Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your treatment of choice for triple class refractory multiple myeloma?
To define triple-class refractory means the patient is refractory to FDA-approved IMiDs (up to Pomalidomide), proteasome inhibitors (bortezomib and carfilzomib), and CD38 naked antibodies (e.g. daratumumab or isatuximab). Refractory is defined as progression or within 60 days of the last dose. I ag...
Does testing for elevated serum homocysteine have any relevance in thrombophilia management?
Homocystine levels is part of a DVT workup. Although rare, it is a factor in DVT risk. The gene mutation in MTHFR contributes to the elevation and the mutation frequency is extremely high. However, elevation is almost never seen due to added and natural folate in the diet.
What are contraindications for growth factors in patients with hematologic malignancies?
This is a challenging question where little data exist to support a good conclusion. In real world situations, patients with cytopenias and suggestion of TR-MN warrant aggressive antibodies find yourself deciding which is the "best of class" in its nature. John
Do you adjust the dose of ruxolitinib in primary myelofibrosis based on hemoglobin?
This is a tough question. It generally depends on how bad the anemia is. You can expect at least a gram (or more) drop in the hemoglobin when starting ruxolitinib, so baseline hemoglobin is important. Also, assuming that the patient is symptomatic, you would want to reduce the dose as little as poss...
How would you approach a resected solitary osseous plasmacytoma?
With a few exceptions, surgery is rarely pursued as a definitive modality in hematologic malignancies. I have never seen an orthopedic oncologist attempt an oncologic resection for a solitary plasmacytoma of bone, so my subsequent thoughts are theoretical. In the (very unusual) situation posed, if t...
How should one manage a patient with leukocytosis and borderline detectable BCR-ABL without other clinical features of CML such as basophilia or splenomegaly?
Leukocytosis has many causes and I will assume within the context of this question that we can narrow the definition to neutrophilic leukocytosis, and that it has been persistent without evidence of an underlying infection, cancer, inflammatory disorder, significant obesity, exposure to a drug or to...
How do you manage severe thrombocytopenia due to splenomegaly and bone marrow involvement in CLL when starting obinituzumab and venetoclax?
This is a tough question without any information about the case. I am assuming the patient is untreated. For this setting, there are really three options supported by randomized phase 3 trials. Venetoclax + Obinuzumab has a single randomized phase 3 trial that showed improved progression free surviv...
What are non-clinical trial options to treat high-risk MDS in a transplant ineligible patient, after progression on hypomethylating agents?
This is often a difficult discussion to have with patients as there are currently no FDA approved second line treatment approaches for such patients, but this remains an active area for clinical investigation. Some approaches are nicely reviewed in Dr. Santini's 2019 How I Treat article in Blood.In ...
Do you ever consider treatment outside of the peripartum period in a patient with a history of obstetric APS?
I agree with Dr. @Dr. First Last that the patient should be treated with prophylactic low molecular weight heparin and low dose aspirin in any future pregnancies. Dr. Broder makes the very important point that modifiable cardiovascular risk factors should be particularly attended to in persons with ...
How would you manage an in-field small volume recurrence of early-stage favorable Hodgkin Lymphoma treated previously with 2 cycles of ABVD and 20Gy?
An established and extremely successful treatment paradigm for early-stage favorable HL is 2 cycles of ABVD followed by 20 Gy of RT. Assuming the patient is PET negative after chemotherapy, 5-year PFS is expected to be ~93-94% based on HD16. Most recurrences after combined modality therapy (CMT) in ...