Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In patients with CML who are receiving 1st line TKI with good molecular response, are you continuing therapy or switching to asciminib based on the ASC4FIRST data?
For a CML patient with optimal response and excellent tolerability to their current TKI, there should not be impetus to switch to asciminib. For patients with less than optimal response, diminished quality of life, and in certain settings of adverse effects from current therapy, consideration of TKI...
How do you approach second-line options for relapsed myeloma after front-line quadruplet therapy?
It depends on the patient's case. In the setting of high-risk disease, whether clinically high risk or with HRC would prefer to use CAR-T in the second line. Currently, SoC allows for bispecific use beyond the 4th line, therefore would use triplet such as DPd (APOLLO) or IsaPD (ICARIA) second line f...
How do you decide the dose of aspirin to use in MPN patients?
The standard dose for aspirin in the USA for MPN patients is aspirin 81 mg daily. I sometimes use 81 mg BID for patients with significant CV comorbidities. Some patients with headaches or microcirculatory symptoms may improve symptomatically with BID aspirin. Lastly, patients with erythromelalgia wi...
What volumes do you treat for ISRT for extranodal DLBCL?
It is important to remember that ISRT, for both Hodgkin and non-Hodgkin lymphoma, consists of a set of principles that can be used to design rational radiation fields in the context of modern treatment planning. In general, only sites of original involvement are treated when patients also receive, a...
When utilizing ISRT for Hodgkin lymphoma, what volumetric expansions (ITV and PTV) are appropriate on top of the CTV that includes the original pre-systemic therapy disease?
First, it is important to realize that involved-site radiation therapy (ISRT) for Hodgkin lymphoma is not a formulaic approach to field design. It requires careful evaluation of pre-chemotherapy imaging, fusing these with post-chemotherapy planning CT scans for optimal target delineation, evaluating...
What is your approach to VTE prophylaxis in hospitalized patients who are already on DAPT?
DAPT by itself is not considered DVT prophylaxis in patients at high risk of DVT. However, LMWH at prophylactic doses can increase the need for transfusions in patients on DAPT, without decreasing VTE rates. In general, I consider patients individually: Do they still need DAPT? With discontinuity o...
What is the appropriate RT dose for an advanced stage follicular lymphoma?
Depends on the specific clinical scenario. However, in general, RT in advanced stage follicular lymphoma is palliative. Therefore, I would start 2Gyx2. Repeat as needed. If cord compression or something serious, would consider 24Gy.
How long would you wait after a cycle of IT MTX to treat a spinal lesion causing cord compression in a patient with stage IV DLBCL?
Intrathecal methotrexate has biphasic half-lives of about 5 hours and 14 hours (Bleyer, Cancer Treat Rep 1977). ILROG recommends typically waiting minimum interval 2 weeks between last IT or high-dose IV methotrexate before starting CNS radiotherapy for CNS leukemia, but urgent radiotherapy may be c...
Do you routinely repeat imaging for PE after anticoagulation treatment to establish a new baseline?
We only do imaging if the patient is symptomatic still after a few weeks or has persistent chest pain or clinical signs of pulmonary hypertension. Rarely I have seen recurrent or progressive thromboembolic disease on anticoagulation. Another possible reason if the patient needs to go to surgery in t...
What is your preferred iron loading strategy for patients with anemia of chronic kidney disease?
I prefer to give ferumoxytol 510 mg X 2 doses of available.