Hematology
Questions discussed in this category
Patient with high titer acquired FVIII inhibitor with no causative etiology. Bleeding is well-controlled on emicizumab, but inhibitor has failed...
81 mg vs 162 mg
Is thrombotic risk too significant? Patient failed OCPs.
i.e. similar to CKD anemia?
When would you consider a bone marrow biopsy?
Complete response was achieved after cycle 3. What extent of bone would you include?
Will you be using the IPSS-M in place of the IPSS-R? How will you be using IPSS-M in practice?
Also how would you manage this perioperatively?
For example, if TSAT is less than 20% but ferritin is over 200.
Other than in the setting of disease progression or significant treatment-related adverse event?
Does your answer change based on clinical or molecular risk factors, and if so how?
Does your answer change if MRD status after induction is unknown?
Infection is not part of the criteria for starting treatment both in UpToDate and in NCCN guidelines.
The patient has no personal history of VTE, but has positive family history of VTE.
Any prophylactic anticoagulation options?
How would manage...
How do you determine whether to add intrathecal chemotherapy in patients with +CSF? Would your approach change for primary vs secondary CNS lymphoma?
Significant history of autoimmune diseases and DVT in family, recent PE/DVT for a month
For instance, if clonal hematopoiesis of indeterminate potential (CHIP) suspected
Do we prophylactically place patients on anticoagulation after one episode?
Besides MRI/MRV brain, are there other diagnostic imaging that should b...
iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.
Would you treat as bulky or non-bulky? Is ISRT indicated? Biopsy was performed because there was concern for soft tissue sarcoma.
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?
Is it time limited since it may have been triggered by the pregnancy or is it indefinite since it is APLS associated?
What would you recommend within the first year after ATG and thereafter if still maintained on cyclosporine?
I.e., what constitutes well-controlled cancer, IBD, nephrotic syndrome, etc. What other diseases do you put in this category (obesity, autoimmune dise...
How do you assess if a patient may be a candidate for CAR-T cell therapy?
Does the fact that the patient is on methotrexate alter your choice?
Does this differ for a patient who had a longer remission before relapse?
When is this discussed? What are the common/less common toxicities you advise patients on? Are there best practices for coordination with referring on...
Given the results of ZUMA-7, TRANSFORM, and BELINDA - how does this inform your current practice? What are the currently approved indications for CAR-...
ALC<200
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...
i.e. long car rides or plane rides
- Dialysis catheter used for hemodialysis- RIJ thrombus in dialysis catheter was incidentally found- Patient asymptomatic with no prior history of VTE...
The CALGB regimen is quite complicated.
CRP 39 mg/L (normal < 10) and normal ESR
The patient has no known history of autoimmune disease.
APLA syndrome, obesity, non compliance ruled out and prefers another oral anticoagulation. Is higher dose of rivaroxaban or apixaban an option?
Does the safety profile impact your choice significantly?
Does your first choice vary by disease histology?
Given the rarity of this diagnosis (5-7% of all AL amyloidosis cases), and the prognostic and clinical differences when compared to non IgM-AL am...
Secondary MF such as post-PV, for example.
Do you apply the same prognostic scoring systems?
My experience has been that patients can be neurologically devastated years out from WBRT. In Medical Oncology practice at my institution, we do not r...
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...
We know the longer we expose patients to lenalidomide, the harder collection will be. Would you collect now or switch to an alternative regimen to ach...
No evidence of palpable splenomegaly, normal hematocrit and platelet count
If so, what would you consider ordering?
Bleeding disorder such as vWD
The said patient has been on Imatinib for 2.5 years and is In MMR. Last rt-PCR was 0.04.
E.g. in a patient with tenuous cardiac function, would starting treatment several weeks earlier potentially improve outcomes?
How does graft function play into your decision making? How do you utilize post allogeneic transplant chimerism in clinical practice? Do you obta...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
Presuming strong indication for ASA - eg history of NSTEMI
Should we stop checking factor VIII levels as part of thrombosis workup?
In the setting of no personal or family history and no other risk factors for thrombosis, is systemic anticoagulation warranted if local treatments (e...
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
(e.g. beta 2 glycoprotein IgM > 20 but <40)
In this case, initial tumor was 9.5 cm craniocaudal but hardware spans the entire femur.
eg. eGFR < 30 ml
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...
e.g. K, Fya, s, etc
If not, what instructions do you give to patients regarding checking temperature at home/return precautions?
Do you routinely check IgG levels during therapy, if not indicated by a study protocol?
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?
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?
Does measuring serum free-light chains make a 24-hour UPEP unnecessary?
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 agents would have sufficient efficacy overlap to treat both?
ET is JAK2+
How do you approach secondary stroke prevention for patients with ischemic stroke, atrial fibrillation, and signs of cerebral amyloid angiopathy/micro...
Initial tumor size:18 cm. Partial response was achieved after cycle 2 and cycle 6 of chemotherapy. Complete response (Deauville 2, size: 6 cm) was ach...
Would the answer differ if the index event was arterial vs venous?
