Chief Complaint
Initial medical oncology consultation for newly diagnosed stage IVB lung adenocarcinoma with an EGFR exon 19 deletion.

History of Present Illness
Addison Aoki is a 61-year-old never-smoking female with newly diagnosed stage IVB lung adenocarcinoma with an EGFR exon 19 deletion who presents for initial medical oncology consultation and treatment planning.

She reports three months of dry cough and mid-back pain, now 5/10, worse at night and partly relieved by ibuprofen. She has lost 3 kg since June. She denies headaches, vision changes, weakness, or shortness of breath at rest. She did not return for nodule follow-up after 2023 while caring for her mother. She states, "I keep thinking about the scan I skipped, and I want to know what my options are now."

Past Medical History

• Stage IVB adenocarcinoma of the right upper lobe, EGFR exon 19 deletion, with brain and bone metastases
• Hypertension
• Nephrolithiasis

03/2021: CT for a kidney stone incidentally showed an 8 mm part-solid right upper lobe nodule with a 3 mm solid component. Follow-up chest CT recommended.

03/2022: Nodule increased to 10 mm with a 4 mm solid component. Continued surveillance recommended.

04/2023: Nodule increased to 12 mm with a 6 mm solid component. PET/CT and biopsy were recommended but not completed.

06/2026: Onset of dry cough and mid-back pain.

08/2026: Imaging showed a right upper lobe mass with mediastinal, bone, and brain metastases. EBUS biopsy confirmed adenocarcinoma with an EGFR exon 19 deletion.

Past Surgical History

• EBUS-guided transbronchial needle aspiration, stations 4R and 7 (08/2026)
• Ureteroscopy with laser lithotripsy, left (2021)
• Laparoscopic cholecystectomy (2015)

Past Imaging
CT Chest With Contrast (08/04/2026):

• 3.8 cm spiculated right upper lobe mass at the site of the previously followed nodule
• Enlarged right paratracheal lymph node, 2.1 cm, and subcarinal lymph node, 1.6 cm
• Lytic lesion of the T8 vertebral body

PET/CT Skull Base to Mid-Thigh (08/11/2026):

• FDG-avid right upper lobe mass, SUVmax 11.2
• FDG-avid right paratracheal (SUVmax 7.8) and subcarinal (SUVmax 6.4) lymph nodes, consistent with ipsilateral mediastinal involvement
• FDG-avid T8 vertebral body (SUVmax 8.1) and left iliac bone (SUVmax 6.3) lesions
• No adrenal, hepatic, or contralateral lung involvement

MRI Brain With and Without Contrast (08/13/2026):

• Two enhancing lesions: 6 mm in the left frontal lobe and 4 mm in the right cerebellar hemisphere
• No surrounding edema, mass effect, or hemorrhage

MRI Thoracic Spine With and Without Contrast (08/13/2026):

• Metastatic lesion involving the T8 vertebral body without epidural extension, cord compression, or pathologic fracture

CT Chest Without Contrast (04/2023):

• 12 mm part-solid right upper lobe nodule with a 6 mm solid component, increased from 10 mm in 03/2022

CT Abdomen and Pelvis Without Contrast (03/2021):

• 5 mm left distal ureteral stone
• Incidental 8 mm part-solid right upper lobe nodule with a 3 mm solid component

Past Labs
Pathology, EBUS-TBNA, Stations 4R and 7 (08/18/2026):

• Adenocarcinoma, TTF-1 positive, napsin A positive, consistent with lung primary
• PD-L1 22C3 tumor proportion score 30%

Tissue Next-Generation Sequencing (08/26/2026):

• EGFR exon 19 deletion (E746_A750del)
• TP53 R273H co-mutation
• No alterations in ALK, ROS1, BRAF, KRAS, MET exon 14, RET, NTRK, HER2, or NRG1
• Tumor mutational burden 3 mutations/Mb

Plasma Circulating Tumor DNA (08/20/2026):

• EGFR exon 19 deletion, variant allele frequency 4.6%

Complete Blood Count (09/02/2026):

• WBC: 7.2 x 10^3/μL
• Hemoglobin: 12.8 g/dL
• Platelets: 310 x 10^3/μL

Comprehensive Metabolic Panel (09/02/2026):

• Creatinine: 0.78 mg/dL
• Calcium: 9.6 mg/dL
• Alkaline phosphatase: 142 U/L (high)
• AST: 24 U/L
• ALT: 21 U/L
• Albumin: 3.9 g/dL

Tumor Markers (09/02/2026):

• CEA: 18.4 ng/mL (high)

Cardiac Baseline (09/2026):

• EKG: Normal sinus rhythm, QTc 428 ms
• Echocardiogram: LVEF 62%

Family History

• Mother with Alzheimer's dementia
• Father with COPD, a long-term smoker
• No family history of lung cancer

Social History
Married and lives with her husband. Works full time as a dental hygienist. Never smoker. Childhood secondhand smoke exposure from her father. Her home has never been tested for radon. Drinks alcohol rarely. Cared for her mother at home from 2023 until her move to memory care in 2025. Two adult sons live nearby.

Current Medications
Amlodipine 5 mg daily
Ibuprofen 400 mg as needed for back pain, about twice daily
Calcium carbonate 600 mg daily

Allergies
Iodinated contrast: Hives, tolerates with premedication

Review of Systems
General: Weight loss of 3 kg since June 2026. Mild fatigue. No fevers or night sweats.
Skin: No rash.
Eyes: No vision changes.
HENT: No hoarseness.
Respiratory: Dry cough for three months. Mild exertional dyspnea. No hemoptysis.
Cardiovascular: No chest pain or palpitations.
GI: No nausea or abdominal pain.
Neurological: No headaches, weakness, numbness, or balance problems.
Musculoskeletal: Mid-back pain 5/10, worse at night. Mild left hip ache.
Psychiatric: Anxiety and guilt related to the missed follow-up.

Physical Exam
General: Well-appearing female in no acute distress.
Vital signs:
BP: 134/80 mmHg
HR: 78 bpm
Temperature: 98.1°F
SpO2: 96% on room air
Weight: 61 kg
Skin: No rash or clubbing.
Eyes: Pupils equal and reactive. No papilledema on fundoscopic exam.
HENT: Oropharynx clear.
Lymph Nodes: No cervical or supraclavicular lymphadenopathy.
Respiratory: Mildly decreased breath sounds at the right apex. No wheezes or crackles.
Cardiovascular: Regular rate and rhythm without murmurs.
GI: Soft, non-tender. No hepatomegaly.
Musculoskeletal: Point tenderness over the T8 spinous process. Full range of motion of the left hip with mild discomfort.
Neurological: Cranial nerves intact. Strength 5/5 throughout. Normal coordination and gait. No sensory level.
Psychiatric: Anxious but engaged, with appropriate affect.

Assessment and Plan
1. Stage IVB Adenocarcinoma of the Right Upper Lobe, EGFR Exon 19 Deletion (cT2a cN2 M1c)
I reviewed her imaging, pathology, and molecular results. The primary tumor measures 3.8 cm with ipsilateral mediastinal nodal involvement and metastases to bone and brain. Tissue and plasma testing both confirm an EGFR exon 19 deletion, which makes targeted therapy the foundation of treatment. I explained that immunotherapy is not recommended despite a PD-L1 of 30% because it is less effective and carries a higher toxicity risk in EGFR-mutated disease.

I presented three first-line options:

• Osimertinib alone: A daily oral pill with strong brain penetration and mild side effects, including diarrhea, rash, and nail changes.
• Osimertinib with pemetrexed and carboplatin: Longer progression-free survival than osimertinib alone, with greater benefit in patients with brain metastases and TP53 co-mutations, at the cost of chemotherapy side effects for the first four cycles.
• Amivantamab with lazertinib: Longer progression-free survival than osimertinib alone, with higher rates of rash, swelling, and infusion reactions, and a need for preventive anticoagulation.

Given her brain metastases, TP53 co-mutation, and high disease burden, I recommended osimertinib with pemetrexed and carboplatin. She chose this option after discussion with her husband.

• Start osimertinib 80 mg daily with pemetrexed 500 mg/m² and carboplatin AUC 5 every 21 days for 4 cycles, followed by maintenance osimertinib with pemetrexed
• Start folic acid 1 mg daily now and give vitamin B12 1000 mcg intramuscularly at least 7 days before the first pemetrexed dose
• Place port before cycle 1
• Chemotherapy teaching visit with oncology nursing
• Target treatment start within 2 weeks

2. Brain Metastases, Asymptomatic
Two small lesions measuring 6 mm and 4 mm are present without edema or symptoms. Osimertinib has high response rates in the brain, which supports close MRI monitoring before radiation in this setting.

• Refer to radiation oncology to review stereotactic radiosurgery and agree on a monitoring plan
• MRI brain 6 to 8 weeks after starting treatment
• Reviewed seizure precautions and driving considerations

3. Bone Metastases at T8 and Left Iliac Bone with Pain
T8 is the main source of her back pain, with no epidural extension or fracture on MRI. Alkaline phosphatase is mildly elevated, and calcium is normal.

• Refer to radiation oncology for palliative radiation to T8, single fraction of 8 Gy
• Dental evaluation, then start denosumab 120 mg subcutaneous every 4 weeks
• Continue calcium and add vitamin D3 2000 IU daily

4. Cancer-Related Pain
Back pain is 5/10 and worse at night despite ibuprofen twice daily.

• Change to scheduled acetaminophen 1000 mg three times daily
• Stop ibuprofen before carboplatin to protect kidney function
• Oxycodone 5 mg every 6 hours as needed for pain at night
• Senna 8.6 mg, 2 tablets nightly while using oxycodone

5. Weight Loss
She has lost 3 kg since June.

• Refer to oncology dietitian
• Weekly weights during chemotherapy

6. Psychosocial Support and Advance Care Planning
She expressed guilt about missing nodule follow-up while caring for her mother. I reassured her that her focus now is on treatment, which offers meaningful disease control. Her husband will be her health care proxy. She is full code.

