iiinova — where your digital self keeps evolving

Mike Pishvaian @mpishvaian.bsky.social · 22/10/2025

#tumorboardtuesday 🤔Hmmm....much more rapid disease progression on the CDK4/6🚫+AI - does this portend for a worse prognosis in subsequent lines of therapy❓

011

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

7/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 4🏫 💊Several FDA👍PIK3CA-inhibitors: Capivasertib or Alpelisib or Inalvosalib 🤔 When and how do you PIK one of the PIK3CA of the 3 available? ☝️Inavolisib+Fulvestrant+Palbo is approved for 1st line mER+ BC after recurrence on/after adjuvant ET therapy

131

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

7/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 4🏫 💊Several FDA👍PIK3CA-inhibitors: Capivasertib or Alpelisib or Inalvosalib 🤔 When and how do you PIK one of the PIK3CA of the 3 available? ✌️Alpelisib & Capivasertib are approved in 2nd line mER+ BC combined with fulvestrant 🔎 NGS results, Baseline A1C

121

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

7/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 4🏫 💊Several FDA approved PIK3CA-inhibitors: Capivasertib or Alpelisib or Inalvosalib 🤔 When and how do you PIK one of the PIK3CA of the 3 available? 📎 pubmed.ncbi.nlm.nih.gov/33246021/

pubmed.ncbi.nlm.nih.gov

Alpelisib plus fulvestrant for PIK3CA-mutated, hormone receptor-positive, human epidermal growth factor receptor-2-negative advanced breast cancer: final overall survival results from SOLAR-1 - PubMed

NCT02437318.

121

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

8/18 #TumorBoardTuesday Back to our case🔎 👩‍🦳 Patient received Capivasertib + Fulvestrant due to PIK3CA mutation. 👉 Not yet considered endocrine resistant so would not move onto capecitabine, sacituzumab 👉 Tumor is HER2 negative so no role for trastuzumab deruxtecan

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

8/18 #TumorBoardTuesday Back to our case🔎 👉 Everolimus + fulvestrant is not favored given the more targeted approach with Capivasterib for the PIK3CA mutation ✅ Tolerated therapy well with mild rash at start of treatment that resolved with antihistamines

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

9/18 #TumorBoardTuesday ⏭️ Case 2 #TumorBoardTuesday #OncTwitter Case 2 👩‍🦳 62 y.o. postmenopausal female 💉 mBC to the🫁, ER 70%, PR 85%, HER2⛔[IHC 1] 🩻 confirmed⬆️Dz on 1L ribo/letrozole at C7 🏃‍♀️ ECOG PS 1. No co-morbidities. ⛔ Normal vital signs, labs 🩸Liquid Biopsy shows ESR1 mutation, TMB-High

211

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

10/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 5🏫 👉 Recurred on adjuvant endocrine tx 👉 Recurred <2y after adjuvant endocrine tx 👉 ⬆️Dz<6mos of starting 1L mBC tx 👉 ⬆️Dz after any duration of >=2nd line of ET-based therapy 👉 Known ESR1 mutation [now have 2 Rx for ESR1m → elacestrant or imlunestrant]

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

11/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 6🏫 EMERALD 👩‍🦳 2L metastatic HR+/HER2- received 💊 Elacestrant, an oral selective ER Degrader (SERD) ✅ 1-2 prior ET including CDK4/6i and < 1 chemo 💊 Elacestrant 400mg daily vs 💉fulvestrant or 💊AI ⬆️⬆️ PFS for prior💊 CDK4/6i > 12 mon with ESR1 mutated tumors

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

11/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 6🏫 ⬆️ Elacestrant benefited all subgroups including: 🦴only, 🫁 visceral mets, > 3 mets ⬆️ Elacestrant benefited all🧬subgroups: ✔️ESR1+PIK3CA, ✔️ESR1+TP53, ✔️ESR1+HER2-low 🤢 Most common AE: N/V

ascopubs.org

ASCO Publications

111

Mike Pishvaian @mpishvaian.bsky.social · 22/10/2025

#tumorboardtuesday Any subtle differences in outcomes based on the specific mutation identified AKT vs. PTEN vs. PIK3CA❓

