Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How long after starting anticoagulation would you remove an IVC filter in a patient with a DVT presenting with stroke and PFO which is now closed?
This can be a complex scenario. The first question to ponder: if the patient could receive anticoagulation (a/c), why was the filter placed? Let us assume that there was a short period of time from the initial presentation of stroke, during which anticoagulation was contraindicated and there was a l...
Do you recommend hydroxyurea in patients with sickle cell disease with hereditary persistence of fetal hemoglobin who have recurrent vaso-occlusive crises requiring hospital admission?
It’s complicated. Patients with sickle cell-HPFH that is due to deletion of the beta-globin gene usually have 30% HbF spread nearly evenly among their red cells (pancellular), and as a result, have almost normal hematology and rarely have sickle vasoocclusive events. They do not require treatment. (...
Is there any benefit to transplant patients with Ph+ ALL who have achieved MRD-negativity?
First, some semantics: Asking if there is a "benefit to transplant" may imply there are randomized controlled trials addressing this question, but none to my knowledge have been performed. The last "donor-no donor" trials done in adults with ALL in first remission largely occurred in the pre-TKI era...
What salvage chemotherapy, if any, would you recommend for a patient with primary refractory DLBCL who progressed after two cycles of R-CHOP?
Primary progressive DLBCL is certainly clinically challenging. After biopsy confirms the diagnosis, how best to proceed depends on many factors including burden of disease, tempo of disease, and patient characteristics. ZUMA-7 establishes axi-cel as superior to the standard approach of platinum-base...
Would you give antithrombin concentrate for surgical VTE prophylaxis in case of congenital AT deficiency?
There is no role for routine antithrombin (AT) infusions. In selected situations, during high risk e.g. periods surgery or labor and delivery, etc when anticoagulants are interrupted, AT replenishment is reasonable.
Are BTK inhibitors safe to use in patients with severe renal failure?
To my knowledge, there are no data related to BTKi in patients with GFR <30 nor those on dialysis. However, these drugs (ibrutinib, acalabrutinib, zanubrutinib) are not cleared by the kidney, and in the clinical trials where measured, PK did not change based upon kidney function. Therefore, my pract...
How has the virtual aspect of tumor boards impacted their educational quality in the Covid-19 era?
In my experience, tumor boards serve 2 purposes. Firstly, they are designed to bring multiple specialists and cancer providers together in real-time to facilitate patient care. Secondly, they help educate the various disciplines based on a robust interaction. Virtual conferences are complicated by d...
What is the optimal treatment for a fit, elderly patient with NGC diffuse large B cell lymphoma that recurred about 1 year after dose-attenuated R-CHOP?
There are a number of appropriate options to consider depending on the specifics of the case. Could the patient be eligible for axi-cel? 2L CAR-T is appropriate for fit elderly patients so long as they fit eligibility for CAR-T and have access, and axi-cel is approved for early relapse/refractory pa...
How would you manage someone with antithrombin deficiency who has recurrent VTE on a DOAC?
There are no large scale controlled studies demonstrating outcomes of use of oral direct-acting anticoagulants (DOACs) in patients with hereditary thrombophilia. One can find published case reports demonstrating success, but the 'failures' likely do not get published. The general approach would be t...
How do you manage a patient with a history of high-risk leukemia who has increasing loss of donor chimerism in the post-transplant setting in the absence of disease relapse?
Decline in donor chimerism is not very common in pediatric patients who underwent myeloablative conditioning regimen for hematologic malignancy, and if chimerism is initially 100% and subsequently falls, it usually represents a relapse of underlying leukemia, or a new malignancy. I always obtain lin...