• Refer to oncology social work and psycho-oncology
• Complete health care proxy documentation at the next visit
• Recommend radon testing of her home

7. Hypertension
Blood pressure is 134/80 mmHg.

• Continue amlodipine 5 mg daily

Ordered

Medications:
Osimertinib 80 mg daily
Folic acid 1 mg daily
Vitamin B12 1000 mcg intramuscularly
Acetaminophen 1000 mg three times daily
Oxycodone 5 mg every 6 hours as needed
Senna 8.6 mg, 2 tablets nightly
Vitamin D3 2000 IU daily
Discontinue ibuprofen

Labs:
CBC with differential and CMP before cycle 1
Hepatitis B surface antigen and core antibody before chemotherapy

Imaging:
MRI brain 6 to 8 weeks after treatment start
Restaging CT chest, abdomen, and pelvis after cycle 2

Procedures:
Port placement
Dental evaluation before denosumab

Referrals:
Radiation oncology for brain metastases review and palliative radiation to T8
Oncology dietitian
Oncology social work and psycho-oncology
Chemotherapy teaching with oncology nursing

Procedures Today:
Vitamin B12 1000 mcg intramuscular injection

ECOG Performance Status (Beta)
ECOG Score 1: The patient continues to work full time with some limitation from back pain and fatigue. She is fully ambulatory, independent in self-care, and restricted only in physically strenuous activity.

Karnofsky Performance Status (Beta)
Karnofsky Score 80: The patient carries on normal activity with effort and has some symptoms of disease, including cough, back pain, and weight loss. She requires no assistance with personal care.

Recommendations as per NCCN Guidelines
For Stage IV Non-Small Cell Lung Cancer with EGFR Exon 19 Deletion:

1. Biomarker Testing:

• Broad molecular profiling, including EGFR, ALK, ROS1, BRAF, KRAS, MET, RET, NTRK, HER2, and NRG1, should be completed before first-line therapy, using tissue and plasma testing together when possible.
• PD-L1 testing should be performed, although immune checkpoint inhibitors are not recommended as first-line therapy for EGFR-mutated disease.

2. First-Line Systemic Therapy:

• Osimertinib alone, osimertinib with pemetrexed and platinum chemotherapy, and amivantamab with lazertinib are all preferred first-line options.

3. Brain Metastases:

• Brain MRI is recommended at diagnosis for stage IV disease.
• For small, asymptomatic brain metastases, CNS-active EGFR therapy with close MRI monitoring may be considered, with stereotactic radiosurgery for growing or symptomatic lesions.

4. Bone Metastases:

• Bone-modifying agents such as denosumab or zoledronic acid are recommended, along with palliative radiation for painful lesions.

5. Monitoring:

• Imaging every 6 to 12 weeks during initial therapy.
• At progression, repeat tissue or plasma testing is recommended to identify resistance mechanisms such as MET amplification or EGFR C797S.

6. Supportive Care:

• Early palliative care and psychosocial support should be offered to all patients with stage IV disease.

‍

Chief Complaint
Weekly on-treatment visit during definitive radiation therapy for unfavorable intermediate-risk prostate cancer, with urinary frequency and loose stools.

History of Present Illness
David Walker is a 68-year-old male with unfavorable intermediate-risk adenocarcinoma of the prostate, Grade Group 3, who presents for his weekly on-treatment visit after fraction 18 of 28 of definitive radiation therapy with concurrent androgen deprivation therapy.

He reports urinating every two hours during the day and three times at night, with a weaker stream since week three. He has three loose stools daily with mild urgency but no bleeding. Hot flashes occur four to five times daily. He denies dysuria, hematuria, fever, or rectal pain. He states, "The bathroom trips are annoying, but I'm still golfing on my off days."

Past Medical History

• Adenocarcinoma of the prostate, Grade Group 3, unfavorable intermediate risk
• Hypertension
• Type 2 diabetes mellitus
• Hyperlipidemia
• Osteopenia
• Erectile dysfunction
• Mild lower urinary tract symptoms at baseline

2019: Screening PSA 4.8 ng/mL. MRI showed a PI-RADS 3 lesion. 12-core biopsy found Grade Group 1 (Gleason 3+3) adenocarcinoma in 2 of 12 cores, each under 10%. Low risk, cT1c. Enrolled in active surveillance.

2021: PSA 5.6 ng/mL. MRI stable. Confirmatory biopsy found Grade Group 1 in 1 of 12 cores. Continued active surveillance.

2023: PSA 6.4 ng/mL with PSA density of 0.14 ng/mL/cc. MRI stable.

03/2026: PSA rose to 9.2 ng/mL. MRI showed a new PI-RADS 4 lesion.

05/2026: MRI fusion biopsy upgraded disease to Grade Group 3. Germline testing negative.

06/2026: PSMA PET showed disease confined to the prostate. After consultation with urology and radiation oncology, he chose radiation therapy with 6 months of androgen deprivation therapy over radical prostatectomy.

07/2026: Leuprolide started.

08/2026: Fiducial markers and rectal hydrogel spacer placed. CT simulation completed.

09/08/2026: Radiation therapy started.

Past Surgical History

• Transperineal fiducial marker and hydrogel spacer placement (08/2026)
• MRI fusion prostate biopsy (05/2026)
• Transrectal prostate biopsies (2019 and 2021)
• Left knee arthroscopy (2014)

Past Imaging
CT Simulation (08/24/2026):

• Three gold fiducial markers in good position within the prostate
• Hydrogel spacer creating 11 mm of separation between the prostate and anterior rectal wall
• Prostate volume 42 cc

PSMA PET/CT (06/15/2026):

• Focal PSMA uptake in the left posterior peripheral zone, SUVmax 9.4
• No PSMA-avid pelvic or retroperitoneal lymph nodes
• No osseous or visceral metastases

MRI Prostate With and Without Contrast (04/10/2026):

• 1.4 cm PI-RADS 4 lesion in the left posterior peripheral zone at the mid-gland
• No extraprostatic extension or seminal vesicle invasion
• No pelvic lymphadenopathy
• Prostate volume 42 cc

DEXA (07/2026):

• Lumbar spine T-score -1.4. Left femoral neck T-score -1.6

MRI Prostate (2019, 2021, 2023):

• PI-RADS 3 lesion in the right transition zone, stable across all three studies

Past Labs
PSA Trend:

• 4.8 ng/mL (2019)
• 5.6 ng/mL (2021)
• 6.4 ng/mL (2023)
• 9.2 ng/mL (03/2026)
• 2.4 ng/mL (09/2026, on androgen deprivation therapy)

Pathology, MRI Fusion Biopsy (05/12/2026):

• Targeted cores, left posterior peripheral zone: Adenocarcinoma, Grade Group 3 (Gleason 4+3=7) in 3 of 4 cores, involving up to 60% of core length, with 60% pattern 4
• Systematic cores: Grade Group 2 (Gleason 3+4=7) in 2 of 12 cores, left side
• Perineural invasion present
• No cribriform pattern or intraductal carcinoma

Decipher Genomic Classifier (06/2026):

• Score 0.62, intermediate risk

Germline Genetic Testing (05/2026):

• Multigene panel negative for pathogenic variants, including BRCA1, BRCA2, ATM, and mismatch repair genes

Testosterone:

• 412 ng/dL at baseline (06/2026)
• 22 ng/dL on leuprolide (09/2026), at castrate level

Complete Blood Count (09/29/2026):

• WBC: 5.9 x 10^3/μL
• Hemoglobin: 13.6 g/dL
• Platelets: 214 x 10^3/μL

Metabolic Labs (09/2026):

• HbA1c: 7.1% (high), up from 6.7% before androgen deprivation therapy
• LDL: 92 mg/dL
• Creatinine: 1.0 mg/dL

Urinalysis (09/29/2026):

• Negative for leukocyte esterase, nitrites, and blood

Family History

• Father with prostate cancer at age 74
• Brother with prostate cancer at age 65
• Mother with type 2 diabetes mellitus

Social History
Married and lives with his wife. Retired civil engineer. Former smoker with a 10 pack-year history, quit in 1990. Drinks two beers per week. Drives himself to daily radiation treatments. Plays golf twice weekly.

Current Medications
Leuprolide 22.5 mg intramuscularly every 3 months (started 07/08/2026)
Tamsulosin 0.4 mg nightly (started 09/22/2026)
Metformin 1000 mg twice daily
Lisinopril 20 mg daily
Atorvastatin 40 mg nightly
Calcium carbonate 600 mg with vitamin D3 800 IU twice daily
Loperamide 2 mg as needed for loose stools

Allergies
No known drug allergies

Review of Systems
General: Mild fatigue in the afternoons. Weight stable.
Skin: No skin irritation in the treatment area.
Cardiovascular: No chest pain or leg swelling.
Respiratory: No shortness of breath.
GI: Three loose stools daily with mild urgency. No rectal bleeding or pain.
GU: Daytime frequency every two hours. Nocturia three times. Weaker stream. No dysuria, hematuria, or retention.
Endocrine: Hot flashes four to five times daily.
Musculoskeletal: No bone pain.
Psychiatric: Mood stable. Some frustration with sleep interruptions.

