Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you approach the outpatient management of bispecific antibody therapy for hematologic malignancies?
Multiple bispecific antibodies (BsAbs) targeting CD20 on lymphoma cells and CD3 on T-cells are now available in follicular and large B-cell lymphoma. A multi-disciplinary team with knowledge of the different BsAb indications and possible toxicities is an important aspect of safely administering thes...
How would you manage relapsed DLBCL in a patient who received second line CD19 CART treatment?
With commercial CD19 CAR-T therapy moving into earlier lines of therapy, post-CAR-T relapses are now more common. There are still many options depending on what first-line/bridging therapy was given, CD19/20/30 expression, and patient preferences. I always get a biopsy if feasible to confirm relapse...
What initial workup do you perform when there is a concern for porphyria?
This is a terrific question. But a broad question. Porphyria refers to a defect in heme biosynthesis leading to the accumulation of porphyrins and porphyrin precursors. We should remember that there are three general categories of porphyria based on clinical manifestations: acute hepatic porphyria (...
When would you opt for a chemotherapy free approach in the first line treatment for hairy cell leukemia?
This is an outstanding question and there are a few reasons to consider treatments other than cladribine or a chemotherapy-free approach. I have considered and used alternatives in special situations, mostly those with infections. I will limit this to the treatment of classic hairy cell leukemia as ...
Has your practice changed to PLEX-free initial therapy for iTTP?
I am not. The reason is that caplacizumab is not on formulary at my institution, and so implementing PLEX rapidly while obtaining caplacizumab (which typically arrives in 24-48 hours) is my current practice. If I had caplacizumab on formulary, I would utilize it as it was utilized in the MAYARI tria...
How would you work up a patient with cutaneous mastocytosis?
Is a BM biopsy a must when there is skin involvement? I think a bone marrow biopsy for cutaneous mastocytosis is most helpful when it is in the setting of a patient being referred by dermatology for a skin biopsy result showing TMEP (telangiectasia macularis eruptive perstans) since TMEP has been ...
Would you use the pneumococcal conjugate-21 vaccine (Capvaxive) instead of the conjugate-20 (Prevnar-20) for routine vaccinations in immunosuppressed patients?
PCV-21 was recently approved by the FDA and supported by ACIP. At this early stage (August 2024), CDC has not finalized guidance on PCV-21, so we do not know how the vaccine schedule will be changed. An important distinction is that PCV-21 covers different serotypes of pneumococcus, as outlined in t...
When, if ever, would you select a three-drug regimen instead of four-drug regimen in patients with newly diagnosed Multiple Myeloma?
Thank you for this question. For older, transplant-ineligible patients, there is no data that patients live longer or better (the true goals of treatment) with four drugs instead of three drugs. Yes, the responses are better, and we hope this may translate to longevity over time, but we do not know ...
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
How do you approach the risk/benefit discussion for IV iron in a patient with concomitant severe iron deficiency and elevated hematocrit due to supra-physiologic testosterone supplementation?
I only administer iron if symptomatic (pagophagia, RLS, etc). I have not seen iron deficiency with testosterone prior to phlebotomy. When it is required, I literally walk both sides of the aisle. If a non-phlebotomized patient presented with ID, I would work it up like any other. If I have to treat,...