Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Following long-term efficacy and safety data from the beti-cel trials, how do you approach gene therapy for eligible patients with transfusion-dependent β-thalassemia?
The results with beti-cel are excellent. So are the results with exa-cel. These two gene therapies use different approaches to modifying hemoglobin production in erythroid stem cells. Beti-cel adds a modified hemoglobin that resembles fetal hemoglobin using viral-mediated transduction, whereas exa-c...
How do you decide when to pursue malignancy workup for patients with cryptogenic stroke?
Agree with above. I would also pursue malignancy work-up in this scenario as well: currently on anticoagulation (whether for afib or another medical reason) and has an ischemic stroke on top of that.
In patients with inflammatory arthritis (RA, psoriatic arthritis) and a history of MGUS are there any concerns regarding use of biologics?
There is no absolute contraindication to any particular biologic used to manage active RA in a patient with MGUS. The literature does point out a small potential risk associated with tocilizumab in terms of development of myeloma influenced by the IL-6 pathway (and I would tend to extend that potent...
Under what circumstances would you consider omitting radiation in patients with early stage, unfavorable (bulky) Hodgkin Lymphoma?
We should first acknowledge that combined modality therapy improves progression-free survival in early-stage HL compared with chemotherapy alone. Stated more succinctly- if you give combined modality therapy, there is a lower risk of relapse; if you give chemotherapy alone, there is a higher risk of...
In a patient who has been receiving 1L Ibrutinib for TP53+ CLL for years with complete hematologic response but detectable MRD, is there any role to switch to the novel BTKi agents given better PFS?
There are a couple of features to this question that need comment. First, the goal of therapy with a single-agent BTKi, regardless of ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib, is NOT to achieve undetectable MRD. Very few patients will achieve this milestone due to the drug's MOA. BTK...
What is your approach to utilizing MRD-guided therapy in previously untreated CLL, particularly in choosing between continuous versus time-limited treatment?
The question of what to do relative to a patient receiving therapy for CLL in first line and being MRD negative in blood/bone marrow with a reliable test (NGS sequencing or high sensitivity flow cytometry) and also no enlarged lymph nodes on CT/exam greater than 1.5 cm is challenging. For ibrutinib ...
How does the CLL17 trial presented at ASH 2025 change current practice guidelines?
The CLL17 study provides some tangential support for time-limited therapy in a subset of patients that I would consider now--those who have low-risk disease with IGHV mutated (non-3-21) and absent TP53 mutation or deletion. Here, we would expect patients to do quite well, and long-term follow-up exi...
What is your preferred 1L treatment for newly diagnosed Del(17p)/TP53 mutation, high-risk CLL?
For patients with TN-CLL with TP53 aberration, the treatment options are usually based on patient factors. If a patient is a candidate for combination therapy, I prefer to treat them with uMRD-guided BTKi+BCL2i ± CD20 mAb. I only add a CD20 mAb to patients with no history of frequent infections and ...
How do you determine the optimal duration for 1L doublet treatment in newly diagnosed High-Risk CLL?
Among patients with high-risk CLL and indications for treatment per iwCLL criteria (Hallek et al., PMID 29540348), treatment regimens can be broadly categorized into fixed-duration, MRD-guided, and indefinite therapies. Fixed-duration doublet regimens include acalabrutinib with venetoclax per the AM...
Does the lack of long-term data influence your consideration of utilizing zanubrutinib and venetoclax 1L in High-Risk CLL?
Not really. The CLL17 data showed essentially equivalent 3yr PFS between ibrutinib + venetoclax, ibrutinib monotherapy, and venetoclax + obinutuzumab. But even before those data were published, with the solid 36-month PFS data for zanubrutinib + venetoclax, it seemed clear that many of these patient...