Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Are there any special considerations when evaluating patients with non-malignant hematologic or immunodeficiency disorders for allogeneic transplant?
In most malignant diseases, we prefer to take patients to allogenic transplant either in complete or partial remission as it will take few months before post-transplant immune-reconstitution results in effective graft-versus-disease response. In non-malignant diseases, we take patients to transplant...
How do you decide between blinatumomab or traditional chemotherapy in combination with TKI for upfront treatment of adult patients with Ph + ALL?
This question is likely inspired by the recent publication of a "chemotherapy-free induction and consolidation first-line treatment" for adults with Ph+ ALL (Foà et al., PMID 33085860; GIMEMA LAL2116). The authors reported relatively high rates of MRD- remissions by bone marrow BCR-ABL1 RT-PCR and i...
What is the role of hydroxyurea in variant sickle cell genotypes?
I have had little success using hydroxyurea in my patients with hgb SC disease and at this point in patients with two or more acute visits over 12 months for pain, I am using crizanlizumab as some of the subjects in the phase 2 study on which the drug received FDA approval had SC disease (Ataga et a...
How do you treat a low-grade B-cell lymphoma with plasmacytic differentiation (Waldenstrom's) confined to the CNS?
This is a rare complication of WM called Bing Neelapu syndrome. It is hard to find a standard of care. Patients tend to have shorter responses to standard therapies such as HD MTX based regimens. Ibrutinib has shown long-term responses (Castillo et al., PMID 30523119).
Do you offer iron supplementation to a non-anemic adolescent athlete with a low ferritin?
I prefer having a TSAT on an overnight fast. Extreme athletes have increased hepcidin. If ferritin is greater than 30, my cut-off, no. If TSAT is 19 or less, yes. I would not criticize someone who gave iron, but PO iron is pretty tough to take. I would prefer staying within the current parameters of...
Would you recommend stem cell transplant or gene therapy for a patient with CML and sickle cell disease currently on imatinib with worsening anemia?
That's a great question. The first question to figure out is what is the status of the CML? If the patient is in a molecular remission on imatinib, I think it's important to understand why the patient has worsening anemia and do a work up. If the patient has anemia due to the TKI, can consider dose ...
How would you manage acquired von Willebrand syndrome secondary to a myeloproliferative neoplasm in a patient who is already on anticoagulation?
Acquired von Willebrand activity is something that can occur with MPN patients. It should be part of routine testing of patients with both ET and PV. Although, historically, usually thought of as a phenomenon of when platelets are greater than 1000, a recent publication (Rottenstreich et al., PMID 2...
What would be your choice for re-induction in a young patient with FLT3+ refractory AML after 7+3 induction therapy with no FLT3 mutation on the day 14 marrow?
I would use a 5+2 regimen with midostaurin and would not put much stock in an absent FLT3 mutation at day 14. If there had been no cytoreduction, some would switch to another chemotherapy regimen but there is little data for that especially in an FLT3+ AML. We are not told what the degree of respons...
What would be your choice of therapy in a fit patient with relapsed CLL previously treated with bendamustine and rituximab who does not want BTK inhibitor therapy?
I am assuming that this individual who has relapsed was receiving initial therapy with bendamustine rituximab is a young, under 65 years of age, CLL patient who does not prefer to have a BTK inhibitor. This is not an uncommon situation given the increasing knowledge of the chronic low-grade toxiciti...
Is a patient with secondary myeloid sarcoma a candidate for hematopoietic stem cell transplant?
There are circumstances where these patients would be candidates for stem cell transplant. The extramedullary presentation is thought to be a high-risk feature and many of these patients will have a relapse in marrow or other sites, so a stem cell transplant done after remission is achieved may help...