Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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...
Is there therapeutic relevance for FLT3-ITD mutation in relapsed APML?
FLT3-ITD mutations are seen in anywhere from 12-38% of APL cases, and there are conflicting data on the prognostic impact of the mutation on outcomes (Kuchenbauer et al., PMID 16029447, Beitinjaneh et al., PMID 20096459, Kiyoi et al., PMID 9305596, Kainz et al., PMID 12522450, Schnittger et al., PMI...
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...