Does this change depending on stage?
Do you have a preferred sequence of therapies for diffuse skin limited MF?
What would you consider as contra-indications to Cladribine?
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?
Recurrent thromboses despite therapeutic enoxaparin. Other hypercoagulable work-up negative.
Peripheral blood flow shows prominent NK cell population but marrow aspiration/bx shows normocellular marrow with trilineage hematopoiesis.
Would you avoid imid's given reported association with transplant rejection?
For pts w/ eGFR between 30-60
In the absence of a VTE would you consider prophylaxis after a surgical procedure? Often non-hematologists order this testing but we are consulted for...
Would pegylated interferon be preferred?
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 you more inclined to use non cytotoxic regimens such as R2 or PI3K inhibitors?
Are there particular clinical scenarios that would affect your decision?
Such as the case in which a patient is unresponsive to steroids, IVIG, TPO-agonist, rituximab, splenectomy, and even fostamitinib.
i.e. treatment-refractory PV, prior to progression to PMF or AML
Do you routinely check IgA anticardiolipin and beta-2 glycoprotein antibody IgA in your practice? And how would a positive result change your manageme...
Are the early results of CASSIOPEIA (Abst 8003) from ASCO 2019 practice changing? What about the GRIFFIN results in 2020?
e.g. DITP from eptifibatide after a cardiac intervention
Do you modify the aspirin dose based off the lenalidomide dose? Do you ever use higher dose aspirin in lieu of an anticoagulant? The NCCN guidelines s...
How does cirrhosis and/or underlying thrombophilia affect your decision?
IVIG, TPO, or other agents?
Conversion tables suggest starting the new drug with the next dose but do not seem to answer this question (i.e. if switching from rivaroxaban 20 mg d...
Which systemic agents would you recommend holding during RT?
What dose/fractionation?
If re-irradiation, what dose would you use?
Concordant low EPO level and bone marrow with megakaryocyte hyperplasia
What about changing standard regimens for TCL with HLH?
i.e. obstretric APS without thrombosis or SLE
e.g. IS < 0.002% by qPCR
CAR-T (any specific preference of product?) vs bispecific antibodies vs any other specific agents not previously utilized?
Given the POLARIX study data presented at ASH 2021, will this replace R-CHOP as the standard of care therapy in your practice? If not, how will y...
Is a repeatedly abnormal serum immunofixation all it takes for MGUS?
DaraCyBorD: daratumumab, cyclophosphamide, bortezomib, dexamethasone
In situations when we are waiting for insurance clearance or due to other logistical reasons.
Plasmacytoma of 6th rib s/p resection. Negative multiple myeloma work-up.
Please comment on bridging.
Does VAF <1% make you want to do a BM biopsy for confirmation?
What should be done with a high level?
Would the presence of JAK2 versus CALR versus MPL influence this decision? What if there are other risk factors for cardiovascular disease?
This is in the setting of a patient who is now on ruxolitinib with rising leukocytosis and thrombocytosis, but cannot be on aspirin due to recent blee...
Is there any role for radiation therapy alone?
If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-f...
Would you continue with daratumumab maintenance per ANDROMEDA or switch regimen?
After 3-4 cycles of RVD, would you automatically take the patient to transplant if he has achieved at least a partial response, or is there any benefi...
For example, for outpatients or resource-limited settings with a moderate probability 4-T score (but low clinical suspicion), would you ever consider ...
Would chemotherapy be preferred over RT?
e.g. in the setting of using prophylactic heparin in the past but now requiring therapeutic anticoagulation
Ki67 = 90% with multiple small nodes on PET scan and normal CBC
Would you offer indefinite anticoagulation if the event is unprovoked and the patient has low bleeding risk?
Aside from addressing the underlying case, is there a role for phlebotomy in secondary polycythemia such as in COPD or post-renal transplant erythrocy...
Please also discuss the type and duration of anticoagulation.
NCCN only recommends palliative ISRT for non-transplant eligible patients with refractory/relapsed DLBCL
The dosing in the literature has a huge range.
What if there are no cardiovascular risk factors? Are VKAs preferred or can DOACs be used?
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 you do recommend resuming carfilzomib, what dose and frequency would you use?
If so, what dose and fractionation would you recommend?
Patient in mid-30s with no major medical history presented with isolated left neck swelling. Incisional biopsy w/ HTLV1/2 associated ATLL, Ki67 of >...
What would be your RT volumes and dose?
Is there a particular sequence you would adjust contributing antirejection or antimicrobial medications? Is the use of G-CSF appropriate and at what c...
If so, what agent(s) do you prefer?
Can you expand on this by sharing exactly what this routine workup should include? What additional tests outside of evaluating for POEMS and amyloidos...
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...
What is your duration of anticoagulation?
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 ...
Would you move straight to second-line systemic therapy or first attempt consolidative ISRT/boost, or employ both? Assume node is biopsy-proven.
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...
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?
Insurance won't pay for harvesting if the transplant is not done within a year.
Are there specific clinical, patient, or disease factors you focus on?
