allows the ability to evaluate an individual tumor's response to therapy, thereby increasing the possibility of breast-conserving surgery and reduction in the extent of axillary surgery. This review will explore the evolution of management of the axilla in patients with clinically node-negative and node-positive disease, and will provide insights into future directions in breast cancer care.
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Remarkable efficacy has been achieved in a variety of cancer types by targeting immune checkpoints. The cytotoxic T-lymphocyte-associated antigen 4 inhibitor ipilimumab, the programmed death 1 inhibitors nivolumab and pembrolizumab, and the programmed death ligand 1 inhibitors atezolizumab, avelumab, and durvalumab are the agents currently approved by the US Food and Drug Administration for the treatment of certain advanced malignancies. ⋯ The irAEs can affect any system in the body and in rare cases are life-threatening. It is critical for the practicing medical oncologist to recognize and promptly treat any irAEs that may develop.