Questions discussed in this category
Is a BM biopsy a must when there is skin involvement?
If tryptase level is mildly elevated but less than 20 would you recommend a BM biopsy?
Treated initially with hATG/CNI/TPO, but then relapsed. Subsequently treated with cyclosporine, danazol, ESA, and alemtuzumab, but still with pancytop...
Provoked or unprovoked VTE: Do you use D-Dimer (or even repeat imaging to reassess residual clot) in any capacity to guide anticoagulation duration? E...
When now would you consider regimens such as BV-AVD or BrECADD in advanced stage HL?
Do you routinely use PET/CT during treatment, such as after cycle 2, to evaluate for response? How would nivolumab treatment affect PET/CT interpretat...
When would you stop anticoagulation?
There is conflicting data on whether the "surprise question" performs adequately enough. Do you use this or other screening tools alone, or in c...
Would you consider holding, deferring, or skipping treatment?
For hepatitis, how would determine if toxicity was immunotherapy vs chemotherapy relate...
Given the POLARIX study data presented at ASH 2021 and subsequent longer term follow up, will this replace R-CHOP as the standard of care therapy in y...
No evidence of VTE on multiple scans. On Crizanlizumab but not tolerant of hydroxyurea. The patient is admitted frequently for VOCs with acute on chro...
Initial labs obtained?
Factors to consider when deciding admission vs outpatient management?
Threshold for treatment?
Treatment with steroids vs ...
Additional risk factors could be family history of VTE or thrombophilia, such as antithrombin deficiency.
Do you consider supportive transfusions, and if so, have you been successful with keeping patients on hospice while receiving transfusions?
Do you us...
Per the NCCN guideline for HR HD, if treated per OEPA-COPDAC, you can omit ISRT. This patient received treatment per AHOD1331, which recommends ISRT f...
Patient has a father and sister with both polycythemia vera with confirmed JAK2 V617F mutations. There is also suspicion for PV in a niece with pulmon...
Is there a target IgG level to aim for?
What should hematologists be aware of in monitoring these patients?
For this subpopulation, are there additional risks such as thrombosis?
Is there a way to determine a safe time period that allows a patient to fulfill their religious obligations or do you just recommend against fasting?
How do you choose between therapies for newly diagnosed ITP that is refractory to steroids and IVIG?
Received dexamethasone 40 mg daily x4 and IVIG without response. No DIC. PB flow cytometry and bone marrow biopsy without pathology. Are there specifi...
The patient has a recurrence of the disease despite tapering prednisone and cyclosporine. Bone marrow exams x2 without MDS. Testing for all other caus...
Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...
How often does this occur and does this lower your suspicion for a "true" or clinically significant lupus anticoagulant?
Presuming good medication adherence.
Based on AALL1731, if in maintenance, is there a certain point at which it is incorporated, or a certain maintenance cycle which it is no longer offer...
vWF and FVIII activities ~200% and were checked because of the patient's family history of "coagulopathy".
Is there any utility in repeating the test...
Assume the patient has infrequent bleeding events every few years, with use of FIX replacement for acute bleeds only.
Do you consider starting Ursodiol? Do you perform routine abdominal ultrasound to monitor for cholelithiasis?
Is there a role for nelarabine and venetoclax in this setting?
Is parasitemia >10% and severe hemolysis with Hb less than 7 enough to initiate this?
After what time period would you consider adding a second iron chelator?
Do you discuss the risk of sickle cell crises with G-CSF? What about for patients with sickle cell trait?
Is there a role for non-myeloablative regimens?
If not, has your practice changed to use vWF replacement therapy more routinely for perioperative or acute bleeding management? Do you still perform D...
Would you consider chronic RBC exchange versus HU?
Are there specific guidelines for managing this patient population?
When do you determine SSRI therapy is unsafe to pursue in such situations?
rWGS did not demonstrate any HLH definable or associated mutations.
qPCR for BCR/ABL was negative. FISH remained positive.
Hb at goal of 9-10
No clear inciting etiology found.
Would you consider dexamethasone +/- cytokine blockade (IL-1, IL-6, or IFN-g)? What do you think about the data for...
Are the INRs reliable? In what scenarios would you not recommend POC INR use for warfarin monitoring?
Are these typically covered by insurance? Are t...
Given nationwide shortage in vinblastine, several of my patients under active therapy are facing delays in their therapies. Is it appropriate to subst...
Do you do additional workup for venous obstruction or any other different testing/evaluation?
Do social or economic factors (i.e., relative cost of acquiring LMWH, the patient being injection averse) affect your decision to use DOACs?
Do you s...
Is there a factor XI goal that you target? Would you consider FVIIa products instead?
Should adult hemoglobin targets be different than pediatrics?