Physical Exam
General: Well-appearing male in no distress.
Vital signs:
BP: 136/82 mmHg
HR: 74 bpm
Temperature: 98.0°F
SpO2: 98% on room air
Weight: 88 kg (88 kg at simulation)
Skin: Perineal and gluteal skin intact without erythema.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm.
GI: Soft, non-tender, non-distended. Normal bowel sounds.
GU: No suprapubic tenderness or bladder distension.
Extremities: No edema.
Psychiatric: Alert and engaged with appropriate mood.

Assessment and Plan
1. Unfavorable Intermediate-Risk Adenocarcinoma of the Prostate (cT2a N0 M0, Grade Group 3, PSA 9.2 ng/mL) on Definitive Radiation Therapy
I reviewed his daily cone-beam CT images and radiation therapist setup notes. Fiducial alignment has been reproducible, with daily shifts under 3 mm, and the hydrogel spacer remains in position. He has received 45 Gy of the planned 70 Gy with no treatment breaks. PSA has fallen to 2.4 ng/mL and testosterone is at castrate level on leuprolide. Disease was upgraded from Grade Group 1 on active surveillance to Grade Group 3, with perineural invasion and a Decipher score of 0.62, and PSMA PET confirms localized disease.

Technique: Intensity-modulated radiation therapy with daily image guidance
Target: Prostate and proximal seminal vesicles
Prescribed Dose: 70 Gy in 28 fractions of 2.5 Gy
Cumulative Dose Today: 45 Gy, fraction 18 of 28
Image Guidance: Daily cone-beam CT with fiducial marker matching
Planned Completion: 10/16/2026

• Continue radiation therapy without interruption
• Continue full-bladder and empty-rectum preparation before each fraction
• Leuprolide 22.5 mg due on 10/08/2026 to complete 6 months of androgen deprivation therapy through 01/2027

2. Genitourinary Toxicity, CTCAE Grade 1
Frequency, nocturia, and weaker stream are consistent with expected radiation cystitis and urethritis. IPSS has increased from 8 at baseline to 14. Urinalysis is negative for infection.

• Continue tamsulosin 0.4 mg nightly
• Limit fluids after 6 PM and avoid caffeine and alcohol in the evening
• Repeat urinalysis if dysuria or fever develops

3. Gastrointestinal Toxicity, CTCAE Grade 1
Three loose stools daily with mild urgency and no bleeding, consistent with radiation proctitis.

• Low-residue diet with soluble fiber during treatment
• Loperamide 2 mg after each loose stool, up to 8 mg daily
• Report rectal bleeding or more than six stools daily

4. Androgen Deprivation Therapy Side Effects
Hot flashes are frequent but tolerable, and fatigue is mild. HbA1c has risen from 6.7% to 7.1%, and DEXA shows osteopenia.

• Discussed venlafaxine for hot flashes. He prefers to wait and reassess after radiation
• Encourage daily walking and strength training to offset fatigue and muscle loss
• Continue calcium and vitamin D supplementation
• Letter sent to primary care regarding HbA1c rise and cardiometabolic monitoring on androgen deprivation therapy
• Repeat DEXA in 07/2027

5. Erectile Dysfunction
Baseline SHIM score was 17, with further decline expected on androgen deprivation therapy and after radiation.

• Discussed penile rehabilitation with a PDE5 inhibitor after radiation is complete

Ordered

Medications:
Leuprolide 22.5 mg intramuscularly on 10/08/2026
Continue tamsulosin 0.4 mg nightly
Loperamide 2 mg as needed

Labs:
PSA and testosterone 6 to 8 weeks after completing radiation

Imaging:
DEXA in 07/2027

Procedures:
Weekly on-treatment visits through 10/16/2026

Referrals:
Letter to primary care regarding cardiometabolic monitoring on androgen deprivation therapy

Procedures Today:
Weekly on-treatment management
Review of daily cone-beam CT image guidance
Radiation fraction 18 of 28 delivered

ECOG Performance Status (Beta)
ECOG Score 0: The patient remains fully active, drives himself to daily treatment, and continues to golf twice weekly, with only mild afternoon fatigue that does not restrict his activities.

Karnofsky Performance Status (Beta)
Karnofsky Score 90: The patient carries on normal activity with minor symptoms of treatment, including urinary frequency, loose stools, hot flashes, and mild fatigue. He requires no assistance.

Recommendations as per NCCN Guidelines
For Unfavorable Intermediate-Risk Prostate Cancer:

1. Primary Treatment Options:

• External beam radiation therapy with 4 to 6 months of androgen deprivation therapy is a standard option.
• Radical prostatectomy with pelvic lymph node dissection is an alternative for patients with life expectancy over 10 years.

2. Radiation Therapy:

• Moderate hypofractionation, such as 70 Gy in 28 fractions, is an accepted regimen.
• Daily image-guided radiation therapy is recommended, and a rectal spacer may be used to reduce rectal dose.

3. Imaging and Risk Assessment:

• PSMA PET may be used for staging in unfavorable intermediate-risk disease.
• Genomic classifiers and germline testing may help refine risk, particularly with a family history of prostate cancer.

4. Androgen Deprivation Therapy Monitoring:

• Bone health assessment with calcium, vitamin D, and DEXA is recommended.
• Patients should be monitored for diabetes, dyslipidemia, and cardiovascular risk during therapy.

5. Follow-up:

• PSA every 6 to 12 months for 5 years, then annually, with a digital rectal exam annually.
• Biochemical recurrence after radiation is defined as a PSA rise of 2 ng/mL or more above the nadir.

‍

Chief Complaint
Medical oncology consultation for adjuvant chemotherapy six weeks after laparoscopic sigmoid colectomy for stage IIIB colon adenocarcinoma.

History of Present Illness
Pete Gibson is a 58-year-old male with stage IIIB adenocarcinoma of the sigmoid colon who presents six weeks after laparoscopic sigmoid colectomy for medical oncology consultation on adjuvant chemotherapy.

He has recovered well, with two to three formed bowel movements daily and no abdominal pain. His energy has improved since an iron infusion in August. He denies numbness or tingling in his hands or feet, fever, or rectal bleeding. He plays guitar in a weekend band and is worried about nerve damage. He states, "I want the best chance at a cure, but my hands are how I relax."

Past Medical History

• Adenocarcinoma of the sigmoid colon, pT3 pN1b M0, stage IIIB
• Iron deficiency anemia, improving
• Type 2 diabetes mellitus
• Hypertension
• Obesity, class I
• History of tubular adenomas of the colon

2018: Screening colonoscopy with removal of two tubular adenomas under 10 mm. Repeat colonoscopy recommended in 5 years.

2023: Surveillance colonoscopy postponed.

05/2026: Fatigue, looser stools, and intermittent blood in the stool. Hemoglobin 9.8 g/dL and ferritin 8 ng/mL, consistent with iron deficiency anemia.

06/2026: Colonoscopy found a partially obstructing mass in the sigmoid colon. Biopsy confirmed adenocarcinoma. Staging CT showed no distant metastases.

07/14/2026: Laparoscopic sigmoid colectomy with primary anastomosis. Discharged on postoperative day 3 without complications.

08/2026: Ferric carboxymaltose 750 mg IV given twice for iron deficiency. Case reviewed at multidisciplinary tumor board on 08/19/2026, with a recommendation for oxaliplatin-based adjuvant chemotherapy.

Past Surgical History

• Laparoscopic sigmoid colectomy with primary anastomosis (07/14/2026)
• Colonoscopy with biopsy and tattoo (06/2026)
• Colonoscopy with polypectomy (2018)
• Right shoulder arthroscopy (2012)

Past Imaging
CT Chest, Abdomen, and Pelvis With Contrast (06/18/2026):

• 5 cm segment of circumferential wall thickening in the sigmoid colon
• Two pericolic lymph nodes measuring up to 9 mm, suspicious for nodal involvement
• No hepatic, pulmonary, or peritoneal metastases

Colonoscopy (06/10/2026):

• Circumferential, friable, partially obstructing mass in the sigmoid colon 30 cm from the anal verge
• Area tattooed distal to the lesion
• No synchronous lesions in the remaining colon

Colonoscopy (2018):

• Two tubular adenomas, 6 mm and 8 mm, in the descending colon, removed completely

Past Labs
Surgical Pathology, Sigmoid Colectomy (07/20/2026):

• Adenocarcinoma, moderately differentiated, 4.5 cm
• Invades through the muscularis propria into pericolorectal tissue (pT3)
• 3 of 18 regional lymph nodes positive (pN1b)
• Lymphovascular invasion present. Perineural invasion absent
• No tumor deposits. Low tumor budding
• Proximal, distal, and radial margins negative, with a distal margin of 6 cm
• AJCC stage IIIB (pT3 pN1b M0)

Mismatch Repair and Molecular Testing (07/2026):

• MLH1, MSH2, MSH6, and PMS2 expression retained, mismatch repair proficient
• Microsatellite stable
• KRAS G12D mutation
• NRAS and BRAF V600E wild-type
• HER2 not amplified

Circulating Tumor DNA, Tumor-Informed Assay (08/12/2026):

• Detected at 0.18 mean tumor molecules/mL, four weeks after surgery

DPYD Genotyping (08/2026):

• No variants detected, normal DPD activity expected

CEA Trend:

• 8.6 ng/mL (06/2026, before surgery)
• 2.1 ng/mL (08/2026, after surgery)

Complete Blood Count:

• Hemoglobin: 9.8 g/dL (05/2026), 10.4 g/dL (07/2026), 11.9 g/dL (08/22/2026) (low)
• WBC: 6.8 x 10^3/μL (08/22/2026)
• Platelets: 268 x 10^3/μL (08/22/2026)

Iron Studies (08/22/2026):

• Ferritin: 210 ng/mL
• Transferrin saturation: 24%

Comprehensive Metabolic Panel (08/22/2026):

• Creatinine: 0.92 mg/dL, estimated creatinine clearance 118 mL/min
• AST: 26 U/L
• ALT: 30 U/L
• Total bilirubin: 0.6 mg/dL

HbA1c (08/2026):

• 7.4% (high)

Family History

• Father with colon cancer at age 66
• Brother with colon polyps at age 52
• Mother with type 2 diabetes mellitus
• No family history of endometrial, ovarian, or gastric cancer

Social History
Married and lives with his wife. Works full time as a regional insurance claims manager, mostly at a desk. Plays rhythm guitar in a weekend cover band. Former smoker with a 12 pack-year history, quit in 2005. Drinks two to three beers on weekends. Walks 30 minutes most days since surgery.

