Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you approach immediate management of paraspinal extramedullary hematopoiesis in patients with transfusion-dependent thalassemia when lesions are enlarging or causing neurologic symptoms?
In general, the goal of transfusion therapy in transfusion-dependent thalassemia (TDT) is to suppress ineffective erythropoiesis. It is the rationale for maintaining a higher pre-transfusion hemoglobin level, at 9.5-10.5 g/dl, well above the general threshold for PRBC transfusion used in oncology pa...
Is the PFS benefit sufficient to adopt up front acalabrutinib plus BR for all patients with MCL?
In my opinion, PFS is not sufficient to adopt BR-acala as a universal treatment, but this can be an important treatment option for many patients. I would offer the BR-acala combo in patients who value maximizing duration of treatment response, recognizing this is a continuous regimen. On the other h...
How would you work up a patient with cutaneous mastocytosis?
In adults, consider mastocytosis as being systemic until you prove it is not. A single normal or low-elevated tryptase does not eliminate the possibility of systemic mastocytosis. All patients should go to Heme/Onc for consideration of bone marrow biopsy and ideally high-sensitivity PCR to look for ...
How do you approach palliative RT dose selection to skeletal lesions in patients with Myeloma who are actively receiving or likely to need systemic therapy?
Multiple myeloma patients with painful bone disease often present a unique constellation of clinical characteristics, such as extensive skeletal involvement, longer life expectancies, and many prior or anticipated systemic treatments. Some key features influencing my choice of radiation dose and sch...
Do you recommend a workup for POEMS and/or amyloidosis for IgM monoclonal gammopathies associated with neuropathy?
While IgM monoclonal disorders, amyloidosis, and POEMS syndrome may all be associated with peripheral neuropathy, they are not often confused with one another. A patient with a peripheral neuropathy can be diagnosed most simply by a serum protein electrophoresis. The presence of a monoclonal IgM spi...
How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?
Patients with metastatic lung cancer are at increased risk of thromboembolic events with an estimated frequency of 13.9% (Connolly et al., PMID 23026639). Preclinical data show that PD-1/PD-1 pathway blockade may lead to increased levels of pro-inflammatory cytokines and T cell driven progression an...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
Would you consider prophylactic anticoagulation for May-Thurner syndrome in pregnancy if prior endovascular intervention has been completed?
In general, I have a very low threshold to initiate prophylactic anticoagulation in pregnancy. For a patient with a history of May-Thurner that has been endovascularly corrected and who has been maintained off of anticoagulation without issue, I would have a risk-benefit discussion about prophylacti...
Do you use MRD testing to guide maintenance therapy discontinuation in newly diagnosed non-high risk myeloma patients?
Patients with high-risk myeloma, whether defined by the IMS/IMWG or the somewhat controversial functional criteria, generally require ongoing treatment given the agents we have available; otherwise, they quickly relapse. It's easy to understand that there must be patients on the other end of the spe...
How do you manage perioperative anticoagulation for a patient with a history of recent, surgically provoked VTE?
In most cases, bridging is rarely indicated because the bleeding risk usually outweighs the risk of VTE recurrence during a short (1–2 day) interruption of anticoagulation. However, after a recent VTE (defined as <3 months), the estimated risk of VTE recurrence is high (>15–20% per year) (still low ...