Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you approach a patient with low grade follicular lymphoma (stage IE) of the breast who presents with local recurrence 1 year s/p lumpectomy?
I would re-stage the patient with imaging. If the disease remains localized, then I would treat with definitive RT (24-30 Gy in 2 Gy fractions using ISRT principles). It would be interesting to look back at the pathology from the original lumpectomy. Unless margins were widely negative, I would prob...
Are there any possible scenarios where you would do phlebotomies for heterozygous hemochromatosis?
The answer is yes but unusual. Occasionally, a heterozygote or double heterozygote will be weakly phenotypically positive. If the ferritin and TSAT (on overnight fasting sample) are high, I will. I prefer that blood donation be used but if not an option, I will take it. The iron parameters must be...
How do you approach the workup for a patient with persistently elevated inflammatory markers (CRP and ESR) whose history and exam do not point to a clear cause?
Our hematologist/oncologist referred just such a patient. No evidence of malignancy, but elevated CRP &ESR. I did an “internist’s” workup as I would for dermatomyositis, starting with the most important and therefore most thorough aspect: taking a full and very “invasive” history, followed by a comp...
What is the treatment approach if an AML patient receiving azacitidine/venetoclax is later found to have FLT3 and IDH2 mutations?
This is solely an opinion as there is little data. Since FLT3 inhibitors are not approved for use with azacitidine and venetoclax and data is just emerging about triplet therapy with the addition of these inhibitors, I would just keep going with azacitidine and venetoclax and reserve FLT3 and IDH2 i...
Do you offer IVIG to myeloma patients with recurrent infections?
I do offer IVIG to patients with myeloma who are having recurrent respiratory infections and have hypogammaglobulinemia (<400 mg/dL). I do counsel patients that we do not have strong clinical trial data to support the use of IVIG in this setting. While I dislike quoting anecdotal experience, I will ...
How should elevated PT of unclear etiology and significance be evaluated?
Mild prolongation of the prothrombin time (PT) may represent a normal ‘outlier’. If there is no obvious explanation for a moderate to marked prolongation of the PT (for example, anticoagulation therapy effect, liver disease, nutritional deficiency like vitamin K deficiency. then the next step is to ...
How would you treat lymphoplasmacytic lymphoma (LPL) with a non-IgM paraprotein?
My treatment approach would be similar to those with IgM LPL (WM).
What's the role of ibrutinib and venetoclax in CLL in light of data emerging from ASH 2022?
Authored by @Dr. First Last and @Dr. First Last The current FDA-approved, standard-of-care for frontline chronic lymphocytic leukemia (CLL) therapy includes continuous therapy with a Bruton tyrosine kinase inhibitor (BTKi) such as ibrutinib or acalabrutinib, with or without an anti-CD20 antibody, or...
When, if ever, would you consider deep venous thrombosis prophylaxis for patients with advanced epithelial ovarian cancer undergoing neoadjuvant chemotherapy?
The Khorana scoring system is a great tool when this question comes up. I use it for all my ovarian cancer patients who have measurable disease in the neoadjuvant and adjuvant settings. I re-evaluate their score every 3 months to ensure they are still candidates for VTE ppx. Mulder et al., PMID 3060...
How would you manage a patient with erythrocytosis of unknown cause in pregnancy?
Pregnancy invokes changes in the blood volume and erythropoiesis: the plasma volume expands, erythropoietin production falls, and the hematocrit (don't use the hemoglobin level) declines (the hydremia of pregnancy) until the last trimester. So that by the third trimester, the hematocrit varies betwe...