Current Medications
Metformin 1000 mg twice daily
Lisinopril 20 mg daily
Atorvastatin 20 mg nightly
Acetaminophen 500 mg as needed

Allergies
Codeine: Nausea

Review of Systems
General: Energy improving. Weight down 3 kg since surgery. No fevers or night sweats.
Skin: Incisions healed. No rash.
Eyes: No vision changes.
HENT: No mouth sores.
Respiratory: No cough or shortness of breath.
Cardiovascular: No chest pain or palpitations.
GI: Two to three formed stools daily. No abdominal pain, bloating, or blood in the stool.
Neurological: No numbness, tingling, or weakness in the hands or feet.
Musculoskeletal: No joint pain.
Psychiatric: Anxious about treatment side effects, especially nerve damage.

Physical Exam
General: Well-appearing male in no acute distress.
Vital signs:
BP: 132/80 mmHg
HR: 76 bpm
Temperature: 98.2°F
SpO2: 98% on room air
Height: 178 cm
Weight: 98 kg
BSA: 2.20 m²
Skin: Laparoscopic port sites and extraction incision well healed without erythema or hernia.
Eyes: Sclerae anicteric. Conjunctivae pink.
HENT: Oral mucosa moist and intact.
Lymph Nodes: No cervical, supraclavicular, or inguinal lymphadenopathy.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without murmurs.
GI: Soft, non-tender, non-distended. No hepatomegaly or masses.
Neurological: Monofilament, vibration, and proprioception intact in hands and feet. Reflexes 2+ and symmetric. Baseline documented before oxaliplatin.
Psychiatric: Alert, engaged, with appropriate mood and affect.

Assessment and Plan
1. Adenocarcinoma of the Sigmoid Colon, pT3 pN1b M0, Stage IIIB, Mismatch Repair Proficient
I reviewed his surgical pathology, operative report, and the tumor board recommendation. He has a completely resected 4.5 cm pT3 tumor with 3 of 18 nodes involved, negative margins, and lymphovascular invasion. CEA normalized after surgery. Adjuvant oxaliplatin-based chemotherapy is recommended for stage III disease. He falls into the low-risk stage III group (T1 to T3 and N1), where 3 months of CAPOX offers similar disease-free survival to 6 months with much less nerve damage.

I discussed that his postoperative ctDNA was detected, which signals higher recurrence risk, but that current guidelines do not support using ctDNA alone to change treatment duration. I presented two options:

• CAPOX for 3 months (4 cycles): Preferred for low-risk stage III disease, with a lower risk of lasting neuropathy.
• CAPOX for 6 months (8 cycles): Small potential benefit in higher-risk disease, with roughly three times the rate of lasting neuropathy.

Given his low-risk stage, normal DPYD genotype, and the importance of hand function to him, he chose 3 months of CAPOX.

• Start CAPOX within the next 2 weeks, within 8 weeks of surgery
• Oxaliplatin 130 mg/m² (286 mg) IV on day 1 every 21 days for 4 cycles
• Capecitabine 1000 mg/m² (2,150 mg) orally twice daily on days 1 to 14 every 21 days
• Peripheral IV access is adequate for 4 cycles, so no port is planned
• Chemotherapy teaching visit with oncology nursing

2. Postoperative ctDNA Detected
ctDNA was detected four weeks after surgery, which is associated with a higher risk of recurrence.

• Repeat ctDNA after completing chemotherapy and every 3 months during the first 2 years of surveillance
• Surveillance CT at any rise in ctDNA or CEA

3. Neuropathy Risk with Oxaliplatin
Baseline neurological exam is normal. He plays guitar and is concerned about lasting nerve damage.

• Counsel on avoiding cold drinks, cold foods, and cold air for 5 days after each oxaliplatin dose
• Assess for neuropathy at every visit and reduce or stop oxaliplatin if grade 2 symptoms persist between cycles

4. Iron Deficiency Anemia, Improving
Hemoglobin has risen from 9.8 to 11.9 g/dL after surgery and IV iron, with ferritin now 210 ng/mL.

• Monitor CBC each cycle
• No further iron needed at this time

5. Type 2 Diabetes Mellitus
HbA1c is 7.4%. Dexamethasone given with chemotherapy may raise blood sugar for 1 to 2 days.

• Continue metformin
• Check fingerstick glucose twice daily for 3 days after each infusion
• Coordinate with primary care if glucose exceeds 250 mg/dL

6. Hereditary Cancer Risk
His father had colon cancer at 66 and his brother had polyps at 52. Tumor testing shows proficient mismatch repair, making Lynch syndrome less likely, but other hereditary syndromes are possible.

• Refer to genetic counseling for germline multigene panel testing
• Recommend his brother and children follow early screening guidance based on family history

7. Chemotherapy Administration Planning

• Premedications for each oxaliplatin dose: palonosetron 0.25 mg IV and dexamethasone 12 mg IV
• Ondansetron 8 mg orally every 8 hours as needed at home
• Urea 10% cream twice daily to hands and feet to reduce hand-foot syndrome
• Loperamide as needed for diarrhea

Ordered

Medications:
Oxaliplatin 286 mg IV day 1 every 21 days for 4 cycles
Capecitabine 2,150 mg orally twice daily days 1 to 14 every 21 days
Palonosetron 0.25 mg IV with each oxaliplatin dose
Dexamethasone 12 mg IV with each oxaliplatin dose
Ondansetron 8 mg orally every 8 hours as needed
Urea 10% cream twice daily
Loperamide 2 mg as needed

Labs:
CBC with differential and CMP before each cycle
CEA every 3 months
Circulating tumor DNA after completing chemotherapy

Imaging:
CT chest, abdomen, and pelvis after completing chemotherapy, then every 6 to 12 months for 5 years

Procedures:
Surveillance colonoscopy 1 year after surgery, in 07/2027

Referrals:
Genetic counseling for germline testing
Chemotherapy teaching with oncology nursing

Procedures Today:
Baseline neuropathy assessment before oxaliplatin

ECOG Performance Status (Beta)
ECOG Score 0: The patient has fully recovered from surgery, has returned to full-time work, walks daily, and plays guitar on weekends without any restriction in activity.

Karnofsky Performance Status (Beta)
Karnofsky Score 90: The patient carries on normal activity with only minor symptoms, including mild fatigue that is improving after iron replacement. He requires no assistance.

Recommendations as per NCCN Guidelines
For Resected Stage III Colon Cancer:

1. Adjuvant Systemic Therapy:

• CAPOX or FOLFOX is recommended for stage III disease.
• For low-risk stage III disease (T1 to T3, N1), 3 months of CAPOX is preferred, while 3 to 6 months of FOLFOX is acceptable.
• For high-risk stage III disease (T4 or N2), 6 months of therapy is preferred.

2. Biomarker Testing:

• Universal mismatch repair or microsatellite instability testing is recommended for all colon cancers.
• RAS, BRAF, and HER2 testing should be completed to inform future treatment if disease recurs.
• DPYD testing may be considered before fluoropyrimidine therapy.

3. Circulating Tumor DNA:

• ctDNA is prognostic after surgery, but there is not enough evidence to use it alone to escalate or de-escalate adjuvant therapy.

4. Surveillance:

• History, physical exam, and CEA every 3 to 6 months for 2 years, then every 6 months to complete 5 years.
• CT chest, abdomen, and pelvis every 6 to 12 months for 5 years.
• Colonoscopy 1 year after surgery, then at intervals based on findings.

5. Genetic Risk Assessment:

• Germline testing should be considered for patients with a family history of colorectal cancer in first-degree relatives.

6. Survivorship:

• Regular physical activity, healthy body weight, and limited alcohol are associated with lower recurrence risk.

‍

Chief Complaint
Nivolumab maintenance dose 5 for metastatic melanoma, with review of restaging imaging and a new itchy rash.

History of Present Illness
Chris Trohman is a 54-year-old male with BRAF V600E-mutated metastatic melanoma to the lungs, liver, and left axilla who presents for nivolumab maintenance dose 5 and review of restaging imaging.

He reports an itchy rash on his chest and back for two weeks and mild aching in his finger joints in the mornings. Energy has returned since starting hydrocortisone for pituitary inflammation in May. He denies headaches, vision changes, diarrhea, cough, or lightheadedness. He has noticed light patches of skin on his hands. He states, "I almost don't believe the scan, so I want to keep doing exactly what's working."

