Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How long would you anticoagulate a patient with recurrent VTE who has ongoing risk factors for intracranial bleeding?
In general, my preferred agent outside of the inpatient setting in patients with a risk of intracranial bleeding is LMWH. In the inpatient setting, utilizing a bivalirudin or heparin gtt is most appropriate. I would monitor carefully, including potentially imaging 24 hours after the therapeutic anti...
Can AMPLIFY data be extrapolated to use of other BTKi's in combination with venetoclax or would you only ever use acalabrutinib/venetoclax in first line?
I prefer NOT to extrapolate results, given that BTKis have unique spectra of kinase activities ("kinomes"), different PK/PD properties (such as half life), different adherence rates and dosing schedules, and have different synergistic (especially in a complex immune context that we are committing to...
In patients with Stage 0 CLL who are clinically doing well and don't warrant treatment, do you typically obtain the CLL FISH Panel and p53 status?
I do a baseline CLL FISH Panel and p53 status on new patients with stage 0 CLL, less for determining treatment options at the moment, and more for an idea of their natural history. For patients with del17p or 11q, I may monitor more closely than patients with a more predicted indolent course.
Would you consider daratumumab monotherapy as standard of care for smoldering multiple myeloma based on the AQUILA trial?
AQUILA is out! There MIGHT be a survival advantage (p<0.05) to early intervention, but to avoid p-hacking all we have now is a healthy hazard ratio and a confidence interval that juts right up to 1 - it was 0.97. If a patient meets the criteria for this trial, considering Dara makes some sense. I do...
How does one approach maintenance treatment in transplant ineligible patients with newly diagnosed multiple myeloma?
IMROZ and BENEFIT trials are interesting in that they are billed as for transplant-ineligible patients, yet frail patients were excluded, so I don't think they give us the answer for how to maintain a frail patient. The best answer for a frail patient is, I believe, the MAIA trial, which gives DRD t...
Is there greater efficacy of TPO-RA in patients who have undergone a splenectomy?
The clinical trials and real world studies do not suggest that there is a difference in efficacy in general based on splenectomy status. In my experience, I have found that a few highly refractory patients have some improvement in responses to treatment with splenectomy. I do not generally think of ...
How would you approach treatment for a patient with a residual disease after resection of a solitary jejunal myeloblastic sarcoma?
Myeloid sarcoma (historically- chloroma or granulocytic sarcoma) is simply an extramedullary form of AML. The majority of patients who present de novo with a myeloid sarcoma will either have bone marrow involvement at diagnosis or will develop such metachronously if systemic therapy is not pursued. ...
What is your preferred treatment agent for type 1 von Willebrand patients needing minor procedures if they have a history of severe hyponatremia with DDAVP?
I would avoid DDAVP. I typically individualize hemostatic management based on the procedure- related risk of bleeding and severity of the VWD. For example, for dental extraction, tranexamic acid alone may suffice; however, communication with the proceduralist to use topical agents such as topical th...
Is it reasonable to treat a solitary plasmacytoma of the lung parenchyma with SBRT?
I have only treated one patient with solitary plasmacytoma of the lung over the past 15 years of doing lung SBRT. It is an extremely rare and unusual disease presentation for myeloma. Given the radiosensitivity of myeloma, I opted for 30 Gy in 5 fractions, which resulted in a completed response in t...
While using bridging therapy prior to CAR-T cells in myeloma, if possible, do you target a certain response prior to proceeding with cell infusion?
While CAR-T cell therapy was, of course, first studied and shown to be highly effective in heavily pretreated patients with active disease, experience and newer data show the following themes: CAR-T cell therapy in earlier lines of therapy appears to lead to more durable responses. Lower disease bu...