Anuj kc

MD Internal Medicine;
DM Medical Oncology,
Benign Hematology,
Neuro-Oncology @ Princess Margaret Cancer Center, Canada

[Anuj kc @dranujkc_onco]

Cis & Carboplatin has been in shortage about 6mnths for now & no step has been taken by the concerned dept. till now. Result, cancer patients are progressing, getting incurable & dying. When will you think about them? Bcoz your people are getting treatment at other country.

[Entisar saleh @Entisar_kilani]

A simple summary for NETs

#Oncology #MedTwitter #nccn

[Anuj kc @dranujkc_onco]

As a panelist in discussion of role of NACT in Penile cancer @SFON

[Anuj kc @dranujkc_onco]

Medical Oncology 2025, beautifuly summerized

[Toni Choueiri, MD @DrChoueiri]

HIGHEST RANKED TRIALS for 2025

TOP 10 #cancerclinicaltrials in 2025 w/MOST Impact

1/ #DeLLphi304 @NEJM led by #Zeusofoncology @g_mountzios @HenryDunantGR : In relapsed SCLC post-platinum, BiTE DLL-3 Tarlatamab improved mOS vs. Chemo (13.6 vs 8.3 m, HR 0.60). PFS and in cancer-related dyspnea also improved.

https://t.co/dlIvlySUT9

[Anuj kc @dranujkc_onco]

Endometrial ca. New update

[Dr Rishabh Jain @DrRishabhOnco]

🇪🇺 ESGO–ESTRO–ESP 2025 GUIDELINES UPDATE

🔹 Core Update
2023 FIGO staging + Molecular classification (POLEmut / MMRd / NSMP / p53abn)
➡️ Biology now defines stage, risk & therapy

🧪 Universal Testing
✅ MMR IHC ± MLH1 methylation → all ECs
🔍 POLE, p53, ER, HER2 testing → guides management
🧠 ER for NSMP, HER2 for p53abn/serous
🧬 Foundation from PORTEC-4a, PROBE, and TCGA data

🏥 Surgery
🤖 Minimally invasive approach = standard
🧭 Sentinel LN biopsy preferred
🚫 Avoid tumour spillage / morcellation

💊 Adjuvant Therapy by Risk

🟢 Low-risk (POLEmut/MMRd/NSMP-ER⁺) → ❌ No adjuvant Rx

🟡 Intermediate (MMRd/NSMP-ER⁺) → 🎯 Vaginal brachy ± omit (<60 yrs)

🟠 High-intermediate → ☢️ EBRT / VBT (if pN0)

🔴 High-risk (p53abn / NSMP-ER⁻ / high-grade) → 💥 EBRT + concurrent/adjuvant chemo

🧬 MMRd stage III–IV → Chemo + ICI (based on NRG-GY018, RUBY-1, DUO-E)

💡 Systemic Therapy
1️⃣ MMRd: Chemo + ICI → ICI maintenance (dostarlimab/pembro/durva)
2️⃣ Non-MMRd: Chemo ± ICI/PARP (DUO-E: durvalumab + olaparib)
3️⃣ HER2 3⁺: Add trastuzumab (NCT01367002)
4️⃣ ER⁺ low-grade: Consider endocrine therapy (PALEO, NSGO-EORTC)

🎯 Bottom line:
Molecular classification is now the treatment compass.
🧬 Precision > anatomy in 2025.

📓 Full paper: Concin N et al., Lancet Oncol. 2025.
https://t.co/kuYDHADdGi

#OncoTwitter #GynOnc #EndometrialCancer
@myesmo @esmo_open @OncoAlert @ESGO_society @ASCO

[Anuj kc @dranujkc_onco]

Somthing new...

[Nieves Martinez Lago MD PhD @DraMartinezLago]

Nab-pac + bev in metastatic ep-NEC
Phase II, single-arm

📊 n=79 | ≥2L 40 pts
✅ ORR 55% | DCR 87%
⏱️ mPFS 5.3 mo | mOS 12.8 mo | mDoR 5.7 mo
⚠️ G≥3 AEs: neutropenia 35%, leukopenia 19%

➡️ High RR &amp; promising survival in pretreated EP-NEC.
🔗 https://t.co/5wBy870CHA

[Dr. Chokri Ben Lamine @abouabdrahman0]

NCCN 2025 – Classic Hodgkin Lymphoma (Stage III–IV, Age 18–60)

🩺 Preferred 1st-Line Regimens

💉 Nivolumab-AVD × 6 cycles (Cat-1; SWOG S1826)

