Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you consider splenectomy for an early stage l/ll primary splenic diffuse large B cell lymphoma followed by R-CHOP?
No reason to remove the spleen in most cases unless it was removed to secure the diagnosis. In this case, I assume the spleen was biopsied already? I would treat as you would a stage I DLBCL (the spleen is nodal tissue), but consider 6 cycles of R-CHOP if possible. If CR by PET at the end of treatme...
Would you consider giving ESA for anemia secondary to chronic kidney disease in a patient with follicular lymphoma in remission and on rituximab maintenance?
Yes. The risk of ESA has been re-evaluated and is not considered a risk of NHL. Even with the prior retrospective data, follicular lymphoma is not a curable disease and therefore ESA would not have been contraindicated.
How do you determine whether to treat a young adult with stage IA Hodgkin Lymphoma with the adult or pediatric treatment paradigm?
There is a long history of pediatric protocols for HL differing somewhat from the adult ones, but not much biologic rationale to support this, as the disease in young adults is biologically the same as in pediatric patients. Side effects of RX may of course differ, particularly with regards to RT an...
Should patients with bleeding disorders increase their home supplies of clotting factors foreseeing a possible shortage of product availability due to COVID-19?
No. The Medical and Scientific Advisory Council (MASAC) for the World Federation of Hemophilia recommends against increasing the already recommended home supply of clotting factors: One month worth of regular prophylaxis doses if on a prophylactic regimen; and one major correction dose, and two mino...
Are patients with bleeding disorders receiving plasma-derived products at increased risk of acquiring COVID-19?
No. The current process of manipulation of plasma derived products eliminates SARS-Cov-2. SARS-CoV-2 is a large virus (120 nm diameter) with a lipid envelope. Therefore, it is highly susceptible to processing steps used in processing such as solvent-detergent, low pH incubation, caprylate-pasteuriza...
Do you routinely prescribe anticoagulation for patients on active chemotherapy?
This is dependent on the risk factors of the patient for the development of VTE. Recently published ASCO guidelines (JCO 2019) incorporated the additional recommendation of VTE prophylaxis for high risk outpatients receiving chemotherapy with either eliquis, xarelto, or LMWH. The Khorana scoring sys...
What is the best approach for patients with DLBCL with early relapse (< 6 months) after initially attaining a CR with 6 cycles RCHOP?
Early relapse, regardless of interim imaging, suggests chemorefractory disease. It may be that we selected a more chemo/rituxan resistant clone that comprised a smaller % initially that has now become dominant. Regardless of pathophysiology, I think for today we are stuck with the same paradigm: sal...
When during ALL induction therapy are you checking for MRD?
It is generally advisable to measure MRD from a bone marrow aspirate at the end of the first course of therapy for ALL. If a pediatric-inspired regimen such as CALGB 10403 is being used, undetectable MRD after Remission Induction (i.e., approximately Day 28) is associated with an excellent rate of d...
Would you stop hydroxyurea for thrombocytosis in a prostate patient receiving radiation?
In cervical cancer literature, when hydroxyurea was used with RT as a radiosensitizer, acute side effects were significantly increased, including myelosuppression. I would consider holding it during RT.
What is your approach to advanced Hodgkin Lymphoma when bleomycin is contraindicated and infectious complications arise with A-AVD?
This is a very good question and a bit complicated. In patients with advanced HL, for whom 6-8 cycles of treatment would be the typical course, I try to maximize the dose intensity and density even in the face of infectious complications. That said, if a patient is already receiving growth factor su...