011

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

3/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 2🏫 CAPItello-291 👩‍🦳 mER+/HER2- breast cancer with PD on AI +/- CDK4/6i 💉2L Fulvestrant +/- capivasertib [oral, 🚫AKT plus.. 🚫PTEN, 🚫PIK3CA] ...continued

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

3/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 2🏫 CAPItello-291 ✅ Capivasertib + fulvestrant ⬆️mPFS in AKT Pathway alterations [7.3m vs 3.1m] ✅ Capi+Fulvestrant benefited all subgroups including: 🦴only, 🫁 visceral mets, prior💊 CDK4/6i, prior ☣️chemo 📎https://www.nejm.org/doi/full/10.1056/NEJMoa2214131

nejm.org

Capivasertib in Hormone Receptor–Positive Advanced Breast Cancer | NEJM

AKT pathway activation is implicated in endocrine-therapy resistance. Data on the efficacy and safety of the AKT inhibitor capivasertib, as an addition to fulvestrant therapy, in patients with horm...

211

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

4/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 3🏫 CAPItello-291: Capivasertib Side effects 💊 Capivasertib taken 4 days on, 3 days off per week 🩺 Need baseline A1C < 8% 🚽 Most common AE: Diarrhea onset ~ day 8 [All grades 72%, G3/4 9.3%] ...continued

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

4/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 3🏫 CAPItello-291: Capivasertib Side effects ☝️ Rash (12%) onset ~ day 12→ Pretreat with oral antihistamine, topical steroids 💉 Hyperglycemia (18%) onset ~ day 15; ⬇️ G3/G4 than other PIK3CA 📎https://www.esmoopen.com/article/S2059-7029(24)01466-2/fulltext

esmoopen.com

Capivasertib and fulvestrant for patients with hormone receptor-positive advanced breast cancer: characterization, time course, and management of frequent adverse events from the phase III CAPItello-2...

Capivasertib is a potent, selective pan-AKT inhibitor. In CAPItello-291, the addition of capivasertib to fulvestrant resulted in a statistically significant (P < 0.001) improvement in progression-free...

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

5/18 #TumorBoardTuesday Back to our case🔎 💉 57yo ♀️ with mBC to the 🦴, liver, ER 100%, PR 95%, HER2⛔[IHC 0]-🩻confirmed⬆️Dz on 1L ribo/letrozole at C47 ✅ Normal labs (A1C=5.8) & VS 🩸Liquid Biopsy: +PIK3CA mutation, TP53 mutation, TMB-Low (4 mut/mb), High tumor fraction (> 5%) 👩🏻‍⚕️What 2L Tx is advised❓

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

6/18 #TumorBoardTuesday POLL What 2L therapy would you give this patient❓ 1) Capecitabine 2) Trastuzumab deruxtecan 3) Sacituzumab govetican 4) Capivasertib + Fulvestrant 5) Everolimus + Fulvestrant

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

2/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 1🏫 ...cont 📝Tissue-based assays or plasma-based assays (ctDNA) can be used ☝️Some alterations may be better detected by tissue-based assays like homozygous loss of PTEN or TMB-H. ☝️Liquid assays may reflect tumor heterogeneity more accurately

121

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

2/18 #TumorBoardTuesday 👩🏻‍🏫Mini Tweetorial 1🏫 Actionable Mutations in 2L mER+/HER2- BC 🧬Several actionable mutations in 2L+ mBC: ESR1, PIK3CA, AKT, PTEN, BRCA (germline, somatic) 🔍Evaluation of acquired mutations at progression will help to direct therapy options Cont.....

