Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your approach for persistent and romiplostim-refractory thrombocytopenia after temozolomide with radiation in a patient with recurrent GBM?
Even if bone marrow does not show leukemia, I would consider checking for CHIP or CCUS variants. I would probably not have a high index of suspicion for immune-mediated thrombocytopenia related to TMZ in this context. Beyond transfusion, time, TPO-RA, and supportive care, I am not sure there are man...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
How would you treat an elderly patient with stage I/II unfavorable classic Hodgkin Lymphoma, who could only tolerate 2 cycles of chemotherapy and has a Deauville 1-2 PET/CT re-staging scan?
Assuming a patient is responding favorably to therapy by PET/CT, there are 5 regimens that are supported by randomized trials and included in national guidelines: Chemotherapy-alone regimens ABVD x 2 + AVD x 4 (RATHL) BrECADD x 4 (HD21) Combined modality therapy regimens ABVD x 4 + RT (30 Gy) (H1...
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
What would be your preferred anticoagulant for recurrent DVT/PE in a patient on hemodialysis with calciphylaxis and prior DOAC failure?
A truly complex case: recurrent DVT/PE in the setting of ongoing risk factors for both VTE (active calciphylaxis, prior DOAC failure, and obesity) and bleeding (ESRD on hemodialysis), each of which constrains a different anticoagulant option. Given the complexity and rarity of this case, recommendat...
For which patients with relapsed/refractory follicular lymphoma do you prefer bispecific antibody-based therapy at 2L vs reserving it for later?
Bispecific antibody-based therapy for 2L FL is a very effective treatment option with high rates of overall response, complete response, and what thus far appears to be durable responses. In the EPCORE FL-1 trial, where patients were randomized to epcoritamab + R2 vs R2, it did add more toxicity to ...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
What is your treatment of choice for triple class refractory multiple myeloma?
To define triple-class refractory means the patient is refractory to FDA-approved IMiDs (up to Pomalidomide), proteasome inhibitors (bortezomib and carfilzomib), and CD38 naked antibodies (e.g. daratumumab or isatuximab). Refractory is defined as progression or within 60 days of the last dose. I ag...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
When testing for patients with symptoms of MPN, do you prefer to do JAK2 cascade testing or a leukemia NGS testing panel?
Genetic testing with regard to the MPN can be usefully employed both diagnostically and prognostically. With respect to diagnosis, if an MPN is suspected based on symptoms such as aquagenic pruritis, ocular migraine, erythromelalgia, or the occurrence of an unexplained thrombosis, the first laborato...