Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you switch from imatinib to another TKI in patients with chronic phase CML who develop renal insufficiency?
Imatinib has been associated with a decline in GFR. It is not certain (and probably doubtful) that this represents kidney damage. If no other causes can be identified, a change could be appropriate. Bosutinib has been associated with a similar decline so nilotinib or dasatinib might be better option...
How do you manage a patient with progressive cerebellar ataxia and positive cardiolipin antibodies?
I would be very cautious attributing ataxia to the presence of ACL (even if they were persistent). While an association between ataxia and apl has been described, the differential is extremely broad and should be carefully worked up in conjunction with a neurology team. Some of the more common cause...
Based on recently published data from COG ANHL12P1, how will you use crizotinib in pediatric and AYA patients with ALK+ anaplastic large cell lymphoma?
I would discuss brentuximab (plus ALCL chemo backbone) with newly diagnosed ALCL with patients and families in the absence of any open trials. The published COG data looks favorable but hasn't been shown in a randomized setting to improve EFS/OS. With the VTE data (and the availability of Brentuxima...
Do you use anticoagulation in cancer patients who develop an unprovoked superficial vein thrombosis?
It depends on the extent of the thrombus and clinical circumstances. Superficial vein thrombosis is triggered by the presence of malignancy. For distal minimal symptomatic thrombosis, I would consider time limited anticoagulation. For more proximal and symptomatic thrombosis, I would consider more e...
Do you check beta 2 microglobulin in patients with MGUS?
I think this question can be answered in two ways - firstly, from the vantage point of clinical utility, and secondly, from the vantage point of cost-effectiveness. I think the short answer to both is no. For patients with suspected smoldering MM awaiting bone marrow biopsy, PET-CT, wbMRI, etc. I ...
When patients develop headaches from luspatercept, do they tend to improve over time?
I've seen two common scenarios with this. One is headaches related to hypertension as a result of luspatercept. By treating the hypertension, the headaches often improve. If the headaches are in the absence of hypertension, I do use a low dose beta blocker to see if it helps, and have had some resul...
What precautions do you take prior to CABG in a patient with sickle cell trait?
Surgery and anesthesia are safe in sickle cell trait (HbAS) when normal precautions are followed. In patients with HbAS and control subjects, the frequency of anesthetic, surgical, and postoperative complications was similar; however, most patients were young, and few thoracic procedures were includ...
For T cell ALL treated in CR (without transplant), how often do you do BM biopsies as part of surveillance, and for how long?
The role of surveillance bone marrow exams in ALL (either B or T-lineage) is a matter of some debate. Thoughtful clinicians can disagree, but in my practice, I do NOT routinely perform these procedures, instead reserving them for signs or symptoms suspicious for relapse. This is analogous to how the...
How do you approach a cervical node biopsy-proven follicular lymphoma in situ in a symptomatic patient with night sweats and PET findings of low SUV uptake throughout the body?
Follicular lymphoma in situ, aka in situ follicular neoplasm (ISFN) is an uncommon entity, representing an early precursor lesion and better conceived of as premalignant as opposed to a true malignancy, and a pathologic diagnosis of ISFN is not an indication for therapy. Most patients with ISFN will...
What are the best labs to trend improvement in HLH?
Unfortunately, there is not one specific laboratory test to definitively trend responses to HLH directed therapy. In general, our approach is to obtain baseline inflammatory labs including CBC with differential, ferritin, soluble IL2 receptor (sIL2r), triglycerides, coagulation studies (PT/PTT) incl...