Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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....
Will you use vadadustat in place of an ESA in treating anemia of chronic kidney disease?
Vadadustat is approved by the FDA only for patients who have been on dialysis for at least 3 months. It is not approved for patients with CKD not on dialysis. Its efficacy and safety are comparable to that of ESAs. I would consider using vadadustat in two patient populations: those on home dialysis ...
How would you approach an asymptomatic older female patient with eosinophilia to 17,000, present for years, and normal eosinophilia workup including marrow and negative FLIP1?
Interesting case. Eos have been in the 17K range for years? Was it incidentally noted? Could just be idiopathic HES. I would worry about cardiac infiltration in an older patient, but if there have never been cardiac issues and no evidence of a myeloid variant, I would probably defer to the patient a...
After induction therapy for acute promyelocytic leukemia with arsenic trioxide and ATRA, at what point do you start consolidation?
During induction, I wait for count recovery (ANC above 1000, transfusion independent- typically around Day 30, but +/- 5 days) and perform a bone marrow biopsy at that point. Patients routinely are still (but not always) + for PML-RAR at this biopsy, but that doesn't matter. As long as the marrow is...
How would you approach choosing a regimen for a patient with multiple myeloma refractory to Daratumumab and Lenalidomide, with severe neuropathy from Bortezomib?
That's an excellent question with many answers. Ideally, CAR-T therapy is a strong option, particularly based on the findings from the CARTITUDE-4 trial. If the patient is uncertain about CAR-T, then carfilzomib-based therapy is a viable alternative. This option can be effectively combined with eith...
How would you manage a CVST secondary to a traumatic brain injury with the presence of intracranial hemorrhage?
When dealing with CVST after TBI, the mechanism of injury is not the same as a spontaneous CVST. There is often direct injury to the vein or the area overlying it. Given that these patients often have other traumatic injuries, and given the lack of clear evidence to support one therapy or another, I...
Does the presence of paraneoplastic pemphigus influence your treatment options in CLL?
Paraneoplastic pemphigus is often difficult to treat, and if traditional measures do not control it, I often will use continuous therapy for CLL to both eliminate the disease and continue suppressing the autoimmune source of this paraneoplastic complication.
What factors should be considered when deciding whether to omit radiation in pediatric/AYA patients receiving N+AVD, particularly regarding long-term outcomes and second malignancy risks?
Based on the early data from S1826, it appears that radiation can be omitted if end-of-therapy scans (after 6 cycles of therapy) show metabolic remission of disease. The ability to limit RT to 1% of patients is encouraging for potential reduction in late effects such as cardiovascular disease and SM...
How would you manage a patient with family history of protein S deficiency, now with provoked VTE and low protein S?
Low protein S would need to be checked at the appropriate time. It should not be checked during acute thrombosis It should not be checked while the patient is on DOAC If the provoking factor was estrogen containing contraceptives, testing should not be performed until the patient has been off of est...
What is the optimal timing for PET/CT to assess disease and treatment response with nivo + AVD?
The S1826 study did not require interim imaging. Despite this, I routinely order an imaging test prior to cycle 3, day 1 for patients on the N-AVD regimen. In most cases, I order PET/CT scans. I continue therapy in patients with a Deauville score of 4 or less (partial or complete response) rather th...