Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your typical workup for a patient with a spontaneous renal infarct?
Broadly speaking, in the setting of a renal infarct, consider a thromboembolic event (venous thrombosis with paradoxical embolism or an arterial source) or a local vascular event such as dissection. The latter can be easily missed because the appropriate imaging is generally not performed. Once a va...
How do you approach transplant eligible myeloma patients with a partial or minimal response to treatment with 3-4 cycles of RVD?
This is something that occurs more often than is reported. Put another way, what to do when a patient's response plateaus after achieving a partial response? Evidence suggests that achieving at least a PR during induction is associated with better post-autologous transplant outcomes. What about VGP...
How would you approach a patient with gastric MALT lymphoma who has CREST syndrome?
The quick answer is, very carefully. To elaborate - I first had to look up what CREST syndrome is - the short answer is limited extent scleroderma, usually the distal upper and lower extremities, but occasionally the head and neck region and most relevant to this question, the esophagus. The literat...
How would one alter therapy in a transplant-ineligible AL amyloidosis with less than a complete response to six cycles of Dara-CyBorD?
If the patient has achieved deep VGPR (but perhaps not CR due to interference of dara), it is probably reasonable to continue dara maintenance as per ANDROMEDA as long as the patient is also clinically improving. If the response has not reached this level or the patient has not had evidence of impro...
What is your experience managing myelosuppression from busulfan, prescribed for PV?
I have no direct experience managing busulfan-induced myelosuppression in PV but I do have experience in managing busulfan-induced aplastic anemia. To begin with, busulfan is an alkylating agent and as such is a leukemogen and its use in a chronic myeloproliferative neoplasm should be restricted to ...
How does one interpret persistently positive lambda light chains on serum immunofixation but without measurable serum monoclonal protein and a normal light chains and ratio?
I would probably also check a 24 hour urine protein electrophoresis with immunofixation to evaluate if any significant and measurable monoclonal proteinuria that would make me more worried about SMM, MGRS, or amyloidosis. Would check urine protein/creatinine ratio to evaluate protein excretion for t...
What is the role for consolidative ISRT for patients with stage III follicular lymphoma following a good response to systemic therapy?
Advanced (stage III-IV) follicular lymphoma is not considered "curable" with either chemotherapy or immunotherapy (or the combination). A complete response may be achieved but an eventual relapse is inevitable. For patients who are asymptomatic without bulky or threatening disease, current guideline...
What options are available for patients with relapsed/refractory AL amyloidosis after Dara-CyBorD, other than clinical trial?
No great answers, unfortunately. Lenalidomide still tends to make me a bit nervous in AL amyloidosis, as does carfilzomib in patients with known cardiac involvement. But pom-based regimens are an option, or carfilzomib-based in the appropriate population.If the patient's BMBx shows t(11;14) by FISH,...
For lymphoma, how long after chemotherapy can you wait to start consolidative radiation therapy?
My general practice is to have patients return 3 weeks after their last cycle of chemotherapy with labs and post-treatment imaging and then proceed with consolidation RT. Depending on the complexity of planning, I am generally starting RT ~4-5 weeks after their last cycle of chemotherapy. This is co...
What are your considerations for peri-operative anticoagulation in patients with a mechanical heart valve undergoing a major noncardiac surgery?
For a patient with a modern (e.g St Jude bi-leaflet) mechanical valve (with or without AF) and who does NOT have a h/o of stroke or TIA, the available evidence suggests that "bridging" may have more risk than benefit: See Kovacs et al., PMID 34108229 and Siegal et al., PMID 22912386. Based on this e...