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

#TumorBoardTuesday POLL What would you do next❓ 1) Start capecitabine 2) Liquid biopsy to assess for actionable mutations 3) Start trastuzumab deruxtecan 4) Check tumor markers Ca 15-3 & Ca 27.29

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 22/10/2025

1/18 #TumorBoardTuesday @KennaKoehler & @drgattimays.bsky.social Case 1 👩‍🦳57 y.o. postmenopausal female 📋Well controlled DM (A1C = 5.8) 🏃‍♀️ECOG PS 0 💉Metastatic BC to bones, liver, ER 100%, PR 95%, HER2- [IHC 0] w/scan confirmed progression on 1L ribociclib/letrozole at C47 in bones ⛔ Normal labs & VS

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 21/10/2025

#TumorBoardTuesday 📢Join us Tuesday, 10-21-25 at 8PM ET as @drgattimays.bsky.social & @KennaKoehler 🗣️ Tx options after CDK4/6⛔️: What to consider in the 2nd line for HR+/HER2– mBC❓ RT and bring others into the discussion‼️

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 21/10/2025

#TumorBoardTuesday 🧠And while we finalize the case details, collect FREE #CME 👉🏽https://integrityce.com/tbt2025

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 21/10/2025

#TumorBoardTuesday ➡️Before @drgattimays.bsky.social & @KennaKoehler 🗣️ 2nd line Tx options for HR+/HER2– mBC, #BCSM tell us your connection to this medical🩺discussion 👇👇🏼👇🏾 1) Onc/Surg/Rad/IR/Gyn Onc 2) Other MD/APP/RN/Pharm D 3) Patient/Patient Advocate 4) Fellow/Resident/Trainee

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 21/10/2025

✅This #TumorBoardTuesday🗣️with @KennaKoehler & @drgattimays.bsky.social‬ is provided by @IntegrityCE 👍Supported by ed grants from Exelixis, Ferring, Ipsen, Lilly, Janssen Scientific Affairs, Merck & Taiho Oncology 🙏 👉🏽Info about 🆓 CME: integrityce.com/tbt2025

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 21/10/2025

#PreTest Q1️⃣#TumorBoardTuesday Free #CME integrityce.com/tbt2025 B4 @KennaKoehler & @drgattimays.bsky.social‬🗣️2nd-line Txs for #breastcancer, test your🧠with these 2❓

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 21/10/2025

🤔What 2L Tx would you offer a 45yo♀️w/ AKT mutated, ER+/HER2- mBC after⬆️Dz on ribociclib➕AI/OFS❓ 1) Capecitabine monotherapy 2) Capivasertib+fulvestrant 3) Elacestrant monotherapy 4) Everolimus + fulvestrant

111

Reposted by Mike Pishvaian

Tumor Board Tuesday @tumorboardtuesday.bsky.social · 21/10/2025

#PreTest Q2⃣#TumorBoardTuesday 🧐 A 75yo♀️w/ER+/HER2- PIK3CA+ mBC is starting 2L therapy with alpelisib+fulvestrant. Baseline A1C=6.1 & BMI is 33. What steps can limit risk for severe hyperglycemia❓ 1) Labs QW x 2, then monthly 2) Baseline A1C, then q3 mos 3) Consider metformin 4) All of the above

111

Mike Pishvaian @mpishvaian.bsky.social · 27/05/2025

#ASCO25 📢Join me & my colleagues EileenMOReilly, Gabi Chiorean, & Brian Wolpin to discuss #PancreaticCancer management in a case-based format 📅Friday, May 30th, 6:30- 8:00pm CDT 📍Sheraton Grand Chicago Riverwalk 4th Floor 📋Link to Registration: (tinyurl.com/mra3pt9s

tinyurl.com

Go To PER in Chicago

020

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 🌇And in our last discussion of the day, @EileenMOReilly shared with us her experience with, and promise of the many ongoing trials of novel KRAS⛔️ 🙏There is real promise here that KRAS⛔️will improve the mOS of #pancreaticcancer patients across the board🙏

000

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc ➡️Pancreatic enzyme insufficiency is very challening for patients with #pancreaticcancer (and difficult for their physicians to manage) ✅We need dieticians like Mary-Eve Brown to help us manage these patients

310

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc ✅@NeehaZaidi presented a slightly different view that we need studies to understand which patients with oligometastatic #pancreaticcancer would benefit from surgery 🤔Should we be considering adjunctive Tx, such as vaccines, that might⬆️long-term control❓