Does this data change your preferred first line treatment regimens when considering other options such as mAb combos, cytotoxic chemotherapy?
Is the non-inferiority margin of 1.429 sufficient, how was this selected?
Is the open label (rather than blinded) study design of any concern?
Is th...
Can experts comment on fungal pneumonia risk with individual BTK inhibitors as seen in ELEVATE-RR and whether this impacts their management decisions?
Do you feel comfortable with BTK inhibitors in these patients?
In ELEVATE-RR patients on a/c were excluded, and rate of atrial fibrillation in the ac...
Such as patients with specific underlying cardiovascular risk factors or other medical comorbidities?
Is leukocytosis and thrombocytosis alone an indication for treatment?
Is the therapeutic purpose of the proteasome inhibitor to maximize total dosage per week or number of infusions per week?
Do you ever recheck JAK2/CALR/MPL/BCR-ABL? Would you recommend a bone marrow biopsy? Is cytoreductive therapy indicated?
Is there a role for aspirin or hydroxyurea? Do you perform phlebotomy, and if so, what goals?
In the case of subtle single lineage dysplasia with normal cytogenetics, do you routinely perform NGS testing for CHIP-type clonal mutations?
Do you ...
Recommendations in guidelines are discordant (ASCO vs NCCN vs UptoDate).
What if the patient is no longer responding to steroids?
Is there data that it actually helps ?
While low-dose aspirin for primary thrombosis prevention in aPL without APS is not typically recommended outside cardiovascular prevention guidelines ...
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...
Is it safe to challenge with other CD20 monoclonal antibodies such as obinutuzumab?
Would you get bone marrow biopsy periodically? Would your approach change based off specific age or platelet count?
Would appreciate expert opinion on when to reimage and when to restart anticoagulation depending on findings.
If yes would you delay initiation of antineoplastic therapy to allow time for the vaccine to start acting?
Is this a reason to start hydrea? Would you give oral iron after adequate control on hydrea?
How would you approach a patient who is intolerant of AI and develops thrombosis while on SERM?
Would your recommendation change based on grade and/or location (weight-bearing vs non weight-bearing bone)?
There are multiple difficulties that could be seen: steroids can precipitate a sickle cell crisis, vasculitis and sickle cell can produce similar clin...
Would your recommendations change if the mass were significantly smaller, say 1-2 cm, and was completely excised with negative margins?
Patient with ferritin level <1000 ng/mL and no evidence of end-organ damage
While there are many factors involving:- type (DVT vs PE, unprovoked vs provoked) and severity of venous thromboembolism (VTE) size- duration of antic...
If all work-up including peripheral flow, bone marrow biopsy, PET-CT returns negative, what additional management (if any) would be recommended?
When do you start treatment in this case?
Does manipulation of blood products (leukoreduction, irradiated) affect your approach? There is growing evidence that routine premedication (at least ...
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...
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?
How is this impacted by patient features, cytogenetics/disease biology, depth of response, or other factors? What would compel you to continue 3 drugs...
How do you factor in patient age, frailty, patients with underlying organ dysfunction, or other clinical features?
Do you still consider CyBorD or R...
e.g. a genetic mutation picked up through a family member
Does transplant eligibility make a difference for management?
Do you opt for VRd, DaraRD, CyBorD or another regimen?
How would this change for a patient with high risk cytogenetics?
In your experience, do certain regimens have more cumulative toxicity, financial impact, or patient convenience factors?
Do you recommend therapeutic phlebotomy to a certain Hct goal? Any strong evidence for thromboembolic risk related to erythrocytosis or if this is mit...
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...
Are there scenarios where you would use a higher dose of lenalidomide in a novel doublet or triplet (eg. relapse on lenalidomide maintenance)?
Given recent data in Blood (Moik et al, 2021), and the potentially overlapping risks with other clinical factors associated with NSCLC.
Will you alte...
Is there any difference between anticoagulants in this clinical context (e.g. anti-Xa inhibitors vs warfarin vs LMWH)?
Is there a role for empiric antibiotics if there is history of opportunistic infection?
With a strong family history
When do you consider initiating eculizumab?
What are your target goals during transfusion, either prophylactically or during acute complication? Does your management change between vaginal deliv...
The use of anti-fibrinolytics is typically contraindicated in DIC, but does it have benefit in DIC states characterized by hyperfibrinolysis?
Does the rate of progression of IgM influence your decision?
Does having a concurrent consumptive process e.g. DIC change your management?
Would you change your radiation therapy treatment dose or volume if you needed to treat a chloroma? If a patient had a separate cancer (e.g. skin canc...
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?
Are there any subsets of patients that you're more inclined to offer maintenance?
What is the potential differential diagnoses for low iron saturation?
AstraZeneca may cause PF4 antibodies leading to vaccine-induced prothrombotic immune thrombocytopenia (VIPIT).
Are there other regimens you employ for patients unsuitable for standard chemotherapy?
Do you always treat with the full 21-day treatment course, or can defibrotide be stopped if certain criteria are met sooner?
