Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What radiation dose do you typically use for relapsed DLBCL following 6 cycles of R-CHOP?
There are several potential scenarios, all with different answers, so I will illustrate a few.Historically, second-line chemotherapy (e.g., R-ICE) would first be pursued for relapsed DLBCL, and if the disease was still responsive to chemotherapy (CR or PR), then the patient would proceed with high-d...
When and how do you initiate therapeutic phlebotomy for patients with hereditary hemochromatosis without evidence of end-organ injury?
Since the management of asymptomatic HH is seamless, if a patient's iron parameters are reflective of iron overload and there is zero evidence of end-organ damage, I recommend that they become blood donors, starting with every 56 days. I monitor on a regular basis to try to get them closer to low no...
What are your recommendations for a male patient who was recently started on imatinib and wants to conceive?
Great question. This comes up often. For males, they can continue to take their CML TKI and conceive a child. Of course, this is much more complicated for women as they should not be pregnant while taking a TKI. I would say that if the patient is having difficulties conceiving, he should undergo a ...
Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?
In this scenario, our patient with lupus is young and does not have features of APS. Nevertheless, any patient with Libman Sacks endocarditis carries a heightened risk for embolization. Regarding anticoagulation, the literature on this subject is anecdotal and conflicting with some authors recommend...
Would you recommend consolidative radiation therapy for advanced stage bulky Hodgkin's lymphoma with a delayed complete response after 6 cycles of A-AVD chemotherapy?
I suppose I have three comments about this question.First, the sensitivity (percentage of true positives) and specificity (percentage of true negatives) are generally higher than the positive predictive value (true positives/all positives) for end-of-treatment PET-CT in lymphoma. In one study, the P...
What are the alternatives to anticoagulation in an individual with an atrial thrombus and absolute contraindications to anticoagulation?
This is not an easily answered question in this sort of a forum. This clinical situation requires multidisciplinary input and individualized approach. Factors to consider include but not limited to, 1) estimated risk of systemic arterial embolism (note, current tools/calculators provide the annual r...
How would you manage a patient with essential thrombocythemia and persistent pruritus despite adequate control of CBC with hydroxyurea and aspirin?
First, I'd make sure to exonerate any other causes of itching. Second, would make sure that supportive treatments like good skin care, anti-histamines, anti-depressants have been tried. I'd then consider if this patient truly has ET, as itching is more common in PV. Ruxolitinib is approved for patie...
What is your institution's practice/guidelines for considering a reduced-intensity (RIC) over a myeloablative (MAC) conditioning regimen?
We don't have an institutional guideline per se. Typically, RIC is used in older patients (e.g. above 60ish), second transplants, people with co-morbidities that preclude high dose therapy, and diseases that are particularly sensitive to immunologic control, or some nonmalignant diseases such as apl...
For a patient with concurrent diagnoses of Hodgkin Lymphoma and Light Chain Myeloma complicated by Myeloma Kidney, how would you approach treatment?
I have seen this once, just once. Two separate but newly diagnosed hematologic malignancies that require treatment simultaneously are rare. More common is a passenger MBL in a myeloma older than 70 y.o., MGUS in the setting of another lymphoid malignancy is not unheard of, and a T-cell gene rearrang...
Do you routinely offer antiviral prophylaxis for patients receiving chemoimmunotherapy?
Yes, with R-CHOP and similar therapies for anyone who may have had chickenpox. I have seen shingles during treatment. I have not been doing routinely for younger patients who had VZV vaccines. Yes also for anyone with a history of HSV. Usually acyclovir BID.