Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you differentiate between JAK2 positive ET and PV when peripheral blood shows erythrocytosis and thrombocytosis?
The answer to this question is very simple. Before the discovery of erythropoietin and accurate assays for it, and before the discovery of JAK2 driver mutations, the diagnosis of polycythemia vera was clinically-based. The Polycythemia Vera Study Group (PVSG) did an extensive epidemiologic study and...
Do you give an etoposide-based regimen/more aggressive therapy for lymphoma-associated HLH, such as da-EPOCH-R over R-CHOP?
The general approach to treat the secondary lymphoma-associated HLH (LA-HLH) is to treat the underlying lymphoma- it works better in B cell lymphoma. Etoposide is probably the only agent consistently that has been shown (in several studies- mostly retrospective) to make a difference in the resolutio...
How do you approach the decision to pursue early versus delayed autologous stem cell transplantation in newly diagnosed multiple myeloma?
An excellent discussion.Why do I have a feeling this will continue to be debated for the next decade?!Reasons to consider early transplant: Age > 65. These patients were not included in the IFM-2009 study that tried to answer this. Patients who defer transplant in this age range may never get to a t...
What is your practice for work up and treatment of incidental splenic infarcts with or without splenomegaly in patients without sickle cell disease?
I obtain CBC/diff, CMP, and LDH in all patients. I assume a CT of the abdomen has already been done because that is what usually leads to the diagnosis of incidental infarcts. Of course, it is important to rule out intra-abdominal pathology which should be visible by CT. I obtain a thrombophilia scr...
For treatment of ITP, what would you add to dexamethasone to achieve the fastest recovery in a patient waiting for a procedure?
I usually use IVIG, particularly if the patient has responded in the past.
How do you sequence therapy in an older patient with newly-diagnosed blastoid mantle cell lymphoma with a 17p deletion?
Tricky question. There are two issues, 1. the morphology and 2. depending on how you evaluate a 17p deletion. The deletion in literature isn't as clearly associated with poor outcomes as compared to mutations. Given that there are two copies, as long as one allele is still present then would still h...
For patients with myeloma on an IMiD, how do you decide on the dosages of aspirin or anticoagulants in VTE prophylaxis ?
The phase III trial by Palumbo et al., PMID 21282540 is still the only prospective randomized trial of VTE prophylaxis in MM with "standard" thromboembolic risk patients eligible for IMiD treatment. In this study, administration of 40 mg enoxaparin was compared with fixed dose of 1.25 mg warfarin...
For patients with mild CKD, how do you decide between zoledronic acid and denosumab for bone protection in patients with multiple myeloma?
In this scenario, I prefer zoledronic acid every 3 months with renally adjusted dose. In my experience, the risk of hypocalcemia seems higher with denosumab. Calcium/vitamin D supplementation would be important as well. The every 3 month dosing is an advantage over denosumab, which would have to be ...
How do you manage drug-induced thrombocytopenia when the implicated drug is essential?
I feel obliged to answer this one as a question of medical sociology as much as a direct medical question, because "essentialness" is nearly always in the eye of the beholder, and I have not personally been in the position of the hematologist who has to confront this question with an interventional ...
In a patient with a heterozygous prothrombin gene mutation who has COVID with minimal symptoms, do you recommend prophylactic and/or therapeutic anticoagulation?
If the patient has no history of VTE, I would not recommend any anticoagulant treatment. Heterozygous prothrombin G20210A polymorphism is a relatively weak risk factor for VTE in comparison to antithrombin, protein C, or protein S deficiency, and in general, is not a finding that should guide decisi...