Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you still recommend bone marrow biopsy in an elderly non-transplant eligible patient with mild cytopenias if NGS from peripheral blood indicates MDS mutations?
Yes. The presence of mutations in peripheral blood is not diagnostic of MDS. The elderly can have CHIP mutations and mild cytopenias which qualify for CCUS rather than MDS. CCUS has a higher risk for progression to MDS but is not MDS by itself. Would get a bone marrow prior to diagnosing MDS and sta...
How do you manage drug-drug interactions between oral anticoagulants and the ARSI agents such as apalutamide and enzalutamide?
Commonly used oral anticoagulants, such as apixaban, rivaroxaban, and warfarin are substrates of hepatic cytochrome P450 enzymes (CYP). Co-administration of an AR signaling inhibitor (ARSI) variably affects the concentration of those drugs depending on the effect on the type of CYP enzymes. For exam...
How would you approach the treatment of an elderly patient with multiple myeloma and CALR+ myelofibrosis with elevated platelets?
Thank you! This is a great question and a very complicated case. Generally, I would be less concerned about thrombocytosis. I would focus more on the symptoms and splenomegaly that the patient may be experiencing. If they are not having significant MF-related symptoms or splenomegaly, then observati...
For an asymptomatic patient discovered during workup for elevated PT/PTT to have mild prothrombin deficiency, would you suggest any preoperative prophylaxis?
In someone with normal liver function otherwise, who was found on preoperative screening to have both mildly prolonged PT and PTT, AND the only abnormality found was a factor II (2, prothrombin) level >60%, I would not administer preoperative prophylaxis. However, I find the question confusing as it...
How should one approach an incidentally found T-cell gene arrangement?
When I see an incidental T-cell clonal rearrangement without any manifestation, my first question is how was this being measured? Many PCR-based methods have a difficult time distinguishing oligoclonal versus monoclonal T-cell populations. My favored test here is looking by flow cytometry at the T-c...
Would you treat a hemochromatosis carrier with IV iron if they have iron deficiency anemia in conjunction with elevated ferritin?
This scenario, with numbers like these, suggests another underlying issue. A carrier of hemochromatosis cannot typically have a ferritin level of >900 due to hemochromatosis. The TSAT of <10% corroborates this statement. If this patient is real, they likely have an underlying inflammatory disorder ...
How would you manage biopsy-proven DLBCL in a patient who was treated with 6 cycles of R-CHOP 15 years ago for DLBCL?
It will be difficult to tell if this is a relapse vs. de novo DLBCL unless you have the old pathology slides available and if a skilled pathologist is able to tell. In general, patients with late relapses > 24 months from achieving remission have favorable outcomes with salvage chemotherapy and auto...
How would you manage a patient with NLPHL and CKD who relapsed after a long disease free interval (i.e. 7 years) following bendamustine?
I honestly might consider BR again depending on the counts. I personally use as little as possible - often stopping the B after 3-4 cycles if the patient is in remission.
Is it possible to give Inotuzumab ozogamicin in the front line setting for an older patient with Ph- Pre-B-ALL?
Yes - there are encouraging data from early-phase trials looking at InO-containing regimens in the frontline setting. Some of these include: Alliance A041703 (InO followed by blinatumomab for older adults with CD22+, CD19+, Ph-negative B-ALL): Wieduwilt et al., Journal of Clinical Oncology 2023, sup...
Would concurrent CRLF2/IgH rearrangement affect your treatment recommendations for an adult patient with Ph+ p190 high risk (Age>35, WBC >30) B-cell ALL that was started on induction therapy with ponatinib + blinatumomab?
Short answer: No. Longer answer: We lack a clear understanding of how to change treatment for adults with CRLF2 fusions with Ph- ALL, and this is the situation where it is more clearly understood to have prognostic significance (Roberts et al., PMID 27870571). In my view, it would be very difficult ...