Does this hold true when the patient has significant inflammation?
Is there utility when classic inflammatory markers (ESR,CRP) or disease specific markers (C3, C4, dsDNA) do not correlate with patients disease activi...
The ASH 2020 guidelines have "recommended that adults with HbSS or HbSβ0 thalassemia be screened at least once for silent cerebral infarcts even ...
What criteria do you use to define steroid-refractory disease?
Does your management different by organ system involved - GI vs skin vs other?
The patient presented with a numb chin, more to the right of his face; an MRI did report mandibular nerve opacity, which is non-specific per neuro-rad...
For example, if patients are unable to receive continuous infusion from home health agencies, or if prolonged hospitalization is cost-prohibitive.&nbs...
NCCN says "consider autologous HCT" while retrospective data seems to support SCT in most histologies like AITL
Have you changed your practice given BMT-CTN 1506/Morpho results?
Would you utilize maintenance therapy in patients who achieve MRD- remission?
How does graft source, conditioning regimen, and indication for transplant affect your decision regarding G-CSF?
At the time of count recovery or do you continue it throughout induction and consolidation?
NGS results are pending
The patient was recently diagnosed with pre-B ALL and is on day 10 of CALGB 10403. He is expectedly neutropenic as he received daunorubicin and vincri...
Antifibrinolytic therapy alone +/- DDAVP?
Ferritin >2200, TSAT >80%
There are various formulations of intravenous iron; each with varying costs, test dose requirement, elemental dose, and number or time of infusions ne...
While follow up ultrasound is not usually recommended in provoked DVT, it often is done either for other reasons or by other physicians. Would this in...
How would you counsel the patient if he/she wants to continue on steroids?
Common thought is that FVIII may be used for differentiating coagulopathy in liver disease (normal to increased, from reduced clearance of VWF/FVIII) ...
I.e. platelet count <30. Would your management change if HIT were only suspected rather than confirmed?
Anemia is secondary to menorrhagia. No gynecologic interventions were possible.
If so, for how long?
E.g. Normal F8, VWF activity ~50%, VWF antigen ~100%, ratio 0.5 sent in a patient with positive bleeding history
Is there any clinical significance t...
Specifically, asymptomatic subsegmental PE diagnosed within a month from planned bilateral mastectomy for breast cancer.
Does the fact that the patient is on methotrexate alter your choice?
Provided that the platelet count is normal, do you usually consider this to be a potential erroneous result or do you pursue additional workup for RBC...
How often do you see non transfusion-dependent thalassemia and how do you approach the treatment?
Although TIBC is negative acute phase reactant, would it be a better indicator of iron deficiency (in combination with ferritin)?
Would a negative NGS eliminate the possibility of MDS?
Is bone marrow biopsy indicated in a patient with pancytopenia with a negative NGS panel?
What else would you consider in your differential?
How would the risk of VTE associated with crizotinib affect your decision? Should we consider using crizotinib in combination with brentuximab?
Such as the case in which a patient is unresponsive to steroids, IVIG, TPO-agonist, rituximab, splenectomy, and even fostamitinib.
Do you re-challenge them? If so, what pre-medications do you give? Do you dose reduce the cytarabine? Or do you switch another regimen?
Would you consider low dose indefinite anticoagulation in any scenario? Any difference in approach between hematological malignancy and solid tum...
No prior thrombosis; no family history of thrombosis. As per endocrine, the only useful therapy for the osteoporosis is estrogen.
How is this entity distinct from other secondary HLH entities?
Would it change your management if the thrombus was symptomatic? Or if larger >3 cm?
For example, a patient with a bone marrow biopsy that shows normocellular bone marrow. Prior management with leflunomide and HCQ with neutropenia attr...
What would your next line therapy be? If the patient had no matched related or unrelated donors, would you consider haploidentical transplant?
Presuming there are no matched unrelated donors.
If hydroxyurea modifies the course of sickle cell disease by increasing fetal hemoglobin, is there any benefit to using it in patients with fetal hemo...
Would you give a trial of IST first or immediately refer for SCT if the patient has matched siblings?
What would you want community oncologists to know when following these patients? Are there any other special issues to follow especially in AYA?
ADAMTS13 level <5%
Inhibitor level <1
How can these interactions be improved?
E.g. pulmonary embolism, portal vein thrombosis, cerebral venous sinus thrombosis
If so, what platelet count threshold would you use? Would age impact your decision? Would you do a bone marrow to rule out primary MPD in adults if th...
What is the ideal approach for female adolescent athletes if they have complaints of fatigue and dizziness and are diagnosed with mild iron deficiency...
That is, extra copy of one of the alpha genes resulting in an atypical alpha thalassemia for the patient, and beta thalassemia heterozygous carrier fo...
