Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you find ELEVATE-RR data and study design compelling to start preferentially using acalabrutinib over ibrutinib?
The inferiority design of the ELEVATE-RR included a 1.429 margin, but the hazard ratio between treatments was 1.0 as related to DFS and 0.82 (favoring acalabrutinib) for OS. This improved OS likely is reflective of lower cardiac events and other adverse events. To me, this is sufficiently beneficial...
What is your preferred maintenance strategy for high risk multiple myeloma?
Ok. First off, what is high risk in the setting of maintenance therapy? I define high risk in this area as R-ISS 3 [incl t(14;20)], ≥ 5% circulating PCs, extramedullary disease [except salivary glands], hypodiploidy, or karyotypic t(8;22). We frequently argue about this definition since there is no ...
For frail patients with cardiac co-morbidities and relapsed CLL with high cytogenetic risk, what are some considerations for using continuous acalabrutinib over fixed duration therapies such as venetoclax/rituximab?
This is a complicated question and I evaluate each patient individually. I worry more about patients with reduced cardiac function on BTK inhibitors than I do those with pre-existing atrial fibrillation, and if they are on anticoagulation as well, that is a further concern. If the patient has reduce...
How would you manage a CLL patient who experienced severe infusion reactions with rituximab and has exhausted all other options?
This is a relatively common question and very relevant to clinical care. Rituximab, Ofatumumab, and Obinutuzumab do target CD20 but all should be viewed as we would view different structural classes of drugs. In general, if one has a very bad reaction to rituximab, depending upon what it is, one can...
What regimen would you offer a young patient with T-cell ALL who recurred a short time after allo-transplant and was initially treated with CALGB10403?
The answer is always clinical trial if feasible. If only commercial options: Assuming morphologic relapse, I tend to favor peg-asp containing regimen if the patient is fit enough to receive – especially if ETP variant. I like SMILE, but important to stress that regimen may come with considerable mye...
How do you counsel patients referred for abnormal light chain ratio when individual light chains are in normal range?
It appears you are referring to a situation where the uninvolved light chain is quite suppressed and the potentially involved light chain is normal, generating an abnormal ratio. There are other situations such as in CKD where both kappa and lambda light chains will be elevated but the ratio will be...
Should we recommend the COVID-19 booster vaccine to patients who had a DVT or any other complications such as hemolytic anemia or thrombocytopenia from prior vaccine doses?
There are a few case reports of VTE following COVID-19 vaccinations (approximately 10 based on my PubMed review today). However, VTE has a high incidence of 0.1% in the general population and much higher after age 45 (Mary Cushman, PMID 17433897), so determining a causal relationship between the vac...
What hematologic conditions are contraindications for a COVID vaccine?
The short answer is that a history of severe allergic reaction is really the only contraindication to COVID-19 vaccination. Perhaps, patients with systemic mastocytosis might be at increased risk of allergic reaction but I'm not aware of data to support that.The longer answer is a question of timing...
When do you check for EPOR gene mutations in your workup for erythrocytosis, and if found, how do you manage it?
Only consider it in instances where there is a life-long (or at least long-term) erythrocytosis and there is no evidence of a secondary erythrocytosis. There is no role for ASA or HU in these instances. I generally do not use phlebotomy either, unless the hematocrit is extreme and the patient is sym...
For young patients with smoldering multiple myeloma who wish to be treated with lenalidomide, how do you go about harvesting their cells for an autologous transplant?
I have serious reservations with treating smoldering myeloma with lenalidomide and in general, discourage it. That is likely a discussion for another day, but my thoughts on this have been summarized here. In general, we are able to secure permission for 'collect and store', and so I would prefer t...