Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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 ...
Would you offer XRT as bridging for all patients with limited pre CAR-T disease or as consolidation for only those with residual PET-avidity on day+30 post CAR-T?
There are no studies comparing these 2 approaches. However, given the detrimental outcomes of post CAR-T relapses, I would consider maximizing peri-CAR-T treatments as much as possible as long as the toxicity profile is reasonable, and would not view these 2 approaches as mutually exclusive. I would...
Do you ever repeat screening for acquired von Willebrand in patients with essential thrombocythemia who have high platelet counts and very low risk disease not on cytoreductive therapy?
I generally check on a regular basis (i.e., yearly) to confirm no changes. Obviously, if there is bleeding I would check at that time.
How do you approach a persistently elevated mean platelet volume and immature platelet fraction in an otherwise healthy patient with a normal platelet count?
I am trying to understand the circumstances where this question might arise. Nowadays, when patients can readily see CBC results before their clinicians, they might notice the H or L designations and ask. In general, I would not think twice about "slightly out of range" CBC parameters in a single me...
For patients with solitary plasmacytoma of the ureter undergoing definitive XRT (40-50 Gy), what dose constraint do you use for the ureter?
Well, since this is a solitary plasmocytoma of the ureter, I presume that parts of the GTV encompass the OAR here. I do not think that you can set any meaningful constraint for the ureter, bearing in mind that this is a serial OAR. You can try to avoid hotspots in the ureter, but that's about it.
Are you now using luspatercept as your first choice for anemia management in patients with low-risk MDS otherwise appropriate for EPO initiation, regardless of presence of SF3B1 or ringed sideroblasts?
Only use luspatercept if the patient is transfusion-dependent. FDA approves luspatercept as first-line treatment of anemia in adults with lower-risk MDS (aabb.org). In patients with MDS who are candidates for epo and transfusion independent then epo is still my first choice.
What is your preferred third-line therapy for a fit patient with symptomatic, relapsed follicular lymphoma who has failed bendamustine-rituximab and lenalidomide-rituximab?
This sounds like the patient where a CART may make sense. If that's not an option for whatever reason, I may go to bi-specific over say, copanlisib at this point. I suppose if EZH2 mutated, tazamezostat might be an option, but less appealing in a young otherwise healthy person.