Past Medical History

• Metastatic melanoma, BRAF V600E-mutated, stage IV, M1c(1)
• Immune-related hypophysitis with secondary adrenal insufficiency and central hypothyroidism
• Immune-related dermatitis, grade 1
• Vitiligo associated with immunotherapy
• Hyperlipidemia

2021: Changing mole on the left upper back. Excisional biopsy showed superficial spreading melanoma, Breslow depth 1.2 mm, no ulceration, mitotic rate 2/mm². Wide local excision with 1 cm margins and sentinel lymph node biopsy, 0 of 2 nodes positive. Stage IB, pT2a N0 M0. Began dermatology surveillance every 6 months.

2023: Atypical nevus on the right thigh excised, with moderate dysplasia and clear margins.

02/2026: Cough and fatigue. Imaging showed metastases to both lungs, the liver, and a left axillary lymph node. Axillary node biopsy confirmed metastatic melanoma with a BRAF V600E mutation. LDH elevated. Brain MRI negative.

03/02/2026 to 05/04/2026: Ipilimumab 3 mg/kg with nivolumab 1 mg/kg every 3 weeks for 4 doses.

05/2026: Headache, fatigue, and low blood pressure. Diagnosed with grade 2 immune-related hypophysitis with secondary adrenal insufficiency and central hypothyroidism. Started hydrocortisone and levothyroxine.

06/08/2026: Nivolumab maintenance 480 mg every 4 weeks started after restaging showed partial response.

Past Surgical History

• Core needle biopsy, left axillary lymph node (02/2026)
• Excision of atypical nevus, right thigh (2023)
• Wide local excision with sentinel lymph node biopsy, left upper back (2021)
• Excisional biopsy, left upper back (2021)
• Appendectomy (1994)

Past Imaging
CT Chest, Abdomen, and Pelvis With Contrast (09/14/2026):

• Pulmonary nodules decreased to under 5 mm, with the largest previously 2.1 cm in the right upper lobe
• Segment 6 liver lesion decreased from 2.8 cm to 0.8 cm. Segment 2 lesion no longer visible
• Left axillary lymph node normal in size at 0.9 cm, previously 2.4 cm
• No new lesions. Near-complete response by RECIST 1.1

MRI Brain With and Without Contrast (09/14/2026):

• No intracranial metastases

CT Chest, Abdomen, and Pelvis With Contrast (06/01/2026):

• Partial response with 55% decrease in the sum of target lesion diameters

MRI Pituitary With and Without Contrast (05/20/2026):

• Diffuse enlargement of the pituitary gland with homogeneous enhancement and a thickened stalk, consistent with hypophysitis
• No compression of the optic chiasm

CT Chest, Abdomen, and Pelvis With Contrast (02/16/2026):

• Multiple bilateral pulmonary nodules, largest 2.1 cm in the right upper lobe
• Two liver lesions, 2.8 cm in segment 6 and 1.4 cm in segment 2
• Left axillary lymph node, 2.4 cm

Past Labs
Pathology, Left Axillary Lymph Node Core Biopsy (02/20/2026):

• Metastatic melanoma, positive for SOX10, Melan-A, and HMB-45
• BRAF V600E mutation detected by next-generation sequencing
• NRAS and KIT wild-type

Pathology, Primary Melanoma, Left Upper Back (2021):

• Superficial spreading melanoma, Breslow depth 1.2 mm
• No ulceration. Mitotic rate 2/mm²
• Margins negative on wide local excision
• Sentinel lymph nodes 0 of 2 positive

LDH Trend:

• 412 U/L (02/2026) (high)
• 210 U/L (06/2026)
• 198 U/L (09/28/2026)

Endocrine Labs at Diagnosis of Hypophysitis (05/18/2026):

• Morning cortisol: 2.1 mcg/dL (low)
• ACTH: 6 pg/mL (low)
• TSH: 0.3 uIU/mL (low)
• Free T4: 0.6 ng/dL (low)
• Sodium: 131 mmol/L (low)

Complete Blood Count (09/28/2026):

• WBC: 6.4 x 10^3/μL
• Hemoglobin: 14.2 g/dL
• Platelets: 236 x 10^3/μL
• Eosinophils: 6%

Comprehensive Metabolic Panel (09/28/2026):

• Sodium: 139 mmol/L
• Potassium: 4.2 mmol/L
• Glucose: 104 mg/dL
• Creatinine: 0.9 mg/dL
• AST: 28 U/L
• ALT: 34 U/L
• Total bilirubin: 0.7 mg/dL

Thyroid Function (09/28/2026):

• Free T4: 1.1 ng/dL on levothyroxine
• TSH not used for dosing given central hypothyroidism

Lipase (09/28/2026):

• 32 U/L

Family History

• Mother with basal cell carcinoma
• Father with coronary artery disease
• No family history of melanoma or pancreatic cancer

Social History
Married and lives with his wife and teenage daughter. Works as a civil construction project manager with years of outdoor sun exposure and a history of several blistering sunburns as a teenager. Returned to full-time work in 07/2026. Never smoker. Drinks one to two beers on weekends. Wears a medical alert bracelet for adrenal insufficiency.

Current Medications
Nivolumab 480 mg IV every 4 weeks
Hydrocortisone 15 mg every morning and 5 mg every afternoon
Hydrocortisone 100 mg intramuscular emergency injection kit
Levothyroxine 75 mcg daily
Atorvastatin 20 mg nightly
Broad-spectrum sunscreen SPF 50 daily

Allergies
No known drug allergies

Review of Systems
General: Energy restored since hydrocortisone. Weight stable. No fevers.
Skin: Itchy rash on the chest and back for two weeks. New light patches on the hands.
Eyes: No vision changes or eye pain.
HENT: No mouth sores or dry mouth.
Respiratory: No cough or shortness of breath.
Cardiovascular: No chest pain, palpitations, or lightheadedness.
GI: No diarrhea, abdominal pain, or blood in the stool.
Endocrine: No headaches, salt cravings, or dizziness on standing.
Musculoskeletal: Mild morning aching in the finger joints lasting about 20 minutes. No swelling.
Neurological: No weakness or numbness.
Psychiatric: Mood good. Hopeful about results.

Physical Exam
General: Well-appearing male in no acute distress.
Vital signs:
BP: 124/78 mmHg
HR: 72 bpm
Temperature: 98.1°F
SpO2: 98% on room air
Weight: 84 kg
Skin: Fine erythematous papules on the chest and upper back covering about 8% of body surface area, without blistering or mucosal involvement. Depigmented macules on the dorsal hands consistent with vitiligo. Well-healed scar on the left upper back without nodularity. Full-body skin exam without new suspicious pigmented lesions.
Eyes: No conjunctival injection. Visual fields full to confrontation.
HENT: Oral mucosa intact.
Lymph Nodes: No cervical, axillary, or inguinal lymphadenopathy.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without murmurs.
GI: Soft, non-tender. No hepatomegaly.
Musculoskeletal: No synovitis or swelling of the hand joints. Full range of motion.
Neurological: No focal deficits.
Psychiatric: Alert and engaged with appropriate mood.

Assessment and Plan
1. Metastatic Melanoma, BRAF V600E-Mutated, Stage IV, M1c(1), Near-Complete Response on Immunotherapy
I reviewed his CT from 09/14/2026, which shows a near-complete response, with lung nodules under 5 mm, the dominant liver lesion down from 2.8 cm to 0.8 cm, and resolution of the axillary node. LDH has normalized from 412 to 198 U/L and brain MRI remains clear. I discussed that his response to ipilimumab and nivolumab is excellent and that BRAF and MEK inhibitors remain available if the disease progresses.

• Proceed with nivolumab 480 mg IV today, maintenance dose 5
• Continue nivolumab every 4 weeks for up to 2 years from the start of treatment, with earlier discontinuation discussed if complete response is confirmed and sustained
• Restaging CT chest, abdomen, and pelvis and MRI brain every 3 months

2. Immune-Related Hypophysitis with Secondary Adrenal Insufficiency and Central Hypothyroidism
His adrenal insufficiency is controlled on hydrocortisone, with normal sodium and no lightheadedness. Free T4 is at goal on levothyroxine. Pituitary recovery after hypophysitis is uncommon, so replacement is likely lifelong.

• Continue hydrocortisone 15 mg every morning and 5 mg every afternoon
• Continue levothyroxine 75 mcg daily, dosed by free T4
• Reviewed sick-day rules: double the hydrocortisone dose for fever or illness, and use the emergency injection for vomiting or severe illness, then seek care
• Continue co-management with endocrinology

3. Immune-Related Dermatitis, Grade 1
Pruritic maculopapular rash covers about 8% of body surface area without blistering or mucosal involvement.

• Triamcinolone 0.1% cream twice daily to affected areas for 2 weeks
• Fragrance-free emollient twice daily
• Cetirizine 10 mg daily for itching
• Continue nivolumab without interruption

4. Immune-Related Arthralgia, Grade 1
Brief morning aching without joint swelling or synovitis.

• Acetaminophen 1000 mg as needed
• Monitor for inflammatory arthritis and refer to rheumatology if swelling develops

5. Vitiligo
New depigmented patches on the hands are associated with immune response to melanoma.

• Reassured that vitiligo is not harmful
• Strict sun protection to depigmented skin

6. Skin Cancer Surveillance

• Dermatology full-body skin exam every 6 months
• Daily SPF 50 sunscreen and protective clothing at work

7. Immunotherapy Administration

• Administer nivolumab 480 mg IV over 30 minutes
• Monitor for infusion reactions

Ordered

Medications:
Nivolumab 480 mg IV
Triamcinolone 0.1% cream twice daily for 2 weeks
Cetirizine 10 mg daily
Fragrance-free emollient twice daily

Labs:
CBC, CMP, free T4, and lipase before each nivolumab dose
LDH every 3 months

Imaging:
CT chest, abdomen, and pelvis with contrast in 12/2026
MRI brain with and without contrast in 12/2026

Referrals:
Continue endocrinology co-management
Dermatology skin exam in 12/2026

Procedures Today:
Nivolumab infusion
Full-body skin examination

ECOG Performance Status (Beta)
ECOG Score 0: The patient has returned to full-time work as a construction project manager and is fully active without restriction. His only symptoms are a mild rash and brief morning finger aching.