Please comment on temperature recommendations and role of exchange transfusion.
While L-glutamine has minimal side effects and would likely be added after hydrea, how do you decide between the use of voxelotor and crizanlizumab?
There are conflicting reports whether it contributes to renal insufficiency. If you do switch, what is your preferred TKI in this scenario?
In the absence of concerning bleeding or thrombosis, family history of coagulopathy, current anticoagulant use, or malnutrition
Although testing was not indicated, what do u do with these results?
Other hypercoagulability work up negative
Would the answer differ if the index event was arterial vs venous?
Do you advise against combination OCPs?
What type, dosage, and duration of treatment do you use? How does your practice change when there is an inhibitor?
What are indications to order gene mutation studies (e.g. ELANE) and how would it help the patient?
What would you recommend within the first year after ATG and thereafter if still maintained on cyclosporine?
Ferritin uptrending >1000, no additional lab abnormalities. HFE wildtype. Too young for age-appropriate cancer screening. Asymptomatic except fatig...
Is thrombotic risk too significant? Patient failed OCPs.
What are the differences in approach to B lymphoid/myeloid and T lymphoid/myeloid MPAL?
For example, if TSAT is less than 20% but ferritin is over 200.
For instance, evaluation by primary care and GI without other etiology for splenomegaly
Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?
If not, how do you choose GVHD prophylaxis regimen? Is there a preference?
Wu et al., PMID 34665865
E.g. would you dose-reduce or continue at same dose?
Baseline ANC was in the normal range
Patient with high titer acquired FVIII inhibitor with no causative etiology. Bleeding is well-controlled on emicizumab, but inhibitor has failed...
The patient has no personal history of VTE, but has positive family history of VTE.
Any prophylactic anticoagulation options?
How would manage...
For instance, if clonal hematopoiesis of indeterminate potential (CHIP) suspected
iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.
I.e., what constitutes well-controlled cancer, IBD, nephrotic syndrome, etc. What other diseases do you put in this category (obesity, autoimmune dise...
ALC<200
i.e. long car rides or plane rides
CRP 39 mg/L (normal < 10) and normal ESR
Do you use a cutoff of 10 cm? Do you measure the size of the largest node or measure the largest conglomerate or measure the total length of the entir...
How does graft function play into your decision making? How do you utilize post allogeneic transplant chimerism in clinical practice? Do you obta...
Presuming strong indication for ASA - eg history of NSTEMI
Should we stop checking factor VIII levels as part of thrombosis workup?
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
(e.g. beta 2 glycoprotein IgM > 20 but <40)
e.g. K, Fya, s, etc
Do you routinely check IgG levels during therapy, if not indicated by a study protocol?
If so, what regimen do you utilize?
How would the approach differ if the patient had a significant bleeding phenotype vs only minor bruising and mucosal bleeding?
This type of etoposide sparing therapy has been previously described in a case series at https://pubmed.ncbi.nlm.nih.gov/32725881/
Last rituximab 6 months ago
What is the impact among patients and providers?
Has your documentation been adjusted now that patients can readily review?
If so, how long after diagnosis do you do so?
Are there situations in which a Deauville 3 would cause you to escalate therapy?
Does treatment with B-cell depletion and/or negative anti-spike antibody status despite COVID mRNA vaccination influence your decision?
FVL heterozygotes are often treated similarly to the general population. Aside from avoiding other VTE risk factors, are there situations where prophy...
Are there particular clinical scenarios that would affect your decision?
e.g. DITP from eptifibatide after a cardiac intervention
IVIG, TPO, or other agents?
Would you offer indefinite anticoagulation if the event is unprovoked and the patient has low bleeding risk?
Also is there value in using voxelotor for the purpose of reducing hemolysis, and if so what parameters do you use to determine when to initiate voxel...
If so, what dose and fractionation would you recommend?
Is there a particular sequence you would adjust contributing antirejection or antimicrobial medications? Is the use of G-CSF appropriate and at what c...
How does belumosudil now fit in your approach to steroid refractory chronic graft-versus-host disease?
Hydroxyurea is demonstrated to reduce complications and improve long-term outcomes in severe genotypes HbSS and sickle beta0 thalassemia. What clinica...
Are there other supportive care interventions that would otherwise be covered by hospice?
What if the patient is triple-positive or has continued seropositivity on repeat lab testing? What is the appropriate interval of monitoring and does ...
Is an LP only recommended in the setting of particular subtypes of lymphoma or symptoms of CNS disease?
Have you used anticoagulants other than coumadin? Or is that the only appropriate agent given monitoring is based on PT/INR?
Especially with the current drug shortage of nelarabine.
