Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you treat a patient with warfarin failure, with therapeutic INR 2-3 at the time of DVT, and no underlying malignancy or hypercoagulable state?
I would give DOACs a shot in this case. The INR of 2-3 at the time of DVT "Diagnosis" might have been <2 at the time of DVT "development/occurrence" depending on how frequently the INR had been checked. I would, of course, maximize risk factors control as well.
How would you approach a woman with APLA but no thrombosis/APLS, a history of ITP without bleeding who is now pregnant?
As a rheumatologist, I would want to make sure this patient does not have SLE. If no suspicion for SLE (and no previous obstetric complications), I would mostly likely monitor closely during pregnancy without any additional interventions.
How do you choose between axicabtagene ciloleucel and tisagenlecleucel in patients with follicular lymphoma for whom you are recommending CAR T-cell therapy?
This is an area of uncertainty. There are no head-to-head data to bring to bear, of course (and, if there were, you probably wouldn’t need to ask). The toxicity profile of the two cells is clearly different, with lower rates of severe toxicity with tisacel than with axicel. As neither product has be...
What is your approach to MRD testing in the frontline treatment of multiple myeloma?
Outside of clinical trials, I am not ordering MRD testing for patients in the newly diagnosed setting, regardless of transplant eligibility. While there are substantial data showing that MRD status correlates with survival outcomes (e.g., Munshi et al., Blood Adv 2020), there is a dearth of informat...
Would you consider post-BMT maintenance therapy for patients with Ph-like ALL with a JAK2 mutation?
In brief, I would not.Here is the evidence I have that leads to this conclusion: The activity of targeted therapy for Ph-like ALL has not been established. There are a number of ongoing studies that are attempting to address this (e.g., AALL1521/INCB18424-269; see Tasian et al., ASH 2022). What data...
Can you use apixaban or rivaroxaban in case of dabigatran failure?
It depends on the indication of anticoagulation, co-morbidities, etc. In the absence of any direct data, in general, failure in the setting of venous thrombosis or atrial fibrillation it would seem reasonable to consider transition to an agent with a different mechanism of action.
How do you manage grade 1-3A Follicle Center Lymphoma of the lower female genital tract, presenting with a cervical mass?
I would treat this with 12 x 2 Gy. Indeed, fertility preservation will be an issue here. Depending on the size of the lesion, if the ovaries can be spared, then 24 Gy delivered to the cervix/uterus may still allow for a pregnancy with a favorable outcome. Another experimental approach, if the patien...
What hemoglobin level prompts you to start erythropoietin in a patient with low-risk MDS?
Depending on the patient's symptoms and clinical context, I will either start an ESA when the patient starts becoming transfusion-dependent (Hgb < 8 g/dL) or, if the patient is not transfusion-dependent, but still symptomatic from anemia, I will start the ESA when their Hgb is < 10 g/dL. Prior to in...
How soon after CAR T-cell therapy can salvage radiation be delivered?
This is another important question. In our practice, the earliest we have treated patients is after their first post-CAR-T PET/CT at day 30. An abstract presented in an oral presentation at this year's ASTRO meeting by Dr. @Dr. First Last describes that radiation to sites of incomplete response at t...
Is there an optimal salvage radiation dose for relapsed post-CART disease?
While there is not enough data to definitively recommend a specific dose, we feel an EQD2 > 37.5-40 Gy is desirable for patients with limited residual or relapsed disease post-CAR T-cell. Our commonly recommended fractionations include 37.5 Gy in 15 fractions, 40 Gy in 15 fractions, and 40 Gy in 20 ...