Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you diagnose MDS in a patient with equivocal morphological findings?
Cytopenic patients suspected of having MDS may often have equivocal findings in the bone marrow such as insufficient dysplasia and a blast proportion of less than 5%. This does not necessarily preclude a diagnosis if other features are present. For example, persistent, otherwise unexplained monocyto...
For a patient with relapsed FLT3 positive AML on HMA and venetoclax, is there ever a role for the addition of midostaurin to the treatment regimen to improve response rate?
Short answer is no. The safety of the combination is unknown and there’s also not an indication for Midostaurin in relapsed AML. The trial that got Midostaurin approved was for combination with 7+3 in newly diagnosed patients. HMA+ venetoclax has better response frontline compared to relapsed/refrac...
How do you treat a gastric plasmacytoma which is not amenable to radiation?
This is a very difficult case. Plasmacytomas are very responsive to radiation. you need to determine reason for not doing radiation: is it location, active bleeding, Perforation? Location should not be a big problem for Radiation oncologist. they can use precision tools now to avoid other structures...
Do you include gemtuzumab ozogamicin for any of your newly diagnosed AML patients who are candidates for 7+3 induction chemotherapy?
Yes, I regularly add gemtuzumab ozogamicin (3 mg/m2 IV days 1, 4 and 7) to 7+3 (daunorubicin dose should be 60 mg/m2 IV days 1-3) in newly diagnosed AML in the following patient groups based on the ALFA-0701 data (Castaigne, Lancet 2012): 1) Favorable/Intermediate-risk cytogenetics- subset analyses ...
What positions and immobilization strategies do you use to minimize breast and heart dose when treating axillary and mediastinal nodes in young women with large breasts who require consolidative radiation (ISRT) for Hodgkins lympoma?
With photon based radiotherapy, I would use a 30 degree slant board if available, deep inspiration breath hold and partial arcs with avoidance parameters for the heart, lungs and breast. The other alternative here is protons.
Would you recommend consolidative radiation therapy to an isolated frontal dural MALT lymphoma after complete response to chemotherapy?
I would treat this with ISRT principles with generous dural margins to 24-30 Gy.
How would you manage a CML patient with a T315I mutation that developed severe abdominal pain requiring hospitalization after starting ponatinib 45 mg?
If abdominal pain started after ponatinib was started it is important to rule out complications related to the drug. Thrombosis was ruled out, which is important as ponatinib can cause venous and arterial thrombosis. It is also important to rule out pancreatitis. If no other etiology is found and th...
When treating DLBCL with induction therapy with R-CHOP, if after 2 cycles, you have a mixed response on PET, would you consider that treatment failure or would you continue R-CHOP?
First, it is not routine practice to evaluate response to RCHOP radiographically after 2 cycles of treatment for DLBCL. If there were clinical concern that the patient were not responding, and imaging was performed with a mixed response - both frankly progressive disease and responding disease - the...
For patients who have exceptionally long responses to HMA with high risk MDS or AML and not candidate for more aggressive therapy/transplant, do you consider treatment holidays or spacing out doses into longer intervals?
Over time, patients with MDS and/or AML on long-term HMA therapy tend to have lower counts, possibly due to less robust stem cell reserve. In general, we prefer to drop the dose (i.e. from 75mg/m2 to 50 mg/m2 for Azacitidine, from 20 mg/m2 to 10-15 mg/m2 for decitabine) as a first. In some patients,...
How do you treat a composite NHL of various subtypes?
There is no single answer here because composite lymphomas are highly varied and variable. The general principles here are to treat the component disease most in need of treatment, as best you can, and not to sacrifice curative intent for an aggressive curable component. For the case of composite ag...