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 👉Some patients with limited metastatic #colorectalcancer can be cured 🤔Can we find which patients with metastatic #pancreaticcancer might also benefit from surgery❓ Dr. Rick Burkhart🗣️the support for surgery for limited, oligometastatic pancreatic cancer

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 🤔We🗣️the use of radiation☢️for localized pancreatic cancer ➡️Randomized trials (with some flaws) have not supported☢️ BUT there is some evidence that ablative☢️may actually⬆️mOS Dr. Amol Narang reviewed this data - giving us a lot of food for thought💭

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 👉You have listen to @EileenMOReilly 🗣️ #PancreaticCancer ➡️Not only does she present a truly comprehensive review of treatment options 🙏But, she has a real knack for raising our hope for improvement for this devastating disease‼️ @PanCAN #WageHope

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 😀I have been eagerly awaiting this Keynote👩‍🏫session on targeting🎯KRAS and the KRAS⛔️ by Dr. Nilo Azad ➡️KRAS inhibition looks so promising for out #GICancer patients particularly #pancreaticcancer and #colorectalcancer

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc ✅Keeping the patient's very personal experience front and center, Cindy Papesh Shephard, our wound/ostomy nurse educates all of us - especially the docs on how to manage and live with an ostomy

210

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc @skopetz is back on stage to🗣️targeted therapies🎯💊for #colorectalcancer ➡️His group brought encorafenib + cetuximab to the forefront for BRAFV600E-mutated CRC🙏 ➡️Overcoming resistance to KRAS⛔️with chemo or IO ➡️Epigenetics ➡️Other2⃣-ary🧬mutations

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 🤔How are you usuing ctDNA testing after resection of a #colorectalcancer ❓ ✅Dr. Valerie Lee presented the current data, and the many persistent questions in this space

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc ✅Whereas, Dr. Ada Graham makes the case for the importance and essential nature of surgery🔪(and some of the challenges with radiation therapy☢️) for rectal cancer

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc ✅Dr. Rachit Kumar, from Radiation Oncology makes a case for chemoradiation, followed by watchful-waiting for rectal cancer with a complete clinical response

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc #RectalCancer mgmt is IMHO the most complicated part of CRC Tx 😟It's harder to decide what we DON'T need to include (i.e. no🔪 or no☢️) Dr. Valerie Lee from @HopkinsMedicine set up the🗣️and debate on how to manage a patient with a localized rectal cancer

111

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc ✅@skopetz.bsky.social guides us through what has become a very complicated field - the management of metastatic, newly diagnosed #colorectalcancer ➡️Triplet vs. doublet chemotherapy ➡️Right vs. Left-sided cancers ➡️Incorporating biomarkers

111

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 🧑‍⚕️We have to consider symptom management in our patients with upper GI cancers ✅Dr. Saowanee Ngamruengphong from Johns Hopkins is a gastroenterologist that provided her advice on the management of severe gastroesophageal reflux after an esophagectomy

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 🗒️Treatment options for advanced upper GI cancers have expanded quite a bit in the last ~10 years ✅Dr. Manish Shah highlighted🔦the many options, in particular targeted therapy🎯💊options in the treatment of advanced gastric/GEJ/esophageal cancers

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc ✅Dr. Jeremy Davis from @ummedschool.bsky.social gave a very⏲️timely🗣️, fresh off the #GI25 👩‍🏫of the DRAGON-01 trial 🤔Should we consider surgery🔪(gastrectomy + cytoreduction +/- HIPEC) for a patient with metastatic gastric cancer with peritoneal carcinomatosis

120

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 🤔Or, do you prefer to incoroporate radiation☢️ ➡️Dr. Adi Halthore makes a case for chemoradiation (i.e. the CROSS regimen)

100

Mike Pishvaian @mpishvaian.bsky.social · 08/02/2025

@hopkinspress.bsky.social #GIOnc 🤔What are your thoughts on the management of a localized esophageal/gastroesophageal cancer❓ ➡️Do you prefer perioperative chemotherapy alone ❓ ✅Dr. Bever makes a case for the ESOPEC data supporting the use of perioperative FLOT

100