Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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...
Do you use bevacizumab in patients with history of VTE (DVT/PE) who are stable on anticoagulation?
I have used bevacizumab in many patients who are stable on therapeutic anticoagulation for prior VTE. If the first VTE occurs during treatment with bevacizumab, I hold the drug and then consider restarting it (if warranted by the clinical situation) after a period of stability on therapeutic anticoa...
How would you manage a young patient with Sjogrens disease with extranodal marginal zone lymphoma involving bilateral parotid glands with bilateral cervical lymphadenopathy?
For patients with low-grade NHLs (e.g., follicular lymphoma, marginal zone lymphoma), staging dictates treatment. If a patient has a localized process (e.g., contiguous stage I-II disease), then a definitive course of RT is typically recommended. The conventional approach is 24-30 Gy, though a dose-...
What are your management strategies for malignant pericardial effusion with a high risk of spontaneous hemorrhage, particularly in patients requiring anticoagulation for chronic atrial fibrillation?
We have many patients with malignant pericardial effusion who tolerate anticoagulation for DVT/PE/afib. In those patients, when AC is restarted (for example after pericardiocentesis), close monitoring with serial echo in a few days would be performed to see if effusion reaccumulates faster. Also, th...
What clinical or logistical factors influence your choice of anti-CD38 antibody in first-line treatment of multiple myeloma?
I generally use daratumumab, because subcutaneous is more convenient for patients, and we go to once-a-month dosing much quicker with daratumumab compared to isatuximab. Once isatuximab subcutaneous is available, this advantage of daratumumab may be lost, but given comfort and familiarity with darat...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
Have you changed your practice in treating CRAO with IV thrombolysis?
The recent THEIA trial had a limited sample size to draw conclusions, even though there was a non-significant trend of improved visual acuity initially in the thrombolysis group. Even the TenCRAOS trial had a small sample size with recruitment challenges, where subtle small differences cannot be acc...
Would you use bone marrow MRD status to guide stopping daratumumab early at 1 year instead of the recommended 3 years of therapy per the AQUILA trial for high-risk smoldering myeloma?
I would venture to say that there is probably a 0% chance that MRD negativity would be achieved with daratumumab alone. The CR rate was 8.8%, but MRD was not assessed, and I would doubt that MRD negativity was achieved in any patient. That said, we can't really extrapolate whether 1 year and stoppin...
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...
How do you modify HMA treatments for a patient with high-risk MDS experiencing prolonged cytopenias after each cycle?
When using azacitidine for the treatment of MDS, I adjust the dose in case of cytopenia for cycle 2 onwards. If there was no baseline cytopenia (ANC >1.5, PLT >75K) but cytopenia developed with treatment, the subsequent cycle is delayed until counts recover, and the dose is based on the nadir and t...