Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you consider a patient with DLBCL to have CNS involvement if no brain lesion is seen on imaging, CSF flow cytometry is negative, but PCR is positive for MYD88 and KMT2D mutations?
Cerebrospinal fluid (CSF) is an ultrafiltrate of plasma contained within the ventricles of the brain and the subarachnoid spaces of the cranium and spine. It is possible that cfDNA fragments containing MYD88 and KMT2D mutations may have found their way into the CSF and thereby detected by PCR techni...
What are your practical considerations for incorporating bispecific antibody therapy into treatment of relapsed DLBCL?
In relapsed/refractory DLBCL, if the patient has not yet received bispecific antibody (BsAb) and/or CAR T-cells, and the patient is eligible and able to receive CAR T-cells, I favor CAR T-cells before BsAb, given extensive follow-up time demonstrating CAR T-cells are a potentially curative approach ...
How are you deciding between available third line therapies for post-transplant relapsed DLBCL?
If a patient relapses after an autologous stem cell transplant and is a candidate for CAR T-cell therapy, I would proceed with CAR T-cell therapy given longer follow up compared to bispecific antibodies, and thus a portion of the patient can achieve a durable complete response. For patients that rel...
What is your preferred first line treatment regimen for patients with untreated transplant-ineligible MM?
For transplant-ineligible patients, there are many excellent choices, including RVD lite and Dara Rd. My practice has shifted to Dara Rd for several reasons: The HR for Dara Rd v. Rd which is 0.56 appears to be better than the HR for RVd v. Rd in SWOG 0777, where it was 0.712 (though it should be no...
Can RT to non-bulky sites be omitted in an early stage (stage I or II) classical Hodgkin's lymphoma case with a CR by PET/CT?
Randomized studies have consistently demonstrated that combined modality therapy is superior to chemotherapy alone in regards to progression-free survival in early-stage Hodgkin lymphoma. The magnitude of the benefit varies across studies, but a relative risk reduction of ~50% can be expected which ...
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
How would you select patients for epcoritamab + R² versus R² or other regimens at second-line relapsed/refractory follicular lymphoma?
In second-line relapsed/refractory follicular lymphoma, I would now view epcoritamab + R² as the preferred option for many patients who are appropriate for active immunotherapy and can tolerate the added cytopenia/infection monitoring. The EPCORE FL-1 data are compelling: ORR 95% vs 79%, CR 83% vs 5...
What is your preferred iron loading strategy for patients with anemia of chronic kidney disease?
My preferred iron loading strategy for patients with iron-deficiency and non-dialysis dependent (NND) CKD is to administer 1 gm IV iron in a single infusion and have it paid for by the patient's health insurance. That excludes sodium ferric gluconate and iron sucrose which require 4-5 infusions to a...
In a patient with cardiac light chain amyloid who has significant heart failure symptoms, including inotrope dependence at presentation, how much clinical benefit does treatment provide?
In patients with cardiac light chain (AL) amyloidosis who present with significant heart failure symptoms and inotrope dependence, the clinical benefit of treatment is a complex and nuanced issue. This scenario often reflects an extreme end of the disease spectrum. Historically, patients with advanc...
Is there a role for anti-fibrinolytic agents in patients with hyperfibrinolytic disseminated intravascular coagulation?
DIC is a complex clinicopathologic syndrome. There are no randomized trials to support evidence-based practice. The following principles apply: 1) antifibrinolytics should not be used in patients with organ failure or those that are asymptomatic. One could justify their use in this group of patients...