Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
When following current COG ALL protocols with the addition of two courses of blinatumomab to treatment for SR and HR patients, how frequently should surveillance bone marrow and MRD evaluations be performed?
With the caveat that I only treat adults, but the general concepts are similar:In our practice, we routinely do bone marrow exams with MRD assessment after the first cycle of blinatumomab. Assuming this shows no detectable disease, we typically will then perform the same before transitioning to main...
Do you use premedications (acetaminophen, diphenhydramine) before pRBC and plt transfusions to prevent febrile nonhemolytic transfusion reactions and allergic reactions?
I do not routinely premedicate patients. There is a recent meta-analysis that shows no benefit. I only premedicate those who have had a prior transfusion reaction. Old studies showed this was a common practice but those studies were performed before universal leukoreduction and other strategies aimi...
Is there a role for anti-fibrinolytic agents in patients with hyperfibrinolytic disseminated intravascular coagulation?
DIC is a complex clinicopathologic syndrome. There are no randomized trials to support evidence-based practice. The following principles apply: 1) antifibrinolytics should not be used in patients with organ failure or those that are asymptomatic. One could justify their use in this group of patients...
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...
Would you offer TPO-RAs to a steroid-refractory chronic ITP patient with history of stroke?
Yes, if needed, though with a bit of trepidation, and it probably wouldn't be my first choice. Second-line chronic ITP treatment can include TPO-RA, rituximab, or splenectomy, and no one treatment is clearly better than the others (Neunert et al., PMID 31794604). Both splenectomy and TPO-RAs have in...
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 treatment considerations do you make for elderly patients with relapsed/refractory follicular lymphoma?
Treatment options for R/R FL patients depend not only on the condition of the patient but what was received in 1st line and the duration of that line of therapy. Given that if a patient has received chemo-immunotherapy in the frontline setting and had a prolonged remission (> 5 years), then these ag...
What treatment do you recommend for marginal zone lymphoma in a patient who previously received bendamustine and rituximab for MALT?
RCHOP or a BITE; I would use cladribine + GAZYVA with curative intent.
How would you manage a patient with polycythemia and MPN symptoms (aquagenic pruritus, fatigue) that is JAK2/CALR/MPL negative but peripheral blood NGS positive for IDH2?
I would approach this through the framing of a polycythemia/erythrocytosis workup and then consider MPN-related interventions if a diagnosis is made! This is an excellent review that provides an overview of erythrocytosis investigation (Noumani et al., PMID 38695361). In brief, I would be thinking a...
How do you decide whether to use pharmacologic VTE prophylaxis in hospitalized patients with decompensated cirrhosis?
For all patients, I begin by using a standard risk prediction tool to determine if the patient is appropriate for pharmacologic VTE prophylaxis. At our institution, the Padua risk prediction tool is embedded in our electronic health record/admission set. Clinical guidelines- including those from the...