Assuming the patient is a candidate for all anticoagulation options (no mechanical valve, antiphospholipid syndrome, patient-specific contraindication...
Is Ommaya placement with CNS-directed therapy preferred to intrathecal or cranial irradiation? How do you interweave this therapy with systemic therap...
Excluding clinical trials
Do you prefer a cHL chemotherapy backbone or PMBL chemotherapy backbone?
Given nationwide shortage in vinblastine, several of my patients under active therapy are facing delays in their therapies. Is it appropriate to subst...
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...
Would you use R-CHOP or a more intensive chemotherapy regimen? Would you consolidate with radiation therapy after 3 cycles or use systemic thera...
While the CKD population is at high thrombotic and bleeding risk, would you consider anticoagulating a patient prophylactically if they had a history ...
The patient who has not responded to steroids, rituximab/bendamustine, and splenectomy?
In a patient with severe factor XII deficiency with a baseline prolonged PTT, what is the best method to monitor their ACT or heparin levels when on c...
How do you approach systemic therapy options? What are your recommended volumes?
Would you give a trial of IST first or immediately refer for SCT if the patient has matched siblings?
Would you consider high-dose dexamethasone (deliberating adverse effects of antenatal steroids) or move to next-line therapies?
Has your medical practice taken any steps either in community outreach or within the clinic to show support for this medically vulnerable population, ...
For a patient with low ferritin, but high TSAT?
Ref: EINSTEIN-CHOICE and AMPLIFY-EXT
Would you approach this differently in patients with inherited thrombophilias?
Does your recommendation differ between autologous and allogeneic transplants?
Does your recommendation differ in allogeneic transplant recipients wh...
For example, in cold agglutinin disease or AIHA, antibodies can be detected via DAT, but are often not observed on assays for monoclonal gammopathies.
Would you offer refractory doses (40-50 Gy) to the RPnodes and send for splenectomy? Or would you offer refractory doses to both RP nodes and spleen?&...
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.
In low-risk patients (age < 40) or patients with very obvious causes of blood loss or iron deficiency (menorrhagia, pregnancy), do you routinely pe...
Are there effective therapy options that do not include steroids?
When do you consider splenectomy? Is there a role for splenic radiation in non-surgical candidates?
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?
Are there particular mutations (eg SF3B1) or syndromes (eg MDS/MPN overlaps such as MDS/MPN-RS-T) where you are more apt to using lenalidomide?
For instance, if the tissue came back SLL, Waldenstrom's, follicular lymphoma, or even nodular lymphocyte-predominant Hodgkin lymphoma, would any or a...
Such as a patient who cannot tolerate oral iron and has had a anaphylaxis to intravenous iron
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.
For example, in a young patient where standard fields would be very large and you want to minimize toxicity
Presented at ASH: FLIGHT trial
An otherwise healthy patient with spleen only diffuse large B cell lymphoma with mild spleenomegaly, Spleenectomy plus Rchop or Rchop plus RT?
If so, what additional testing do you send?
For example, a patient on cytoreductive therapy and aspirin BID, but suffers an arterial event, or a patient who is already on therapeutic anticoagula...
In a patient with a medical or personal indication to induce oligomenorrhea/amenorrhea, how would you manage OCP therapy if a patient develops a VTE d...
If autoimmune neutropenia already suspected, is this test informative or unnecessary?
What is the lowest level you have seen with uncomplicated or complicated crises?
Can results from emerging AML data be extrapolated to high risk MDS populations?
Is there data to guide the choice of continuing the HMA in combinati...
Relapsed disease occurred 3.5 years after initial treatment
Do you go straight to TMPRSS2 genetic testing or what other lab testing (e.g. hepcidin) could be helpful?
There are various formulations of intravenous iron; each with varying costs, test dose requirement, elemental dose, and number or time of infusions ne...
If there are a low-risk patients who can be monitored, how would you do so?
If unprovoked, would you consider stopping anticoagulation?
Individuals with MPNs may be at higher risk for thrombosis and be placed on antiplatelet therapy or even anticoagulation because of prior thrombosis. ...
Should we use a different dose in critically ill patients in the ICU? When should we consider intermediate-dose anticoagulation?
What if it is a young patient?
Is there a preferred strategy of transfusional support versus reduced-dose anticoagulation during the duration of thrombocytopenia?
In this scenario, is systemic treatment better given bilateral involvement? In a patient who has already had cataract surgery and is not at risk for c...
Does your dose recommendation change if a patient has cord compression or has undergone surgery? There is a range of doses in the ILROG guidelin...
Is there any data justifying the use of systemic therapy over localized therapy (e.g. radiation or surgery) in this situation prior to a progression e...
Rituximab has entered the treatment algorithm in the first-line setting for the initial treatment of TTP. However, in remission, the role of adjuvant ...
What if this was "triple-negative" antiphospholipid syndrome?
Does recent iron intake affect the iron panel, and if so, do you often order fasting labs in practice?