💉 BrECADD + G-CSF × 6 cycles (Cat-1; age 18-61 y; HD21-adapted)

⚙️ Alternative / Certain Circumstances
💉 BV-AVD + G-CSF (Cat-1) ➡️ if CPI not candidate / neuropathy risk

💉 ABVD × 2 cycles ➡️ if BV or CPI unavailable / contraindicated

🔎 Response-Adapted Strategy

ABVD-Based Approach
Start ABVD × 2 cycles ➡️ FDG-PET/CT

✅ Deauville 1-3 ➡️ AVD × 4 cycles (RATHL)

⚠️ Deauville 4-5 ➡️ BrECADD + G-CSF × 3 cycles ➡️ restage
 - ✅ If response → ±ISRT ➡️ 🟢 follow-up
 - 🔴 If Deauville 5 persists → biopsy
  - ➕ Positive → treat as primary refractory (HODG-13)
  - ➖ Negative → consolidate with ISRT

BrECADD-Based Approach

Start BrECADD × 2 cycles ➡️ FDG-PET/CT
✅ Deauville 1-3 ➡️ continue BrECADD × 4 cycles ➡️ restage
  - ✅ If response → ±ISRT ➡️ 🟢 follow-up
  - 🔴 If Deauville 4-5 → biopsy
   - ➕ Positive → primary refractory
   - ➖ Negative → ±ISRT
Nivolumab-AVD Approach
Nivo-AVD × 6 cycles ➡️ FDG-PET/CT
✅ Deauville 1-3 ➡️ 🟢 follow-up
🔴 Deauville 4-5 ➡️ biopsy → manage as above
📌 Key Notes

🧬 Interim PET crucial for risk-adapted therapy

🩻 Consider ISRT for initially bulky / residual PET-positive sites

⚠️ Deauville 5 always needs biopsy if feasible
🟢 Growth factor (G-CSF) used with BrECADD; optional with ABVD/Nivo-AVD (per SWOG S1826)
🧪 If biopsy positive → escalate to primary refractory pathway (HODG-13)
#HodgkinLymphoma #NCCN2025 #ABVD #BrECADD #NivolumabAVD #BVAVD #FDGPET #DeauvilleScore #ISRT #Oncology

[Dr. Chokri Ben Lamine @abouabdrahman0]

🧵 IV Iron in Hematology 👇

💉 When IV Iron?
•Oral iron failure
•CKD, HF, IBD, Cancer anemia
•Pre-chemo, ESA, pre-op anemia

📊 Monitor Parameters:
•Hb 📈
•Ferritin 🎯 >100 µg/L
•TSAT 🎯 >20-30%
•Retics in 1-2 wks

📅 Response:
•Hb ↑ 1-2 g/dL in 2-4 weeks
•Recheck ferritin, TSAT at 4-8 wks

📌 Dose Calculation — Hb Deficit Formula:
Total Iron Needed (mg) =
👉 (Target Hb - Actual Hb) x Weight (kg) x 2.4 + 500 mg (iron stores)

🔎 Target Hb: 13 g/dL
🧮 Example: Hb 9, weight 70 kg
(13-9) x 70 x 2.4 + 500 = 1172 mg

📌 Ferric Carboxymaltose (FCM):
•Max 1000 mg/infusion
•Repeat dose in 1 week if needed

📌 Iron Derisomaltose (Monofer):
•Up to 20 mg/kg single dose
•One-step correction

⚠️ FCM & Phosphate:
•No routine phosphate check
•Check if:
•Fatigue
•Bone/muscle pain
•Weakness
•Fractures
•FCM = ↑ hypophosphatemia risk vs Derisomaltose

📅 When to Repeat Ferritin:
•After 4-8 weeks
•Don’t re-dose before 4 wks

🎯 Practice Tips:
✅ In inflammation: rely on TSAT
✅ ESA + IV iron = better response
✅ Recheck Hb, ferritin, TSAT q2-3 months in chronic diseases

#Hematology #IVIron #FCM #Derisomaltose #BoardReview #ExamTips

[Rohit Malde @roxboxfix]

Adjuvant ET in EBC = Individualised Approach

Nice article from ESMO

[Anuj kc @dranujkc_onco]

@SuyogCancer Interested

[Khushali Jhaveri @JhaveriKhushali]