While building a trusting patient-physician relationship, what therapies could be discussed that may be aligned with naturopathic medicine? (i.e. L-gl...
There are multiple difficulties that could be seen: steroids can precipitate a sickle cell crisis, vasculitis and sickle cell can produce similar clin...
Does manipulation of blood products (leukoreduction, irradiated) affect your approach? There is growing evidence that routine premedication (at least ...
While this is a known risk factor for venous [Meijers et al NEJM 2000] and potentially arterial [Yang et al, Am J Clin Pathol 2006] thrombosis, it is ...
Are there major differences in standard conditioning and/or GVHD prophylaxis regimens utilized?
Does the non-relapse mortality different significantl...
Would this change with someone who has a history of thrombosis (e.g. DVT/PE, MI, CVA)?
Would this change with someone who is more fit vs more frail?
Such as patients who are frail, elderly, renally impaired?
Would you consider sirolimus over cyclosporine or tacrolimus for safer nephrotoxicity prof...
How often do you monitor ADAMTS-13 levels off therapy?
For example, do we prefer one regimen over the other in patients with a bleeding history or who have relapsed after a lengthy remission?
In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients.
If given both options, which donor would one prefer: haploidentical related donor or 7/8 mismatched unrelated donor using post transplant cyclophospha...
Is there a role for empiric antibiotics if there is history of opportunistic infection?
With a strong family history
While benefits outweigh known harms and limited data, do you worry about vaccination in patients with a history of or active autoimmune cytopenias (e....
Do you follow the 2019 EULAR Guidelines that SLE patients with asymptomatic, positive aPL should be on low-dose ASA?
Would you consider this type of patient as having polycythemia?
How long after eculizumab infusion would you wait before giving blood transfusions?
What is the potential differential diagnoses for low iron saturation?
Do you always treat with the full 21-day treatment course, or can defibrotide be stopped if certain criteria are met sooner?
Do you prefer a cHL chemotherapy backbone or PMBL chemotherapy backbone?
While thrombophilia testing is not routinely recommended prior to starting OCPs, how about after the development of a VTE?
Especially in a triple-positive patient with an acute ischemic stroke who may have urgency for anticoagulation with high bleeding risk and severe thro...
The patient who has not responded to steroids, rituximab/bendamustine, and splenectomy?
Has your medical practice taken any steps either in community outreach or within the clinic to show support for this medically vulnerable population, ...
During the Stimate recall, how are we performing DDAVP challenges for newly diagnosed hemophilia A or von Willebrand disease?
Are most places administering oral iron as once daily or every other day dosing due to upregulation of hepicidin receptors following oral iron adminis...
There is no uniform guideline in the literature. AAP recommends until 5 years old or 1-year post-splenectomy. Some for 5 years post-splectomy.
Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?
Given the high cost of eculizumab, are there patient characteristics that inform which patients, if any, should be on indefinite therapy versus a time...
How do you manage an uncomplicated DHTFR versus a hyperhemolysis?
For example, a patient with hypogonadism unless it matters which organ is involved. Are other markers of iron storage useful in guiding therapy?
For example, in a patient who is steroid-refractory, requiring regular transfusion, and has not had response to rituximab after several weeks.
Presented at ASH: FLIGHT trial
If so, what additional testing do you send?
If autoimmune neutropenia already suspected, is this test informative or unnecessary?
What is the lowest level you have seen with uncomplicated or complicated crises?
Is there a preferred strategy of transfusional support versus reduced-dose anticoagulation during the duration of thrombocytopenia?
What if this was "triple-negative" antiphospholipid syndrome?
CT scans show omental and pelvic disease.
Would you consider “bridging” therapy with something like an HMA?
Is it at neutrophil recovery, at documentation of CR on bone marrow biopsy, or is there a different point in time?
Does acute leukemia sub-type affect your decision?
Assuming CBC w/ different and complete metabolic panel are within normal limits, what (if any) further evaluation or management is needed?
If so, what dose would you recommend?
At what age would you treat an early stage hodgkins lymphoma patient with ABVD + RT (adult treatment) vs OEPA x 2 or AV-PC x 3 (pediatric paradigm)?&n...
Guidelines indicate RCHOPx3 +RT as category I and RCHOP x 6 below that; long term f/u for SWOG 8736 showed similar PFS and OS. Do you have and approac...
We often see young women with favorable, early stage disease in the mediastinum who have had a complete response to chemotherapy. With current smaller...
What dose do you recommend?
After ABVE-PC X4 and Ifos/vinorelbine x 2 per AHOD 0831 (and is unable to have these sites biopsied), what dose would you treat to and what volume wou...
Are the results of AHOD0031 practice changing?
It seems that with the arms up, you get better lung blocking but with arms akimbo, you might have a lower dose to the humeral head.
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