Does your opinion change based on the specific underlying inherited thrombophilia? The original case was a central retinal artery occlusion in a patie...
Especially in a patient without hemophilia or thrombosis history?
Do you only give intrathecal chemotherapy or systemic therapy?
What are the scenarios in which a rebiopsy is warranted for follicular lymphoma?
Would you offer this routinely or only if specific complications arise, such as distal emboli?
Does the absence of an OS benefit in the AG221-AML-005 presented at ASCO 2020 deter you from this strategy?
CT scans show omental and pelvic disease.
At what point would you recommend transfusion? At what point would you stop radiation?
In patients who are intolerant to hydroxyurea, anagrelide and interferon
Is there any benefit to getting it prior to starting cytoreduction?
Would you consider “bridging” therapy with something like an HMA?
Would it make a difference if the VTE diagnosis occurs during bevacizumab therapy or whether it preceded the cancer diagnosis?
Is it at neutrophil recovery, at documentation of CR on bone marrow biopsy, or is there a different point in time?
The patient received R-EPOCH followed by consolidative RT (36 Gy in 18 fractions) approximately one year ago and was subsequently salvaged with RICE.
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?
Do you offer adjuvant chemoimmunotherapy after IFRT for Stage I to II low grade follicular lymphoma?
TROG 99.03 showed nearly 20% improved PFS at 10 years with chemoimmunotherapy despite 31/75 patients assigned R-CVP vs 44/75 assigned CVP without ritu...
For example, for joing replacement surgery? Do you hold the revlimid for certain about of time before and after?
Is there a preference for obinutuzumab over rituximab in early relapsed DLBCL, or in primary refractory disease?
There seems to be a wide variety of palliative doses used in clinical practice (8 Gy x 1, 2 Gy x2, and 20 Gy in 10 fx). Do you have a preferred ...
If so, what dose would you recommend?
For instance, would you discontinue when there is resolution of adenopathy and normalization of counts? If so, do you overlap ibrutinib with other the...
The NCCN recommends both regimens.
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...
How do you decide between WBRT, maintenance chemotherapy, or stem cell transplantation?
The unfavorable risk factors for stage I-II Classic Hodgkin's Lymphoma differ depending on the cooperative group (GHSG, EORTC, NCCN), which criteria d...
Risk of CNS relapse in a reported series is less than 5%.
Given the rarity of DLBCL with MYC/BCL2/BCL6 rearrangements, do you approach this disease differently than DLBCL with MYC/BCL2 or BCL6 rearrangement, ...
Or do you consider addition of this agent in the re-induction setting for refractory disease?
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...
Do the potential late effects offset any benefit of mediastinal XRT in a young patient with bulky disease?
To me, the recent NEJM study is flawed in that the control arm did not have maintenance treatment while the experimental arm used maintenance Dar...
Would you proceed to autologous transplant, or switch to an alternate regimen (eg. daratumumab-based) first?
Would the type or degree of organ involv...
If so, what is your approach to laboratory and clinical testing?
In a patient with no evidence of bleeding, do you use a platelet cutoff? Do you utilize genomic testing (eg CALR, MPL, JAK2, etc.) to decide on cytore...
Once a tissue biopsy has confirmed light chain amyloid, what additional tests do you perform as part of a standard workup?
In whom should treatment b...
Do these events mandate discontinuation of lenalidomide therapy or switching to a different agent? Can appropriate therapy for these skin cancers be r...
For a stage IAE DLBCL (in this case, of the oral cavity) that was completely excised, s/p R-CHOP, is the ISRT target volume just the preop volume plus...
(ie Deuvelle criteria 1-3) Is it appropriate to discontinue brentuximab like you would with bleomycin?
Specifically, do you consider repeating maintenance therapy after second line therapy if a patient had already received 2 years of maintenance rituxim...
If a young and otherwise healthy patient with normal echocardiogram and no other cardiac risk factors needs treatment for DLBCL, but has previously re...
Would you still proceed to high-dose therapy and autologous SCT?
Would you incorporate radiation pre- or post- transplant? Or offer additional salvag...
If the patient has not experienced significant infectious complications? If so, what agent?
How would your dose and/or volume change if the patient refuses chemotherapy?
Specifically, do you utilize 3 cycles of chemo with ISRT or 6 cycles? Do you use R-EPOCH or R-CHOP in these cases?
For instance, do you ever start with dasatinib 50 mg daily? Are there any titration schedules that you follow?
Any experience treating patients prone with openings for both breasts, no minimize breast overlap with axilla and mediastinum?
Given the PFS benefit seen in the most recent ECOG-ACRIN, and the prior study of Rd showing an OS benefit, is your practice to put any high-risk SMM p...
e.g. mixed indolent/aggressive NHL, mixed NHL/HL? Is there a definitive way to discern composite from transformation? NCCN does not list recommendatio...
if so, are there specific cytogenetic, molecular, clinical, or hematologic factors that you take into consideration?
Have you changed your practice based off the FLYER trial presented at ASH 2018?
The patient is not a transplant candidate due to multiple co-morbidities. Some of the sites in question have had a complete response and other have ha...
