Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you consider restarting IMID therapy in a patient with recent stroke while on IMID?
This is a very good question, and practice likely differs across institutions as data is limited. The discussion below refers primarily to the immunomodulatory (IMID) agents lenalidomide and pomalidomide.As you are aware, IMID therapy is known to be associated with an increased risk for venous throm...
How do you approach ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?
My default recommendation for patients with localized, high-risk prostate cancer is to recommend the use of long-term ADT. This intervention seems to offer a relatively large, clinically significant OS benefit for patients in the modern era receiving dose-escalated ADT. This benefit has been observe...
Do you utilize D-dimer to inform anticoagulation duration in the treatment of VTE?
I had developed a policy during my last eight or ten years of practice evaluating how long patients should be treated after a thrombosis and I'd like to share some impressions over these years as well as conclusions that I reached. These conclusions formed the basis of my approach to this problem. I...
How do you manage the side effects of ropeginterferon alfa 2b for polycythemia vera patients?
Great question. Although ropeginterferon is better tolerated than other interferons, it is still associated with adverse events. If counts are controlled, I would recommend lowering the dose or spacing out the dosing interval, as that usually helps. For flu-like symptoms, I recommend pre-emptive man...
Can post op RT be omitted in a surgically repaired pathological fracture site in multiple myeloma if the patient will receive systemic therapy?
For extremities (e.g., the femur), if the pain is largely from structural instability, which resolves after surgical stabilization, then proceeding with systemic therapy without post-op RT would be very reasonable. On the other hand, if the patient is having persistent pain after surgery from the os...
What is your approach to pregnant patients with type 2B von Willebrand disease, particularly when thrombocytopenia is already present?
The gist of this challenging clinical problem is that the high estrogen levels in the third trimester of pregnancy raise the VWF level normally. In type 2B VWD, this effect raises the level of the abnormal VWF, which clears more platelets from the circulation, and can lead to severe thrombocytopenia...
How do you manage anemia associated with belzutifan therapy?
Anemia is a common toxicity with belzutifan. In a recent pooled safety analysis (Choueiri et al., The Oncologist KCRS Meeting 2024), anemia was seen in 84% of patients (any grade; 29% grade 3) with a median time to onset of 29 days. It is an on-target effect resulting from HIF regulation of erythrop...
In a patient with high risk acute promyelocytic leukemia, when do you consider ATRA+ATO with GO vs ATRA+ATO with idarubicin?
Given the recent publications with ATRA/ATO and GO in high risk patients or low risk patients who develop leukocytosis (Blood 2017) and the long term follow up of the comparative study form the NCRI AML Working Group (Blood 2018), GO is my preference in all cases unless there is hepatic toxicity or ...
How would you treat a patient with two concurrent plasmacytomas whose bone marrow showed no evidence of multiple myeloma and has no other MM defining features?
This is by definition Multiple Myeloma and I would treat it as such with systemic induction chemotherapy followed by transplant. These patients do better than the standard MM oftentimes. IMWG Criteria for the Diagnosis of MM | Inl Myeloma Fn
What is your escalation strategy for chronic GvHD?
There are now several available options for steroid resistant cGVHD. The old standbys - ECP and rituxan are useful in about 30% of patients. Ibrutinib was the first new drug to get FDA approval. Unfortunately, I don't think the real-world experience is anywhere near as good as the trial (Chin et al....