DA-EPOCH-R ⬆️outcomes in HGBCL-DH-BCL2 vs historic R-CHOP
2-yr TTP 71% vs 47%,p=0.02
2-yr OS 75% vs 47%, p=0.008
OS worse in DZsig⁺ but still &gt; historic
MYC partner not prognostic
IPI-adjusted HR 0.38 for both TTP &amp; OS.
Still no RCTs, but evidence is mounting.
#ICML2025 #lymsm

[Anuj kc @dranujkc_onco]

Added Training on Neuro-Oncology at prestigious Princess Margaret Cancer Center, Toronto, Canada to my CV. Thank you

[Erman Akkus @Erman_Akkus]

📘mCRPC guideline update
@ASCO @JCO_ASCO

👉https://t.co/Spkc8ANEr5

@OncoAlert #cancer #oncology #MedX #ASCO25

[Dr. Chokri Ben Lamine @abouabdrahman0]

🧬 LGL Leukemia (LGLL)
Rare chronic lymphoproliferative disorder → clonal expansion of cytotoxic T cells (T-LGLL, 85%) or NK cells (NK-LGLL, 15%)
Linked to STAT3/STAT5B/TET2 mutations & autoimmune diseases ♻️

⸻

🧪 Pathogenesis
• JAK/STAT mutations ⚡
• Chronic antigen stimulation
• Epigenetic events (e.g., TET2)
• ↑ pro-apoptotic ligands (FasL, TRAIL) → cytopenias
• Associated with RA, PRCA, neutropenia, splenomegaly

⸻

🔬 Diagnosis
• Cytopenia + LGLs >0.5×10⁹/L
• Flow:
 - T-LGLL: CD3⁺CD8⁺CD57⁺
 - NK-LGLL: CD3⁻CD16⁺CD56⁺
• Clonality: TCR (T-LGL), NK score ≥4 (NK-LGL)
• Molecular: STAT3, STAT5B, TET2, TNFAIP3
• Rule out polyclonal/reactive causes (e.g. post-transplant, viral)

⸻

🧭 Treatment
Only treat if symptomatic (80%)
• 1st-line:
 - Cyclophosphamide (Cy) 100 mg/day
 - Methotrexate (MTX) 10 mg/m²/wk
 - Cyclosporine A (CyA) 3 mg/kg/day
• Assess @4 months
 - Responders → maintenance
 - Refractory → switch agents
• Relapsed/refractory:
 - JAKi, HDACi, HMA, IL inhibitors, Anti-CD94
 - Clinical trials

⸻

📊 Prognosis & Molecular Notes
• STAT3mut → ↓ granulocytes & survival
• TET2mut ~30% (esp. in NK-LGLL)
• STAT3 & CCL22 mutations mutually exclusive
• Overlap with MDS/CMML possible

⸻

Ref: Marchand et al. Blood. 2023; DOI: 10.1182/blood.2023021790
#LGLL #HemeOnc #LGL #TCell #NKCell #JAKSTAT #Cytopenia #ASH

[Anuj kc @dranujkc_onco]

Rectal cancer explained

[Dr. Nina Niu Sanford @NiuSanford]

Rectal cancer 101 video!

I'm making GI onc disease subsite videos.

Figured was giving same lecture over &amp; over to residents on my service, now recording so can watch pre-rotation &amp; hit the ground running.

Other subsites forthcoming. Full YouTube video &amp; slides in replies🧵1/8

[Esk @esenthil84]

Systemic Management of Advanced/Metastatic HR+, HER2- Breast Cancer

1️⃣ Definitions

Estrogen Receptor (ER) Positive:

≥1% of tumor cells exhibiting ER membrane positivity on IHC.

Menopausal Status

Postmenopausal:

Age >60 years.

Age <60 years with ≥12 months of amenorrhea (in the absence of chemotherapy, tamoxifen, or ovarian suppression).

Prior bilateral oophorectomy.

FSH and estradiol levels consistent with postmenopausal status.

Endocrine-sensitive disease (ESD):

Patients who derived prolonged benefit from endocrine therapy before progression.

Endocrine-resistant disease:

Disease progression within 6 months of adjuvant endocrine therapy or progression on first-line endocrine therapy.

Visceral crisis

Life threatening organ dysfunction due to the disease requiring rapidly efficacious treatment

[Esk @esenthil84]

Management of Advanced/Metastatic ALK-Positive NSCLC 🫁

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🔬 Clinical Features of ALK-Positive NSCLC

ALK-positive cases constitute less than 5% of NSCLC.