How would you handle high risk features (eg double hit) with the limitations of dialysis?
What dose and fractionation would you recommend for a localized primary bone marginal zone lymphoma?
The patient has no bone marrow involvement.
Although not approved, for example, are you every using AVD-nivolumab?
Would you give 3 cycles of RCHOP followed by consolidative IFRT or 6 cycles of R-mini CHOP? Is there a role for 3 cycles of R-mini CHOP followed by IF...
Assuming the patient has an indication for treatment.
Thrombosis was ruled out and no etiology was found. Would you start ponatinib back at a lower dose, transition to omacetaxine or begin transplan...
Assuming there are no other indications at the moment.
Some specific questions:
Would you recommend repeat biopsy to confirm residual disease?
How would your recommendations vary if the patient had pre...
Would this affect your decision regardless of the stage and symptoms?
Do you await molecular and cytogenetic results prior to initiating therapy, or does age and function status primarily drive your choice?
NCCN does not list any preferences for the TKIs in their guidelines.
If the breast was previously radiated 15 years ago, would that change your decision?
If there was residual lymphoma on cytology of a chronic se...
I.e., Can day 2 Rituximab (RCHOP) or day 6 Rituximab (DA-EPOCH, Hyper CVAD) be given? Or should only Day 1 Rituximab be used with chemoimmunotherapy i...
Would you recommend RCHOP x 3-6 or RCHOP x 3 + ISRT? If you end up doing ISRT, would your target be any different than the principles that guide...
Since some prior studies (eg. Eskelund et al. Blood 2017 130:1903-10.) have shown intensive chemoimmunotherapy does not overcome the ad...
Since ECHELON-1 trial showed an improvement in PFS (but not OS), are there any situations where you would replace bleomycin with brentuximab...
Is your scoring based on SUV uptake vs the subjective interpretation of the radiologist? How do you go about reconciling Deauville scoring when there ...
For example - Would you offer tandem transplantation in a young, fit patient in a CR after first transplant, but with MRD detectable?
Would you follow an algorithm such as the one proposed by Hall et al?
How do you decide between intrathecal chemotherapy vs systemic therapy with HD-...
Pathology is clear this is not a concurrent DLBCL and is indeed transformed CLL
FDA package insert lists posaconazole as strong cyp3A4 inhibitor and states to consider other therapies.
Can it be added after 2 or 3 cycles of HMA?
Does presenting total white blood cell count affect your decision? Does myeloid subtype affect your decision?
How might your decision change if the patient had a suitable 10/10 donor? How about if the patient had a targetable molecular mutation such as IDH2?
Repeat EGD and additional biopsies of the stomach were all negative for MALT lymphoma and H. Pylori. A CT of the C/A/P was done showing no evidence of...
Although the MMR vaccine is contraindicated in immunosuppressed patients on anticancer treatment according to CDC/ACIP and IDSA guidelines, data on sa...
Is there a specific Ki67 percentage? P53-negativity?
For example, would you go ahead with 20 Gy of ISRT if medical oncology has already treated a stage I-IIA patient with 2 cycles of ABVD meeting all oth...
If they are symptomatic do you relax that time interval? Do you ever consider partial brain radiation instead of whole brain to minimize neurotoxicity...
In a patient who absolutely cannot receive chemotherapy due to impaired performance status, what dose would you use for WBRT and what dose would you u...
I have received inquiry from a patient's gastroenterologist regarding use of Entyvio or Stelara in such a situation.
Prior trials of systemic therapy including alkylating agents and rituximab have failed and the patient is medically inoperable with no history of Hepa...
The staging bone marrow biopsy was negative. The staging manual simply states "bone involvement is identified using appropriate imaging studies."...
Given the recent results presented from the Griffin trial, would you choose a daratumumab-based regimen (eg. D-VRd) over other salvage options (V...
Would you use a similar dose and fractionation as gastric MALT (30Gy in 1.5 Gy fractions)?
Should prechemo PET positive disease from bowel or other structures be carved out?
Would the site of disease relapse play a role in your decision (i.e. isolated lymph node recurrence versus failure at primary site of disease)?
Has the recent data presented at ASH affected your choice of regimen?
Would your choice differ between transplant-eligible and transplant-ineligible ...
Shanafelt et al. recently presented results from the phase III E1912 study at ASH 2018. Will you still utilize FCR as first-line or now use Ritux...
Would MRD assessments affect your clinical decision making for MM patients outside of a clinical trial?
Do you use etoposide-based regimens such as R-CEPP? How about substitution with liposomal doxorubicin?
Do you generally always boost the scalp and/or soles even if those sites are not involved with disease?
Would you consider observation following surgical resection with negative margins? Would you recommend WBRT and/or ISRT? What would be your preferred ...
Specifically, what regimen would you choose in a patient with new renal failure but not requiring dialysis?
What factors influence your decision (patient/disease characteristics, additional agents added to induction chemotherapy, CR1 or later, etc)?