Karnofsky Performance Status (Beta)
Karnofsky Score 90: The patient carries on normal activity and work with minor symptoms of treatment, including itching and mild joint aching. He requires no assistance.

Recommendations as per NCCN Guidelines
For Stage IV Melanoma:

1. First-Line Systemic Therapy:

• Anti-PD-1-based immunotherapy, including ipilimumab with nivolumab, is preferred first-line therapy for metastatic melanoma, including BRAF V600-mutated disease.
• BRAF and MEK inhibitor combinations are an option at progression for BRAF V600-mutated disease.

2. Duration of Therapy:

• Anti-PD-1 therapy may be continued for up to 2 years, and discontinuation may be considered after confirmed complete response.

3. Immune-Related Adverse Events:

• Hypophysitis requires hormone replacement, with stress-dose steroid education and emergency injection kits for adrenal insufficiency.
• Grade 1 dermatitis can be managed with topical steroids and emollients without holding immunotherapy.

4. Monitoring:

• CT or PET/CT every 3 to 6 months and brain MRI periodically during treatment.
• Thyroid, adrenal, and liver function should be checked before each immunotherapy dose.

5. Skin Surveillance:

• Full-body skin exams at least every 6 to 12 months, with patient education on self-exams and sun protection.

‍

Chief Complaint
Hematology consultation for newly diagnosed transformation of follicular lymphoma to diffuse large B-cell lymphoma.

History of Present Illness
Sabrina Zimmerman is a 62-year-old female with follicular lymphoma diagnosed in 2019, now with biopsy-proven transformation to diffuse large B-cell lymphoma, who presents for hematology consultation and treatment planning.

She reports a rapidly enlarging right neck mass over six weeks, drenching night sweats three to four nights weekly, intermittent fevers to 100.8°F, and 5 kg of unintentional weight loss. She has mild trouble swallowing large pills. She denies headaches, vision changes, back pain, or weakness. She states, "For years this was something we watched, and now it suddenly feels urgent."

Past Medical History

• Diffuse large B-cell lymphoma, germinal center B-cell type, transformed from follicular lymphoma, Lugano stage III
• Follicular lymphoma, grade 1 to 2 (diagnosed 2019)
• Hypertension
• Hyperlipidemia
• Gastroesophageal reflux disease

03/2019: Painless enlarged nodes in the left neck and left groin. Excisional biopsy of a left inguinal node showed follicular lymphoma, grade 1 to 2, with t(14;18). PET/CT showed stage III disease with low tumor burden. FLIPI score 2. Managed with watch and wait.

06/2022: Symptomatic enlargement of a left axillary node to 4 cm. Treated with rituximab 375 mg/m² weekly for 4 doses with partial response. Returned to observation.

2024: Surveillance CT showed stable, small-volume nodal disease.

06/2026: Rapidly enlarging right neck mass with night sweats, fevers, and weight loss. LDH rose to 486 U/L.

08/2026: PET/CT showed a highly FDG-avid right neck mass, discordant from her prior follicular disease. Core biopsy confirmed transformation to diffuse large B-cell lymphoma.

Past Surgical History

• Core needle biopsy, right cervical lymph node (08/2026)
• Excisional biopsy, left inguinal lymph node (03/2019)
• Total abdominal hysterectomy (2008)

Past Imaging
PET/CT Skull Base to Mid-Thigh (08/12/2026):

• Right cervical nodal conglomerate, levels II to IV, measuring 6.8 x 5.2 cm, SUVmax 21.4
• Mediastinal lymph nodes up to 2.2 cm, SUVmax 7.6
• Retroperitoneal and mesenteric lymph nodes up to 3.1 cm, SUVmax 8.2
• Two focal splenic lesions, SUVmax 9.1
• No focal bone marrow uptake. No CNS or other extranodal involvement
• Lugano stage III

Echocardiogram (08/2026):

• LVEF 60% with normal left ventricular size and function

CT Neck, Chest, Abdomen, and Pelvis (2024):

• Stable small-volume nodes in the left axilla, mesentery, and left inguinal region, all under 2 cm

PET/CT (03/2019):

• FDG-avid nodes in the left cervical, left axillary, mesenteric, and left inguinal regions, SUVmax up to 6.4
• Largest node 3.2 cm. Spleen normal

Past Labs
Pathology, Right Cervical Lymph Node Core Biopsy (08/18/2026):

• Diffuse large B-cell lymphoma with a background component of follicular lymphoma, grade 2
• CD20, CD10, and BCL6 positive. MUM1 negative. Germinal center B-cell type by Hans algorithm
• Ki-67 85%
• FISH: BCL2 rearrangement present. MYC and BCL6 rearrangements absent. Not double-hit
• Reviewed by hematopathology

Pathology, Left Inguinal Lymph Node Excisional Biopsy (03/2019):

• Follicular lymphoma, grade 1 to 2
• CD20, CD10, and BCL2 positive. t(14;18) detected by FISH

LDH Trend:

• 210 U/L (2019)
• 230 U/L (2022)
• 486 U/L (06/2026) (high)
• 612 U/L (08/28/2026) (high)

Complete Blood Count (08/28/2026):

• WBC: 7.8 x 10^3/μL
• Absolute lymphocyte count: 0.9 x 10^3/μL (low)
• Hemoglobin: 11.2 g/dL (low)
• Platelets: 182 x 10^3/μL

Comprehensive Metabolic Panel (08/28/2026):

• Creatinine: 0.9 mg/dL
• Potassium: 4.3 mmol/L
• Calcium: 9.4 mg/dL
• Phosphorus: 3.8 mg/dL
• Uric acid: 7.8 mg/dL (high)
• AST: 30 U/L
• ALT: 26 U/L
• Total bilirubin: 0.6 mg/dL
• Albumin: 3.5 g/dL

Other Labs (08/28/2026):

• Beta-2 microglobulin: 3.8 mg/L (high)
• Hepatitis B surface antigen and core antibody: Negative
• Hepatitis C antibody: Negative
• HIV antigen and antibody: Negative

Prognostic Scores:

• International Prognostic Index: 3 of 5, high-intermediate risk (age over 60, elevated LDH, stage III)
• CNS International Prognostic Index: 3 of 6, intermediate risk (age over 60, elevated LDH, stage III)

Family History

• Mother with breast cancer at age 70
• Father with coronary artery disease
• No family history of lymphoma or leukemia

Social History
Married and lives with her husband. Works as a middle school science teacher and has taken medical leave starting this week. Never smoker. Drinks one glass of wine weekly. Two adult daughters live nearby and will help with transportation.

Current Medications
Lisinopril 10 mg daily
Atorvastatin 20 mg nightly
Omeprazole 20 mg daily
Acetaminophen 650 mg as needed for fever

Allergies
Penicillin: Rash

Review of Systems
General: Drenching night sweats three to four nights weekly. Fevers to 100.8°F. Unintentional weight loss of 5 kg over two months. Fatigue.
Skin: No rash or itching.
Eyes: No vision changes.
HENT: Right neck swelling. Mild trouble swallowing large pills. No hoarseness or stridor.
Respiratory: No cough or shortness of breath.
Cardiovascular: No chest pain, palpitations, or leg swelling.
GI: Early fullness after meals. No abdominal pain or change in bowel habits.
Neurological: No headaches, weakness, numbness, or confusion.
Musculoskeletal: No back or bone pain.
Psychiatric: Anxious about the change in her disease.

Physical Exam
General: Well-appearing but fatigued female in no acute distress.
Vital signs:
BP: 128/78 mmHg
HR: 92 bpm
Temperature: 99.6°F
SpO2: 97% on room air
Height: 165 cm
Weight: 66 kg
BSA: 1.74 m²
Skin: No rash, petechiae, or jaundice.
Eyes: Sclerae anicteric.
HENT: Oropharynx clear. No tonsillar enlargement.
Lymph Nodes: Firm, fixed, non-tender right cervical mass measuring about 7 x 5 cm. Small left axillary and left inguinal nodes under 2 cm, unchanged from prior exams.
Respiratory: Clear to auscultation bilaterally. No stridor.
Cardiovascular: Regular rhythm, mildly tachycardic. No murmurs.
GI: Soft, non-tender. Spleen tip palpable 2 cm below the left costal margin. No hepatomegaly.
Extremities: No edema.
Neurological: Cranial nerves intact. No focal deficits.
Psychiatric: Anxious but engaged, with appropriate affect.

Assessment and Plan
1. Diffuse Large B-Cell Lymphoma, Germinal Center B-Cell Type, Transformed from Follicular Lymphoma, Lugano Stage III
I reviewed her PET/CT, biopsy, and hematopathology findings. Transformation is supported by a rapidly growing right neck mass with an SUVmax of 21.4, far above her prior follicular disease, rising LDH, B symptoms, and biopsy showing diffuse large B-cell lymphoma with a background follicular component and BCL2 rearrangement. She is not double-hit. Her IPI is 3, placing her in the high-intermediate risk group. Because her only prior treatment was single-agent rituximab, she is treated as a new diffuse large B-cell lymphoma, with curative intent.

