Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you recommend treatment for CLL patients with biopsy proven infiltrative lesions in the liver without hepatic dysfunction or hepatomegaly?
This is a very difficult question without context of why the biopsy of the liver was done. In general, for virtually all body sites, when CLL is found as an asymptomatic surprise finding, I continue observation. This is particularly true when it is an area of high disease presence at the time of aut...
Do you routinely evaluate for PE if a DVT is found?
I would not routinely evaluate for PE in a patient with new DVT, unless they had symptoms or signs suggestive of PE diagnosis. But I would usually evaluate for DVT in a new PE patient. This is in case the patient develops leg swelling or pain in the future and DVT is found then. It's difficult, oc...
Does anything need to be done if hyperlymphocytosis (i.e. ALC > 300K) develops in a CLL patient just starting ibrutinib?
Leukostasis is a feared complication of acute myeloid leukemia (AML) in patients developing peripheral WBC counts >100,000. The cells in AML are large, sticky, and invasive. By contrast, the lymphocytes in chronic lymphocytic leukemia are small (10 microns or so; not much larger than red blood cells...
What hypofractionated radiotherapy dose regimen is acceptable for plasmacytoma?
At the end of the day, it all comes down to delivering a reasonable BED in the range of +/- 50 Gy in fractions of 2 Gy. The type of fractionation chosen is a question of the treatment volume, location, and adjacent OARs. I have treated a few plasmacytomas with SBRT (for instance in the ribs) with 3-...
Do you routinely genotype adult beta thalassemia patients?
Yes, this is recommended by the American College of Medical Genetics and Genomics and is helpful for prognosis and complications. I also test for alpha gene duplication or triplication if there is a mismatch between the beta thalassemia genotype and the phenotype.
For patients with microcytosis MCV 75-79 and normal Hb, low TIBC, and normal ferritin do you always rule out thalassemia?
Microcytosis is typical in thalassemia. With a normal ferritin and hemoglobin concentration, I would start screening by measuring HPLC, HbA2 levels that are high in beta-thalassemia carriers. (HbA2 can be normal with “mild” thalassemia alleles and for several other reasons.) Microcytosis without iro...
How do you manage anemia in a patient with myelofibrosis and hemochromatosis?
It is a good question. There isn’t much more you can do. There are new targeted therapies for myelofibrosis which are best answered by an MPD specialist. As for the hemochromatosis, you should still check iron parameters, because if deficiency is present it SHOULD be treated, in this case with IV ir...
What is the target ferritin level for patients with hereditary hemochromatosis and signs of end-organ damage?
I believe the best marker to guide phlebotomy therapy for iron overload is the serum ferritin concentration. I use a target ferritin level of approximately 50 ng/ml. However, one could justify a ferritin level of <200 ng/ml from the literature of serum ferritin compared to body iron stores in HFE he...
In patients who relapse during a treatment-free period after achieving remission on prior 1st/2nd generation TKI, what factors should be taken into consideration when restarting treatment?
I would usually restart therapy in patients who lose MMR after a failed TFR attempt. I would usually use the same TKI they were using before stopping, unless part of the reason for stopping was toxicity, in which case I would consider an alternative TKI that may have a lower probability of having a ...
What front line therapy would you recommend for a patient with CLL on chronic dual antiplatelet therapy?
Given the bleeding risks associated with BTKi, I personally may prefer venetoclax-based therapy if feasible, in treating patients who require dual antiplatelet therapy (DAPT). This is based on safety considerations. I consider both BTKi-based therapy and venetoclax-based therapy great options for fr...