Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is the preferred approach for an AYA patient with VHR B-ALL with iAMP21 mutation with an isolated early CNS relapse?
For relapsed high-risk disease such as iAMP21, the recommended approach is to achieve remission followed by consolidation with allogeneic stem cell transplantation. However, in cases of isolated CNS relapse, I favor CAR T-cell therapy first to achieve and deepen CNS remission, as it has demonstrated...
What is your standard for monitoring triglyceride level during therapy for ALL, particularly in regards to receiving pegaspargase?
Routine monitoring of triglyceride levels is not considered standard practice during pegaspargase therapy. Although hypertriglyceridemia is a common side effect of asparaginase treatment, it typically has no significant clinical impact on management decisions or future use of asparaginase. The condi...
What parameters would you use to monitor and interpret iron levels in a hemochromatosis patient where ferritin is unreliable due to underlying chronic inflammation?
The biggest question in these situations is whether the patient truly has iron overload vs. just high ferritin. If iron sat is not elevated, true iron overload is very unlikely. If both ferritin and iron sat are elevated, but they don't have a homozygous C282Y genotype, I make sure that the patient ...
Would you recommend indefinite or extended anticoagulation in any scenario of a provoked clot?
The answer, like most decisions with the duration of anticoagulation after a VTE, is it depends. The provoking factor is key to determining whether anticoagulation continuing beyond the treatment of the acute event is needed. If the provoking factor was a joint replacement surgery, even in the prese...
How do you think about using Ropeginterferon Alfa 2B for polycythemia vera in patients with active autoimmune disease?
Great question. In general, I avoid interferons in patients who have an autoimmune disease. In the PROUD-PV/CONTI-PV study, a medical history of autoimmune disease was an exclusion criterion. There have been reported cases of interferon-induced autoimmune disease, most commonly autoimmune thyroiditi...
How do you manage reactive thrombocytosis and potentially symptomatic fatigue from JAK2+ P Vera with iron deficiency?
This is a challenging scenario since if you start supplementing iron, you can increase erythropoiesis, raise the hematocrit, require more therapeutic phlebotomies, and end up chasing your own tail. For these reasons, I generally recommend against iron supplementation in PV. Regarding the fatigue and...
Do normal methylmalonic acid levels absolutely rule out vitamin B12 deficiency?
An elevated MMA is a good indicator of B-12 deficiency but a normal level does not argue strongly against B-12 deficiency. Normal MMA levels have been reported in 10-25% of patients with known B-12 deficiency (B-12 levels below 100). Testing for an elevated homocysteine level might help but this tes...
What is your preferred treatment for CML that presents with thrombocytosis?
In short, I do not change my TKI recommendations for patients with newly diagnosed CML who present with thrombocytosis. Prognostic scores demonstrate that thrombocytopenia is associated with poorer outcomes (Pfirrmann et al., PMID 26416462), but thrombocytosis does not seem to have any specific prog...
In addition to supportive transfusions, do you consider other interventions for symptomatic anemia and thrombocytopenia associated with chronic neutrophilic leukemia?
Assuming the CSF3R mutation that is seen is the T618I mutation, you can consider ruxolitinib. Dao et al., PMID 31880950, reported on a prospective trial of ruxolitinib in 44 patients with CNL or atypical CML. The overall response rate was 35%. However, responses were enriched in patients with CSF3R-...
What dose constraints do you use when treating gastric MALT or DLBCL with radiation therapy?
Treatment of the entire stomach is recommended for gastric MALT lymphoma. A dose of 24-30 Gy is recommended, generally in 1.5 Gy fractions to limit acute toxicity. I am starting to utilize 24 Gy more frequently though, most studies have used 30 Gy. Gastric MALT tends to be multifocal, is not well vi...