I presented two first-line options:

• R-CHOP for 6 cycles: The standard regimen for transformed follicular lymphoma, with long-term cure in a majority of patients without prior chemotherapy.
• Pola-R-CHP for 6 cycles followed by 2 doses of rituximab: Improved progression-free survival in newly diagnosed diffuse large B-cell lymphoma with an IPI of 2 or higher. Patients with transformed lymphoma were not included in the trial, so the benefit is less certain for her.

She chose R-CHOP after discussion with her husband.

• Start R-CHOP every 21 days for 6 cycles within the next week
• Rituximab 375 mg/m² (652 mg) IV on day 1
• Cyclophosphamide 750 mg/m² (1,305 mg) IV on day 1
• Doxorubicin 50 mg/m² (87 mg) IV on day 1
• Vincristine 1.4 mg/m², capped at 2 mg, IV on day 1
• Prednisone 100 mg orally daily on days 1 to 5
• Interim PET/CT after cycle 3 and end-of-treatment PET/CT 6 to 8 weeks after cycle 6

2. Tumor Lysis Syndrome Risk
Bulky disease, an LDH of 612 U/L, and a uric acid of 7.8 mg/dL place her at intermediate risk.

• Start allopurinol 300 mg daily 2 days before cycle 1
• Encourage 2 to 3 liters of oral fluid daily during the first week
• Check CMP, uric acid, and phosphorus on days 1 and 3 of cycle 1

3. CNS Relapse Risk
CNS-IPI is 3, which is intermediate risk, without kidney, adrenal, or testicular involvement.

• CNS prophylaxis is not indicated
• Report new headaches, vision changes, or weakness promptly

4. Febrile Neutropenia Prevention and Infection Risk
Her risk of febrile neutropenia on R-CHOP at age 62 supports primary prophylaxis. Hepatitis B testing is negative.

• Pegfilgrastim 6 mg subcutaneous on day 2 of each cycle
• Fever precautions reviewed, with instructions to call for temperature of 100.4°F or higher

5. Anthracycline Cardiotoxicity Monitoring
Baseline LVEF is 60%. The planned cumulative doxorubicin dose is 300 mg/m².

• Repeat echocardiogram at the end of treatment or sooner for cardiac symptoms

6. B Symptoms and Supportive Care
Night sweats, fevers, and weight loss are expected to improve quickly after treatment begins.

• Acetaminophen 650 mg as needed for fevers
• Ondansetron 8 mg every 8 hours as needed and prochlorperazine 10 mg as needed for nausea
• Senna and polyethylene glycol to prevent vincristine-related constipation
• Refer to oncology dietitian for weight loss

7. Port Placement and Treatment Logistics

• Port placement before cycle 1
• Chemotherapy teaching visit with the oncology nurse navigator
• Social work for medical leave paperwork

8. Advance Care Planning
She named her husband as her health care proxy. She is full code and hopeful about curative treatment.

• Complete health care proxy form at the next visit

Ordered

Medications:
Rituximab 652 mg IV day 1
Cyclophosphamide 1,305 mg IV day 1
Doxorubicin 87 mg IV day 1
Vincristine 2 mg IV day 1
Prednisone 100 mg orally days 1 to 5
Pegfilgrastim 6 mg subcutaneous day 2
Allopurinol 300 mg daily
Ondansetron 8 mg every 8 hours as needed
Prochlorperazine 10 mg every 6 hours as needed
Senna 8.6 mg, 2 tablets nightly
Polyethylene glycol 17 g daily

Labs:
CBC with differential, CMP, uric acid, phosphorus, and LDH on days 1 and 3 of cycle 1, then before each cycle

Imaging:
Interim PET/CT after cycle 3
End-of-treatment PET/CT 6 to 8 weeks after cycle 6
Echocardiogram at end of treatment

Procedures:
Port placement before cycle 1

Referrals:
Chemotherapy teaching with oncology nurse navigator
Oncology dietitian
Oncology social work

Procedures Today:
Review of PET/CT and hematopathology with treatment planning

ECOG Performance Status (Beta)
ECOG Score 1: The patient is fatigued from night sweats and fevers and has stopped working, but she remains fully ambulatory, independent in self-care, and able to do light activity at home.

Karnofsky Performance Status (Beta)
Karnofsky Score 80: The patient carries on normal activity with effort and has clear signs of disease, including a neck mass, fevers, night sweats, and weight loss. She requires no assistance with personal care.

Recommendations as per NCCN Guidelines
For Histologic Transformation of Follicular Lymphoma to Diffuse Large B-Cell Lymphoma:

1. Diagnosis and Staging:

• Biopsy of the most FDG-avid site is recommended when transformation is suspected.
• FISH for MYC, BCL2, and BCL6 rearrangements should be performed to identify high-grade B-cell lymphoma.
• PET/CT is preferred for Lugano staging.

2. Systemic Therapy:

• For transformation with no or minimal prior therapy, anthracycline-based chemoimmunotherapy such as R-CHOP is recommended.
• Pola-R-CHP is an option for newly diagnosed diffuse large B-cell lymphoma with an IPI of 2 or higher.

3. Pretreatment Evaluation:

• Hepatitis B testing, echocardiogram before anthracycline, and tumor lysis risk assessment are recommended.

4. CNS Prophylaxis:

• CNS prophylaxis should be considered for a CNS-IPI of 4 to 6 or for involvement of the kidney, adrenal gland, or testis.

5. Supportive Care:

• Growth factor support is recommended for regimens with a febrile neutropenia risk of 20% or more, or 10% to 20% with patient risk factors such as age over 60.

6. Response Assessment:

• Interim PET/CT may be performed after 2 to 4 cycles, with end-of-treatment PET/CT using the Deauville 5-point scale.
• For relapsed or refractory disease, CAR T-cell therapy and other second-line options should be considered.

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Chief Complaint
Cycle 5, day 1 of azacitidine and venetoclax for acute myeloid leukemia, with review of restaging bone marrow biopsy.

History of Present Illness
Joel Walker is a 74-year-old male with acute myeloid leukemia with myelodysplasia-related changes, evolved from myelodysplastic syndrome, who presents for cycle 5, day 1 of azacitidine and venetoclax and review of his recent bone marrow biopsy.

He reports improved energy and has not needed a transfusion since July. He walks his dog twice daily. He denies fevers, bleeding, bruising, mouth sores, or shortness of breath. He has mild nausea on venetoclax days, controlled with ondansetron. He states, "My counts are finally behaving, and I want to keep it that way without spending my last years in a transplant unit."

Past Medical History

• Acute myeloid leukemia with myelodysplasia-related changes, ELN 2022 adverse risk, in complete remission
• Myelodysplastic syndrome with multilineage dysplasia (2023)
• Coronary artery disease, status post drug-eluting stent to the left anterior descending artery (2019)
• Chronic kidney disease, stage 3a
• Hypertension
• Benign prostatic hyperplasia

2021: Mild macrocytic anemia with hemoglobin 11.6 g/dL and MCV 104 fL. Vitamin B12, folate, and thyroid studies normal. Monitored by primary care.

03/2023: Hemoglobin 9.4 g/dL and platelets 98 x 10^3/μL. Bone marrow biopsy showed myelodysplastic syndrome with multilineage dysplasia, 3% blasts, and del(20q). IPSS-M low risk. Started epoetin alfa with response for about one year.

2024 to 2025: Became transfusion dependent, needing 2 units of red blood cells monthly despite epoetin alfa.

04/2026: Fatigue, bruising, and 14% circulating blasts. Bone marrow biopsy confirmed acute myeloid leukemia with myelodysplasia-related changes. Considered unfit for intensive chemotherapy based on age, coronary disease, and kidney function.

05/04/2026: Cycle 1 of azacitidine with venetoclax started in the hospital with venetoclax ramp-up and tumor lysis monitoring. Febrile neutropenia on day 18, treated with cefepime, cultures negative.

06/2026 to 08/2026: Complete remission with incomplete count recovery after cycle 1. Venetoclax shortened to 21 days in cycle 2 and 14 days from cycle 3 for prolonged neutropenia. Last red blood cell transfusion on 07/09/2026.

08/2026: Transplant consultation. He declined allogeneic transplant after discussing risks, recovery time, and his role as caregiver for his wife.