Affects patients 1–2 decades younger than typical NSCLC, fifth decade

Aggressive disease course with frequent brain metastases (~30–40%).

Predominantly adenocarcinoma histology in non-smokers.

---

🔬 Molecular Testing

Preferred:

NGS for ALK fusions, resistance mutations, and screening multiple driver mutations in a single test.

IHC -- affordable and sensitive

Other Options:

FISH
RT-PCR

Utility: Guides initial therapy and subsequent treatment decisions during progression.

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📊 First-Line ALK Inhibitors – Trial Data

Alectinib (2nd Gen)

ALEX Trial:

Median PFS: 34.8 months.

CNS ORR: 81–94%.

HR: 0.47.

J-ALEX: HR for PFS: 0.37.

ALESIA: HR for PFS : 0.22.

Key Side Effects: Nausea, ALT/AST elevation, constipation, anemia, myalgia.

Brigatinib (2nd Gen)

ALTA-1L:

Median PFS: 24 months.

CNS ORR: 78%.

HR: 0.49.

Key Side Effects: Pulmonary toxicity, nausea, ALT/AST elevation, myalgia, hypertension.

Lorlatinib (3rd Gen)

CROWN Trial:

Median PFS: >5 years (landmark in thoracic oncology).

CNS ORR: 83%.

HR: 0.28.

Key Side Effects: Cognitive changes, hyperlipidemia, edema.

Ensartinib (2nd Gen)

eXalt3 Trial:

Median PFS: 25.8 months.

CNS ORR: 64%.

HR: 0.51.

Key Side Effects: Rash, ALT/AST elevation, elevated creatinine.

Crizotinib (1st Gen)

PROFILE 1014:

Median PFS: 10.9 months.

Poor CNS efficacy with high progression rates.

Note: No OS benefit ( although attributable to crossover) ; no longer used in first-line therapy.

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📊 Subsequent-Line Therapy

Ceritinib (2nd Gen)

ASCEND-4 Trial:

Median PFS: 16.6 months.

CNS ORR: 73%.

Key Side Effects: GI toxicity, ALT/AST elevation.

Lorlatinib (Post-Progression)

B7461001 Trial:

ORR: 47%.

Median PFS: 6.9 months in ALK resistance mutations.

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💊 Sequencing Treatment Options

First-Line Alectinib or Brigatinib

Progression:

→ Lorlatinib.

→ Chemo ± Immunotherapy.

First-Line Crizotinib

Progression:

→ 2nd Gen Inhibitors (Alectinib or Brigatinib).

→ Lorlatinib.

→ Chemo ± Immunotherapy.

Post-Chemotherapy

1st: Alectinib or Brigatinib.

2nd: Lorlatinib for progression.

3rd: Chemo ± Immunotherapy (IMpower 130/150).

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📋 Resistance Mutations and Drug Efficacy

Mutations: G1202R, L1196M, I1171T.

Efficacy:

Lorlatinib: Effective for G1202R.

Brigatinib: Active against some resistance mutations.

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🧠 Management of Brain Metastases

Asymptomatic Brain Mets

CNS-penetrating TKIs: Lorlatinib, Alectinib, Brigatinib.

Symptomatic Brain Mets

Steroids ± Radiotherapy (whole brain or stereotactic), followed by CNS-penetrating ALK inhibitors.

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Investigational Therapies

NVL-655: Investigational 4th-gen ALK inhibitor with activity in resistance mutations (e.g., G1202R) and minimal neurological toxicity.

[Anuj kc @dranujkc_onco]

Teaching &amp; Learning at BPKIHS, Dharan

[Dr.Dhruv Chauhan @DrDhruvchauhan]

Let’s understand what’s absolutely wrong in this post :

• Navjyot kaur (who is herself a gynaecologist) was undergoing Chemotherapy for a 2nd stage invasive cancer .

• On 10th august @sherryontopp posted pictures of her undergoing 5th chemo and her treatment in a modern medicine hospital .

• She was being managed for supportive as well as pain palliative in a modern medicine hospital .

All the major treatment she received was of the evidence based medicine by a team of oncologists and Onco surgeons but then why are claims like “Defeated due to Ayurveda” are coming ?

Nobody has problem with Ayurveda , but being thankless to the actual treatment and showing how a supportive diet treatment is the reason behind the cure of a possible lethal disease is what makes me surprised and curious!

[Anuj kc @dranujkc_onco]

New paper Alert!
Low dose olanzapine efficacious and cheaper than expensive antiemetics..