Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is the role of radiation in a patient with stage IV DLBCL with bilateral testicular involvement?
I tend to loosely recommend consolidation RT to the testicles in this situation if in CR. This recommendation is based on pattern-of-failure studies in primary testicular lymphoma where prophylactic contralateral testes RT is usually recommended, and the principle that the testicles are a sanctuary ...
What is the role of RT for a patient with double-hit DLBCL and a single site of relapse who can no longer tolerate chemotherapy?
Double-hit DLBCL, now referred to by the WHO as "High-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements" is an aggressive non-Hodgkin lymphoma. The MYC rearrangement results in accelerated growth of the lymphoma while a BCL2 rearrangement (more common than BCL6) results in an anti-a...
What is the optimal VTE prophylaxis for hospitalized patients with COVID-19?
At the moment, my personal recommendation, in general, is to follow the ASH guidelines. If the patient has cancer and other major comorbidities along with COVID-19, a discussion is warranted around adjusting the dose of anticoagulation to the presumed risk of VTE in the individual patient, understan...
Is there any role for direct oral anticoagulants in the treatment of antiphospholipid syndrome?
Triple-negative APS is a confusing category as includes seronegative APS, APS with non-conforming aPL such as anti-phosphatidylserine-prothrombin amongst others, and the universe of patients with thrombotic events unrelated to antibody-mediated hypercoagulable state (eg Protein S, C or anti-thrombin...
What is your approach for treating transplant-ineligible patients with relapsed blastic plasmacytoid dendritic cell neoplasm (BPDCN) who have progressed on tagraxofusp?
First, I would have to wonder why the patient is not transplant-eligible. A lot of times we say this, but evaluation at the transplant center might find a patient is eligible for a nonablative approach. Second, I would strongly recommend the patient enter a clinical trial. The mustang biotech bpdcn ...
What is the preferred immunosuppressive modality for patients with an acquired factor 8 inhibitor?
Classic steroids. If no response in a month, would consider cyclophosphamide. A variety of immunosuppressive agents have been used. In Chapel Hill, they use rituximab, but a fair number of patients have relapses and older groups get infections. I typically use rituximab last.
How do you evaluate an isolated prolonged aPTT in patients?
This is a common problem. First, if possible, find out if there has been a normal PTT in the past which usually eliminates inherited deficiencies. Second, take a bleeding and clotting history including family history, presence of known liver disease, and any medications. Sometimes it is not recogniz...
How do you manage VTE in the setting of persistent severe thrombocytopenia?
The thrombosis versus bleeding risk ratio should be weighed. The risk of VTE recurrence or propagation is highest in the first 30 days and we know that thrombocytopenia does not attenuate this risk. Providers should favor anticoagulation. In the case of cancer-associated thrombosis and chemotherapy-...
How would you approach moderate neutropenia (ANC < 1000) in a solid organ transplant recipient?
There are limited data addressing the safety and efficacy of G-CSF in the solid-organ post-transplantation setting. Most case series report no increase in graft rejection with G-CSF treatment, although this question is not rigorously answered. Most cases of neutropenia in the post solid-organ transp...
Are there any situations you would recommend prophylactic anticoagulation for a patient with Factor V heterozygosity?
In short, no. Thrombotic risk is a complex variable with many contributing components. The presence of a single FVL allele, while it appears to increase the risk somewhat, is not sufficiently predictive of overall risk to provide a basis for administering prophylactic anticoagulation in a clinical s...