If a patient obtains a PR or less to front line cladribine, what factors help you chose between a second course of cladribine, an alternative pur...
How about if disease is found in the CSF?
When is it warranted to utilize targeted therapies for known mutations (eg. midostaurin or an alternative TKI for FLT3 mutations, ivosidenib for ...
Does the choice of initial induction regimen affect your decision for when to employ lenalidomide maintenance?
Are there situations where you would c...
Are you routinely using letermovir as CMV prophylaxis in high-risk patients?
Any special considerations with its use versus other antiviral agents?
...
Would you consider switching regimens?
Would you treat differently for de novo disease vs disease arising from large cell transformation of an indolent NHL?
Given the rarity of this in MF, is it still predictive of response to lenalidomide therapy?
Does their candidacy for autologous HSCT affect your decision to use maintenance lenalidomide?
The patient had a bilateral orchiectomy (pathology demonstrated no invasion of the tunica) followed by R-CHOP x 6 and IT Mtx with a PET CR in a para-a...
The patient is a 75 yo immunocompetent man who has a history of inverted papilloma of the sinuses and presented with a new lesion in the right maxilla...
Would you change to an alternative triplet therapy, or switch to maintenance therapy?
Are there variations in depth of response short of CR that woul...
Does the more recent data regarding the continued utility of brentuximab vedotin and the utility of PD-1 inhibitors factor in to your reasoning at all...
Do you have experience administering these agents in the outpatient setting?
Could one make a case for addition of Rituxinab frontline to increase the chances of a complete remission and even maybe achieve MRD-negative status ?
Does it differ from the treatment of other relapsed peripheral T-cell lymphomas?
Are there any clinical trials or case series focused on SPTCL?
Is t...
Do we continue the hypomethylating agent indefinitely?
Technically, you can have up to 55% of larger cells circulating and still be called CLL.
Would you observe until progression or would you place the patient on maintenance?
Would you use 10 Gy in 1 Gy per fraction as mentioned in a litterature review in Pubmed?
What factors influence your choice to treat as well as dose and target?
Once you decide to begin treatment, any special precautions you would use for protein levels starting that high.
The patient does have significant weight loss, drenching night sweats, but no evidence of other involved sites on PET, thorough skin exam, and has nor...
In the case of an excised groin node with no residual disease and no chemotherapy in a young adult patient, how large should the fields be? Is it requ...
Assuming that the involved area is too widespread for RT. Would you try single agent rituximab first? Or obinutuzumab? What if rituximab alone gave on...
The recent NEJM phase II trial http://www.nejm.org/doi/full/10.1056/NEJMoa1715519?query=featured_home looked at a small cohort of 24 patients and show...
How do you choose between 3 and 4?
the MZL was untreated in the past prior to transformation.
Do these patients have a higher risk of recurrence post CR as opposed to patients with de ...
How do you get 17p testing on someone with only lymphadenopathy
I have a patient with low volume disease of Castleman's disease with cervical lymphadenopathy and tonsillar hyperplasia that is suspicious but not bio...
If a patient has an increase in PET avidity between the PET/CT done after 2 cycles of ABVD and after completion of chemo, how would you proceed? Would...
Specifically, in patients that had progression or developed toxicity on ibrutinib? Idelalisib is very toxic and venetoclax a labor-intensive drug to g...
Even though Venetoclax is not FDA-approved yet, assuming you can get it off label?
1. Gemtuzumab: What dose/schedule and which HMA?
2. Venetoclax: W...
Would you consider resection? Or maybe anti-CD20 monoclonal antibody?
My practice had always been to transfuse for plts < 10, but the recent ASCO guideline change suggests that in the post-autoSCT setting it is ...
In the absence of any other classic CLL indications for treatment.
Does your follow-up differ depending on the dose you used (e.g. boom boom vs. 24 Gy)? Do you routinely image? If so, do you use MRI or PET...
If filgrastim, how many days would you give? Pegfilgrastim is often not covered by payers if given less than 14 days before chemotherapy.
The patient has no medical problems and no history of leukemia/MDS. Biopsy of the filum terminale and arachnoid confirmed a myeloid sarcoma and MRI sh...
Subq has been shown to have lower risk of neuropathy. Is there any reason to use weekly IV still?
Would it change your management if patient if IgVH mutated?
This is a recently described entity with poor prognosis, so even with a CR after RCHOPx6 cycles, is your bias to push for ISRT due to EBV being poor p...
In a patient with multiple poor risk features including TP53 mutation, 1q amplification, stage III, and circulating plasma cells, would you consider a...
For example, how significant does the M protein have to increase for you to begin a conversation about new therapy?
If the patient had a CR by PET/CT after 2 cycles of ABVD and received 6 cycles of ABVD would you recommended consolidating only the bulky disease and ...
Specifically, to you lean towards elotuzumab or a daratumumab-based regimen?
What technique do you use (IMRT vs direct electrons w bolus)?
The ILROG paper on extranodal NHL says "For tumors confined to the conjunctiva or...
