Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In what situations would you offer salvage radiotherapy for relapsed/refractory DLBCL?
There are a number of different clinical scenarios when I would consider RT in patients with relapsed/refractory DLBCL. NCCN guidelines (page BCEL-7 and BCEL-8) list RT as an option in several of these settings.1. Relapsed disease s/p autologous or allogeneic stem cell transplantation - In patients ...
When would you consider stopping chronic transfusion therapy in a sickle cell patient with history of abnormal TCDs but no stroke?
Fortunately, we have good data to answer this question. The TWiTCH trial aimed to determine the efficacy of hydroxyurea at maintaining TCD velocities after discontinuation of initial transfusion therapy to prevent primary stroke. Patients on this non-inferiority trial with a history of abnormal TCD ...
In patients who develop a VTE, what conditions do you consider as persistent, provoking risk factors, and at what point are they controlled enough to stop anticoagulation?
Not a lot of controlled trials that address each situation so we rely on expert consensus and judgement, and more importantly, balancing the risk of hemorrhage vs thrombosis. ASH guidelines define chronic persistent risk factors as 1) Active cancer (e.g., ongoing chemotherapy; recurrent or progressi...
What radiation dose and fractionation is appropriate for hairy cell leukemia presenting as an isolated skeletal lesion, where systemic treatment is not recommended?
If the patient is not a candidate for any systemic therapy like cladribine or pentostatin, treatment of the bone lesion to 20-30 Gy with conventional fractionation is a reasonable approach. Some of the older case series would treat lesions up to 60 Gy, but HCL is ultimately a radiosensitive B-cell l...
In patients with high-risk polycythemia vera with a history of thrombosis, should aspirin be used in addition to indefinite anticoagulation and cytoreduction for prevention of recurrent thrombosis?
I do not continue aspirin in patients who require anticoagulation out of concern for an increased risk of bleeding. In an analysis of the REVEAL database, patients receiving anticoagulation in combination with aspirin were over 4-fold as likely to have a hemorrhage (HR [95% CI] = 4.22 [2.57, 6.94]; ...
What induction combination(s) would be appropriate for newly diagnosed standard cytogenetic risk multiple myeloma who have a transplanted kidney?
This is a tough question! On one hand, the risk of allograft rejection with IMiDs is a real concern. On the other hand, one must consider that the evidence for this is limited to case reports/series (ex Walavalkar et al., PMID 29661456; Lum et al., PMID 28189378; Nguyen et al., Blood (2019) 134 (Sup...
In young patients with essential thrombocythemia and early significant atherosclerotic disease but no thrombotic history, would you consider the addition of cytoreductive therapy?
This is a good question without an evidence-based answer. It's important to understand why this person has early atherosclerotic disease, have other modifiable risk factors been identified and addressed? For example, familial conditions that lead to hyperlipidemia, or smoking, obesity, etc. If the p...
How do you manage a patient with transfusion-dependent MDS with concurrent hemochromatosis requiring phlebotomy?
I actually have a couple patients like this. If the ferritin is >1500, I add deferasirox. However, if MDS is responsive to ESAs, you might be able to manage with occasional phlebotomies. It's a tough problem.
How would you manage an asymptomatic elderly frail patient with newly diagnosed mantle cell lymphoma with TP53 mutation?
While p53 mutations are known to impact clinical outcome after administration of cytotoxic chemotherapy in frontline MCL (Eskelund et al., PMID 29794145, Elhassadi E et al. Presented at: 2019 European Hematology Association Congress; June 13-16, 2019; Amsterdam, The Netherlands. Abstract PF493, Ferr...
How do you manage a patient with superficial venous thrombosis with close proximity (<3 cm) to deep veins and an inherited thrombophilia ?
I would treat the patient for 3 months with a DOAC and then repeat the scan. If the clot is resolved, I would order a d-dimer and Factor VIII level on anticoagulation. If the tests are negative, I would stop the DOAC and retest at 30, 90, and 180 days. If tests remain negative then stay off anticoag...