Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What factors besides disease progression would lead you to de-intensify or change MM therapy for a patient with ongoing response?
After initial therapy (which may or may not include an autologous stem cell transplant), patients are generally on continuous/maintenance therapy with e.g. lenalidomide as the most common regimen. Most patients do well on this as maintenance. However, loose stools are probably the most common compla...
How do you counsel patients with newly diagnosed transplant-ineligible multiple myeloma on the expectations of treatment in terms of disease control, duration of therapy, monitoring and follow up?
I'm going to take this question very literally and write a paraphrase of my general explanation to patients at an initial diagnosis and treatment planning visit. Forgive me, this is long, a paraphrase of a 30-60 minute visit with a patient. I hope this will result in others sharing how they navigate...
When do you consider re-treatment with lenalidomide in later line therapy for relapsed multiple myeloma?
It is a challenging question due to the fact all studies post lenalidomide failure even in maintenance never included lenalidomide based therapy in first up to third line of therapy: such as Dara/Pom/dex, Dara/Car/dec, Elo/Pom/dex, Pom/Vel/dex … some argue that since the patient was on low dose of l...
Do you routinely obtain bone marrow biopsy in newly diagnosed autoimmune hemolytic anemia when working up potential underlying etiologies?
Thank you for the question. For patients with cold agglutin disease, I perform a bone marrow biopsy and flow cytometry at diagnosis/before initiating therapy on all patients. I base the decision whether to do a bone marrow biopsy after initial diagnosis of warm autoimmune hemolytic anemia based on w...
How does evidence of cerebral amyloid angiopathy/microbleeds affect choices for secondary stroke prevention in patients with a history of ischemic stroke and atrial fibrillation?
This is a discussion I have with the patient, mentioning that the positive predictive value of cortically based cerebral microhemorrhages is not absolute, especially when there is a small number of them and there are no other signs of small vessel disease (such as FLAIR changes or enlarged peri-vasc...
How do you advise a patient with VTE on indefinite anticoagulants regarding the Ad26.COV2.S Johnson & Johnson/Janssen COVID vaccine?
The thrombotic events seen with the Ad26.COV2.S vaccine do not appear to be associated with a prior history of clotting events. It seems to be a different entity, similar to heparin induced thrombocytopenia, with clinical presentation of thrombosis and thrombocytopenia. Muir et al., PMID 33852795The...
What strategies have you found to be most effective in engaging PCPs in a primary-care or shared-care model of survivorship for pediatric and AYA patients who will receive ongoing care in their communities away from their primary oncology treatment site?
This is a challenge for our center, and many other centers as well. The ideal approach would be to have adult primary care physicians associated with our center who have dedicated clinic time to care for cancer survivors, direct access to our expertise and medical records. While we haven't been succ...
How often do you follow ferritin and organ iron-deposition in a patient who has known hereditary hemochromatosis, but no current evidence of iron overload?
Once diagnosis is made, I stress blood donation or less optimally, therapeutic phlebotomy. If donation every 56 days until ferritin <100 and TSAT <30. This assumes asymptomatic without LFT abnormality. Thereafter the intervals can be adjusted to keep parameters in the desired range. I never follow o...
What is the optimal initial therapy and management of Erdheim-Chester disease without actionable mutations such as BRAF or MAPK-ERK pathway alterations?
Would refer to the latest ECD consensus guidelines and NCCN guidelines on histiocytic neoplasms for the answer to that question: Goyal et al., PMID 32187362 In short, here are the considerations:1. Even patients without bonafide MAPK-ERK pathway mutations can respond to a MEK-inhibitor such as cobim...
How long do you continue caplacizumab in relapsed refractory TTP?
While there are no data from studies to guide our answer, general practice is to continue caplacizumab until the ADAMTS13 activity is at least 20% on two occasions, or greater than 30% assuming it was measured at least 4-5 days after the last plasma exchange procedure. The goal is to have stable rec...