If a patient will receive a total of 4 cycles ABVD and has a CR by PET/CT after cycle 2, can RT be omitted to non-bulky sites to avoid toxicity?
Specifically I am thinking if a PET scan shows complete response, would it be reasonable to stop bleomycin and continue AVD?
What dose and volumes would you use?
Drug information indicates a patient may need 3-4 months off TKI. This seems like a long time off drug. Would a MMR of a certain duration make it less...
Would you ever give another IMiD?
Specifically when given as a single agent. Any role for G-CSF?
PET/CT/bone marrow biopsy negative for evidence of distant disease. Following 4 cycles of combination chemotherapy with no evidence of progressive dis...
With the advent of many new agents, any thought to initial therapy different from CHOP or CHOEP?
For example: would you treat the entire Waldeyer's ring? For a stage II patient who also has cervical lymph node involvement on one side, do you...
At what point is the neuropathy a contraindication to further bortezomib therapy?
Although bendamustine + rituximab is a standard option for advanced follicular lymphoma when treatment is required, does the regimen rituximab + lenal...
Specifically, can you rechallenge after the effusion has resolved (e.g. therapeutic thoracentesis)? If so, how long do you wait to rechallenge (especi...
Imatinib, or a second-generation TKI? Are there specific factors that make you choose one over the other?
We often see young women with favorable, early stage disease in the mediastinum who have had a complete response to chemotherapy. With current smaller...
If so, do you use antivirals and/or antibiotics? Does it matter if the patient has mantle cell lymphoma, CLL, or Waldenstrom's macroglobulinemia?
How have the results of the UK RAPID study (Radford et al NEJM 2015) changed your practice?
Specifically, do you just wait for count recovery? Do you check for morphologic or molecular remission at all during this time?
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?
Specifically, is there still a role for dd RCHOP followed by ICE, or do you recommend DA-R-EPOCH for all patients?
What is the best evidence to support or refute this?
Would you include one vertebral body above and below the involved vertebral body? Is IMRT appropriate in order to reduce dose to small bowel? What oth...
NCCN guidelines suggest XRT as standard of care for this stage of disease. However, occasionally patients have their tumors completely excised when un...
Would you continue ibrutinib even if they are placed on anti-platelet therapy such as clopidogrel or ticagrelor?
What re-induction regimen without cytarabine or an anthracycline is likely to be most effective?
If a patient had recently completed R-EPOCH x 6 cycles, would you change your dose for a low grade follicular lymphoma?
Is surgery an adequate treatment for Stage IE DLBCL of the cervix?
What is the best treatment management of low grade early stage follicular lymphoma of the mesentery?
If the mesentery is widely involved with small lesions would this change your management? What if the patient was symptomatic?
When treating with radiation therapy, what dose-fractionation do you typically utilize?
What is the utility of repeating FISH studies to evaluate for clonal evolution if FISH studies were done at diagnosis?
The NCCN guidelines recommend all patients receive 3 cycles RCHOP followed by ISRT unless they have bulky disease greater than 7.5 cm. However, are th...
In what situations would you feel comfortable omitting RT to bulky disease in stage III/IV Hodgkin's lymphoma?
With the field moving more toward ISRT/ INRT, and conformal radiation, would you generate separate PTV for initial nodal involvements that are within ...
If so, what data should be presented to insurance companies to cover the cost?
What dose do you recommend?
When nodal regions not amenable to biopsy but are enlarged without significant SUV uptake, should they be treated as involed and recieve RT?
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...
Is there a preferred low dose splenic irradiation regimine?
When radiation therapy is utilized, what should the radiation therapy treatment fields include and what imaging studies should be completed to assist ...
If so, should involved site radiation thearpy (ISRT) or involved field radiation therapy (IFRT) be used for the radiation therapy treatment fields? Wo...
Are the results of AHOD0031 practice changing?
When the disease (in this case, lymphoma) involves almost all of the entire muscle compartment of the distal lower extremity, what is a safe dose? I'm...
In drawing the lung blocks approximately 1 cm in from the chest wall, diaphragm and mediastinum, should the blocks stop underneath the clavicle o...
If a patient with stage I, low grade follicular lymphoma achieves a complete response after rituxan and treanda is there any role for consolidative ra...
Specifically for marginal zone or follicle center?
Is it necessary to treat the whole orbit or is conformal treatment ok?
After a nerve sparing parotidectomy, would you offer postoperative radiotherapy? If so, what volume and dose? Would it change your management if the p...
In a patient with Stage IE DLBCL, is your treatment volume postchemo ISRT or whole breast? Would you consolidate if a lumpectomy was performed prior t...
Would you prescribe to a higher dose? Treat with wider margins? Encourage the use of systemic therapy?
Hoskin et al (Lancet Oncology 2014) suggest 24Gy/12fx is more effect RT dose compared to 4Gy.
Is there a benefit to IMRT when we treat to relatively low doses (as compared to squamous cell cancers of the head and neck)?
Or is it more appropriate for certain sites/stages/histologies?
Specifically, for a diffuse large B cell lymphoma of the femur?
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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