Past Surgical History

• Bone marrow biopsies (03/2023, 04/2026, 06/2026, 09/2026)
• Percutaneous coronary intervention with drug-eluting stent to the left anterior descending artery (2019)
• Transurethral resection of the prostate (2017)

Past Imaging
Echocardiogram (04/2026):

• LVEF 55%. Mild anterior hypokinesis, unchanged from 2019. No significant valvular disease

Chest X-ray (05/22/2026, during febrile neutropenia):

• No focal consolidation, effusion, or pneumothorax

CT Chest Without Contrast (05/23/2026):

• No nodules or infiltrates suggestive of fungal infection

Past Labs
Bone Marrow Biopsy After Cycle 4 (09/08/2026):

• Normocellular marrow, 40% cellularity, with trilineage hematopoiesis
• Blasts under 1% by morphology
• Measurable residual disease by flow cytometry: 0.05%
• Cytogenetics: 46,XY[20], del(20q) no longer detected
• NGS: IDH1 R132H variant allele frequency 2%, SRSF2 P95H 4%, ASXL1 3%
• Complete remission with full count recovery

Bone Marrow Biopsy After Cycle 1 (06/01/2026):

• Hypocellular marrow, 15% cellularity
• Blasts 2%
• Measurable residual disease by flow cytometry: 0.8%
• Complete remission with incomplete hematologic recovery

Bone Marrow Biopsy at Diagnosis (04/28/2026):

• Hypercellular marrow, 80% cellularity
• Myeloblasts 32% with multilineage dysplasia
• Cytogenetics: 46,XY,del(20q)[12]/46,XY[8]
• NGS: IDH1 R132H variant allele frequency 38%, SRSF2 P95H 41%, ASXL1 frameshift 29%
• NPM1, FLT3-ITD, FLT3-TKD, and TP53 negative
• Acute myeloid leukemia with myelodysplasia-related changes, ELN 2022 adverse risk

Complete Blood Count (09/21/2026):

• WBC: 3.2 x 10^3/μL
• ANC: 1.4 x 10^3/μL
• Absolute lymphocyte count: 0.8 x 10^3/μL (low)
• Hemoglobin: 10.6 g/dL (low)
• Platelets: 128 x 10^3/μL (low)
• Peripheral blasts: 0%

Blood Count Trend:

• ANC: 0.3 x 10^3/μL (04/2026), 0.6 (06/2026), 1.1 (08/2026), 1.4 (09/21/2026)
• Platelets: 32 x 10^3/μL (04/2026), 64 (06/2026), 102 (08/2026), 128 (09/21/2026)
• Hemoglobin: 7.8 g/dL (04/2026), 8.6 (06/2026), 9.9 (08/2026), 10.6 (09/21/2026)

Comprehensive Metabolic Panel (09/21/2026):

• Creatinine: 1.3 mg/dL, eGFR 54 mL/min/1.73 m²
• Potassium: 4.2 mmol/L
• Uric acid: 5.1 mg/dL
• AST: 22 U/L
• ALT: 25 U/L
• Total bilirubin: 0.8 mg/dL

Transfusion History:

• Red blood cells: 2 units monthly from 2024 to 07/2026. None since 07/09/2026
• Platelets: Last transfusion 06/2026

Family History

• Father with coronary artery disease
• Mother with breast cancer at age 76
• No family history of leukemia or other blood disorders

Social History
Married and lives with his wife, who has early Alzheimer's dementia and depends on him for daily care. Retired postal supervisor. Former smoker with a 20 pack-year history, quit in 2000. No alcohol use. Daughter lives nearby, drives him to appointments, and is his health care proxy. Walks his dog twice daily.

Current Medications
Azacitidine 75 mg/m² subcutaneous on days 1 to 7 every 28 days
Venetoclax 70 mg daily on days 1 to 14 every 28 days, reduced for posaconazole
Posaconazole delayed-release 300 mg daily during each cycle
Acyclovir 400 mg twice daily
Levofloxacin 500 mg daily when ANC is below 0.5 x 10^3/μL
Ondansetron 8 mg every 8 hours as needed
Aspirin 81 mg daily
Metoprolol succinate 25 mg daily
Atorvastatin 40 mg nightly
Tamsulosin 0.4 mg nightly

Allergies
Sulfa antibiotics: Rash

Review of Systems
General: Energy improved. Weight stable. No fevers, chills, or night sweats.
Skin: No bruising, petechiae, or rash.
Eyes: No vision changes.
HENT: No mouth sores, gum bleeding, or nosebleeds.
Respiratory: No cough or shortness of breath.
Cardiovascular: No chest pain or palpitations.
GI: Mild nausea on venetoclax days. No diarrhea or blood in the stool.
GU: No blood in the urine.
Neurological: No headaches or dizziness.
Psychiatric: Mood good. Stress related to caring for his wife.

Physical Exam
General: Well-appearing elderly male in no acute distress.
Vital signs:
BP: 128/74 mmHg
HR: 68 bpm
Temperature: 97.9°F
SpO2: 97% on room air
Height: 178 cm
Weight: 78 kg
BSA: 1.97 m²
Skin: No petechiae, ecchymoses, or rash. Prior injection sites on the abdomen without induration.
Eyes: Conjunctivae pink.
HENT: Oral mucosa intact without ulcers or gingival bleeding.
Lymph Nodes: No cervical, axillary, or inguinal lymphadenopathy.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without murmurs.
GI: Soft, non-tender. No hepatosplenomegaly.
Extremities: No edema.
Neurological: No focal deficits.
Psychiatric: Alert and engaged with appropriate mood.

Assessment and Plan
1. Acute Myeloid Leukemia with Myelodysplasia-Related Changes, ELN 2022 Adverse Risk, in Complete Remission
I reviewed his bone marrow biopsy from 09/08/2026, which shows complete remission with full count recovery, blasts under 1%, and MRD by flow cytometry reduced from 0.8% to 0.05%. The IDH1 R132H variant allele frequency has fallen from 38% at diagnosis to 2%, and del(20q) is no longer detected. He has been transfusion independent since July. I discussed that azacitidine with venetoclax is continued until progression or intolerance, and that ivosidenib remains available for his IDH1 mutation if the leukemia returns.

• Proceed with cycle 5, day 1 of azacitidine and venetoclax today
• Azacitidine 75 mg/m² (148 mg) subcutaneous on days 1 to 7
• Venetoclax 70 mg daily on days 1 to 14 while on posaconazole
• Repeat bone marrow biopsy with MRD and NGS after cycle 8, or sooner for falling counts or circulating blasts

2. Treatment-Related Cytopenias
ANC is 1.4 x 10^3/μL and platelets are 128 x 10^3/μL, meeting the thresholds of ANC at least 0.5 x 10^3/μL and platelets at least 50 x 10^3/μL to start the next cycle. Counts have recovered steadily since venetoclax was shortened to 14 days.

• Continue the 14-day venetoclax schedule
• CBC weekly during cycle 5
• Delay the next cycle if ANC is below 0.5 x 10^3/μL or platelets are below 50 x 10^3/μL on day 1

3. Transfusion Support
He has been transfusion independent since 07/09/2026.

• Transfuse leukoreduced red blood cells for hemoglobin below 8 g/dL given his coronary artery disease
• Transfuse platelets for counts below 10 x 10^3/μL, or below 20 x 10^3/μL with fever or bleeding
• Hold aspirin if platelets fall below 50 x 10^3/μL

4. Infection Prophylaxis
Posaconazole is a strong CYP3A4 inhibitor, which is why venetoclax is dosed at 70 mg.

• Continue posaconazole 300 mg daily during each cycle
• Continue acyclovir 400 mg twice daily
• Restart levofloxacin 500 mg daily if ANC falls below 0.5 x 10^3/μL
• Administer inactivated influenza vaccine today. Avoid live vaccines

5. Allogeneic Transplant Discussion
He declined allogeneic transplant at his consultation in 08/2026, citing his age, recovery time, and responsibility as his wife's caregiver. His decision was reviewed and remains unchanged.

• Continue lower-intensity therapy as his long-term plan
• Revisit transplant if his circumstances or wishes change

6. Coronary Artery Disease and Chronic Kidney Disease
Stable without chest pain. Creatinine is 1.3 mg/dL and stable.

• Continue aspirin, metoprolol succinate, and atorvastatin
• Monitor creatinine with each cycle

7. Caregiver Strain and Advance Care Planning
He is the primary caregiver for his wife, and his daughter supports both of them. His daughter is his health care proxy. He wishes to continue treatment and is full code, but would not want prolonged ICU care.

• Refer to oncology social work for in-home support and respite for his wife during treatment weeks
• Document his preferences in an advance directive at the next visit

Ordered

Medications:
Azacitidine 148 mg subcutaneous days 1 to 7
Venetoclax 70 mg daily days 1 to 14
Posaconazole delayed-release 300 mg daily
Acyclovir 400 mg twice daily
Ondansetron 8 mg every 8 hours as needed

Labs:
CBC with differential weekly during cycle 5
CMP before cycle 6

Procedures:
Bone marrow biopsy with MRD flow cytometry, cytogenetics, and NGS after cycle 8

Referrals:
Oncology social work for caregiver support

Procedures Today:
Azacitidine subcutaneous injection, cycle 5, day 1
Inactivated influenza vaccine administered intramuscularly in the left deltoid

ECOG Performance Status (Beta)
ECOG Score 1: The patient is fully ambulatory, independent in self-care, and walks his dog twice daily, but he is limited in physically strenuous activity and has mild nausea during treatment days.

Karnofsky Performance Status (Beta)
Karnofsky Score 80: The patient carries on normal activity with effort and has some symptoms of treatment, including fatigue and nausea during venetoclax days. He requires no assistance with personal care.

Recommendations as per NCCN Guidelines
For Acute Myeloid Leukemia in Patients Not Candidates for Intensive Induction Therapy:

1. Systemic Therapy:

• Azacitidine or decitabine with venetoclax is a preferred regimen.
• For IDH1-mutated disease, ivosidenib with azacitidine is also a preferred option.

2. Post-Remission Management:

• Therapy is continued until progression or unacceptable toxicity.
• After remission, venetoclax duration may be shortened and cycles delayed to allow count recovery.

3. Drug Interactions:

• Venetoclax dose should be reduced when given with strong CYP3A4 inhibitors such as posaconazole.

4. Response Assessment:

• Bone marrow evaluation after cycle 1 and periodically thereafter to confirm remission.
• MRD and molecular monitoring may help predict relapse.

5. Transplant Evaluation:

• Allogeneic transplant should be considered for eligible patients in remission with adverse-risk disease.

6. Supportive Care:

• Antifungal and antiviral prophylaxis should be considered during periods of neutropenia.
• Transfusion support should follow established thresholds, with leukoreduced blood products.
• Inactivated vaccines are recommended, and live vaccines should be avoided.

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