Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What factors do you look at while deciding between a daratumumab-based quadruplet induction versus standard triplet induction such as VRd for newly diagnosed MM?
This is becoming an increasingly thorny issue. A few guidelines to keep in mind:1) Dara-VRd has only been studied (thus far) in transplant-eligible patients. So this discussion of Dara-VRd vs. VRd is hard to apply to patients without intent for transplant. 2) When you look at the CASSIOPEIA and GRIF...
How would you approach early stage unfavorable classical Hodgkin lymphoma with metabolic CR apart from a single residual positive node after 6 cycles of ABVD?
If a patient with early-stage, unfavorable HL had an excellent response to 6 cycles of ABVD, but had a single lymph node that only achieved a PR (Deauville 4), then there are two primary options.1. If you judge that the patient has achieved a reasonable response to chemotherapy, suggesting that syst...
At what platelet count would you feel comfortable dosing aspirin 81 mg for coronary artery disease in a patient with ITP?
In a patient with ITP, I would certainly feel comfortable dosing aspirin 81mg daily at a platelet of 50,000 or greater. As you know, the risk of bleeding in a patient with ITP is less than would be expected at a particular platelet count because the circulating platelets in ITP are young and large. ...
What is your preferred anticoagulant for acute portal vein thrombosis?
The most common reason for portal vein thrombosis is underlying portal hypertension from cirrhosis. Thus, treatment choice is limited by the underlying liver disease. If they have liver disease with prolonged baseline PT, coumadin should not be used. Likewise, if they have liver disease, I don't fee...
What is your standard workup and treatment for an incidentally-noted splanchnic vein thrombosis?
Splanchnic vein thromboses are clots found in the portal, splenic, mesenteric or supra-hepatic veins. These can be very challenging because they are often incidentally found and asymptomatic and for these folks, it is very unclear whether we even need to treat them or do any other evaluation. As wit...
How do you manage HIT in a patient with high bleeding risk?
If bleeding risk associated with the administration of an alternative anticoagulant is unacceptably risky, I usually recommend the administration of IVIG. Theodore E. Warkentin, PMID 31274032
Would you re-challenge a patient with refractory multiple myeloma with carfilzomib who responded well but developed grade 3 heart failure and subsequently recovered the EF upon holding carfilzomib?
I avoid rechallenging and try to find a different regimen if applicable. If Carfilzomib was the only option left for RRMM, then you might consider a dose reduction with close follow up with cardio-oncology to optimize HF medications.
Are you comfortable using DOACs in obese patients with VTE?
Although there are no direct randomized trials in this population of patients, emerging data from systematic reviews suggest that DOACs are non-inferior to warfarin in patients >120 kg. (Elshafei et al., PMID 32556939).
What's the optimal management of stage IA nodal ATLL in a young fit patient?
It is a difficult question to answer. More data is needed to give recommendations: LDH, Ca, circulating ATL, lymphocytosis, etc. as it will be useful to sub-categorize her disease as lymphoma-type vs. chronic-type (favorable or unfavorable). It looks like you are treating her as a lymphoma-type whic...
Does discovery of clonal hematopoiesis on liquid biopsy for solid tumors change your treatment approach in terms of which chemotherapy to offer for the solid tumor?
CHIP findings are relatively common. A small percentage of patients with CHIP abnormalities will evolve into a Hematological malignancy depending on the mutation in the 1-2% range. I am unaware of any data that indicates that this percentage increases due to treatment for solid tumors. Therefore, I ...