Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you consider just treating radiographic residual disease (as opposed to all original sites of disease involvement, per ILROG guidelines) in a patient with bulky early-stage Hodgkin's lymphoma of the mediastinum?
If the patient is treated with > 4 cycles of chemotherapy and the disease is considered chemo-refractory, and if dose constraints to critical structures especially to the lungs can be achieved, I would recommend treating all the original sites of disease involvement, then add boost to the residual s...
Do you recommend long term anticoagulation for all patients with first time unprovoked VTE?
I consider long term anticoagulation after a first unprovoked proximal DVT or PE in patients with low bleeding risk, especially if they are male. Risk/benefit discussion is employed for patients who have a higher bleeding risk after a first unprovoked VTE event.
When do you utilize lenalidomide in patients with MDS without del(5q)?
Lenalidomide is beneficial in low-risk and int -1 risk MDS patients with anemia even without del 5q in combination with EPO as shown in ECOG 2905 study.List et al., PMID 33439748These low-risk MDS tend to be MDS with refractory anemia and ringed sideroblasts.MDS RS with thrombocytosis tends to be re...
How would you approach a patient presenting with pancytopenia and splenomegaly whose bone marrow biopsy is morphologically normal but has a positive Philadelphia chromosome in bone marrow as well as peripheral blood?
Given pancytopenia and splenomegaly, I’m surprised bone marrow is read as normal. Look for evidence of myelofibrosis in marrow by performing reticulin stain. How big is the spleen? This picture is consistent with CML. What is the blasts % in blood and marrow? What is the basophil %? I would treat as...
How do you approach anticoagulation in patients with catastrophic antiphospholipid syndrome and thrombocytopenia?
Due to the rarity of CAPS, there are no evidence-based guidelines available and most treatment is empiric or based on expert guidance. Most would agree that the mainstay of treatment is anticoagulation, and the preferred anticoagulant is unfractionated heparin. In a recent guideline paper, therapeut...
Do you approach the diagnosis and treatment of HIT patients differently in the outpatient setting or in a resource-limited community setting?
The concern for heparin induced thrombocytopenia is a complex problem. If the patient has HIT by 4T score and thrombosis, then admission to the hospital for initial management including direct thrombin inhibitor is the correct path awaiting confirmation by ELISA and platelet release assay. If negati...
How do you manage a delayed hemolytic transfusion reaction in a patient with sickle cell disease?
The diagnosis and management of a delayed hemolytic transfusion reaction (DHTR) requires a high index of suspicion. In those patients in whom a DHTR is suspected or confirmed, further RBC transfusion should be withheld unless absolutely necessary, and if then only with the most compatible RBC units....
How many years of oral antibiotics prophylaxis do you recommend for a teenager with hereditary spherocytosis post-splenectomy?
If older than 5 and vaccinated, no proph.
How do you workup erythrocytosis with a normal or elevated serum erythropoietin?
First, I would consider using the term erythrocytosis rather than polycythemia. Too often, use of the term polycythemia may suggest polycythemia vera (PV) (a malignancy) rather than something more benign.The recommended up front testing in the evaluation of erythrocytosis consists of up front JAK2V6...
Is there any benefit in continuing VRd instead of VR as maintenance therapy in transplant ineligible multiple myeloma?
I love this question - mostly because it makes me think of just one study, but really, I'm excited to hear what others have to say. I always think of RV-MM-PI-0752 (ASH 2018) studying the efficacy and feasibility of dose/schedule adjusted Rd-R vs continuous Rd in elderly and intermediate-fit newly d...