Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you consider TPO mimetics for chemotherapy induced thrombocytopenia that persists despite dose reductions?
The reported evidence on using a TPO-RA in chemotherapy-induced thrombocytopenia (CIT) is complicated but this seems like a situation where it is worth trying a TPO-RA. Repeated dose reduction and/or delay is not good for treatment of a cancer in general. It is very important to individualize the ca...
If Ianalumab + eltrombopag (VAYHIT2) gains regulatory approval, what would make you consider its use for second-line therapy after glucocorticoid failure/relapse, given its potential hematologic toxicity?
I would consider this in patients who have a more immunoinflammatory phenotype (perhaps with other autoantibodies or with a significant family history of autoinflammatory disease) or in patients who have significant bleeding symptoms and need rapid control of the disease.
How would you manage suspected MGRS in a patient refusing a kidney biopsy?
To diagnose MGRS, a biopsy is necessary. If a patient has M protein on serum protein electrophoresis (SPEP) but shows no evidence of paraprotein-mediated kidney disease, this indicates MGUS. In contrast, conditions like PGNMID are also paraprotein-mediated but can be caused by a small clone that is ...
Do you utilize ctDNA-based MRD testing after frontline chemotherapy for DLBCL?
I do not, as part of the standard of care, in part because of limitations of the ClonoSEQ assay in this setting, and in part because of a lack of clarity around how best to manage a positive. However, there are a number of sophisticated clinical trials exploring this question prospectively, with a f...
How would you treat a stage I fully resected double hit DLBCL?
In patients with fully resected DLBCL, I still give chemotherapy. That also applies to double-hit lymphomas. Limited-stage DHL does not seem to have a poorer prognosis than non-DHL, and intensive regimens do not make a difference. I would treat with RCHOP x 3-4 cycles. Torka et al., PMID 31945157 Lu...
Has the data for the ENRICH study changed your practice for the initial treatment of mantle-cell lymphoma?
While the information presented was intriguing, it has not yet caused any change in my approach to initial therapy for MCL. I say this due to the fact that the IR arm did not seem better than BR, save for those with a P53 mutation. I have routinely avoided CIT in this patient population, so this inf...
In light of data from TRIANGLE, ECHO, and ENRICH, what is the best strategy to treat newly diagnosed patients with the blastoid variant MCL?
The management of MCL for almost 2 decades was driven by extrapolated data from aggressive B-cell lymphoma. However, aggressive chemotherapy and stem cell transplantation have failed to produce a plateau on overall survival curves, and patients inevitably have relapsed. It is now clear that MCL, par...
What is your approach to treatment of mantle cell lymphoma in someone with a mutated gene downstream of the BTK receptor, such as mutated CARD11?
For those with primary refractory MCL after a cBTKi, I would still not proceed with chemotherapy, given the limited data to support benefit after a patient progresses on a cBTKi. Only data thus far is with a bendamustine/cytarabine-based regimen, which, if/when they relapse, would potentially impact...
Would you give adjuvant radiation after complete resection of a small primary cutaneous follicular lymphoma of the scalp?
Not a lot of data, but here goes. First, one has to go back decades in the literature to find series of patients with lymphoma rx'd with surgical resection alone. In general addition of RT improved outcome even when ostensibly resected with neg margins. With today's technology risk of additional RT ...
What is your approach to the management of chronic GI bleeding from AVMs in an elderly patient on DOAC for atrial fibrillation?
I would definitely strongly consider the left atrial appendage occlusion device in these patients. While usually these devices (such as Watchman) do require anticoagulation for about 45 days until the device has an endothelial layer form on it (we usually confirm with a CT scan or TEE), there are so...