Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you approach the workup and initial treatment of systemic AL amyloidosis?
1: Ensure that this is light chain. Mass spectroscopy of the tissue to identify/confirm is very important. Even if a patient has positive serum monoclonal protein or light chain, it does not indicate that this is light chain amyloidosis. I have had patients with MGUS and smoldering myeloma with ATTR...
Do you recommend work up for POEMS and/or amyloidosis for IgM monoclonal gammopathies associated with neuropathy?
While IgM monoclonal disorders, amyloidosis, and POEMS syndrome may all be associated with peripheral neuropathy, they are not often confused with one another. A patient with a peripheral neuropathy can be diagnosed most simply by a serum protein electrophoresis. The presence of a monoclonal IgM spi...
How do you choose between therapies for newly diagnosed ITP that is refractory to steroids and IVIG?
The important questions here are what are the symptoms and what are the platelet counts? In patients who fail to respond to either corticosteroids or IVIG, the concern is whether this is actually immune thrombocytopenia or another cause of thrombocytopenia. With "normal" flow and bone marrow results...
How would you manage presumed gestational thrombocytopenia with moderate thrombocytopenia for delivery planning?
Thanks for this question. First and foremost, it's critical to rule out a placental-mediated complication such as pre-eclampsia and HELLP, and to evaluate for other more nefarious causes of thrombocytopenia (TTP, aHUS, etc., though of course rare). While a diagnosis of exclusion, gestational thrombo...
Can anti-cardiolipin or anti-beta-2 glycoprotein antibodies cause prolonged PTT in the absence of a lupus anticoagulant?
Lupus anticoagulants are a heterogeneous group of antibodies that do not have uniform activity in all assays. Furthermore, testing procedures are not well-standardized. Since relevant clotting factor deficiencies have been ruled out and the long PTT does not correct with mixing, and since there is o...
How do you do risk stratification for patients with light-chain-only MGUS?
This is a great question, Dr. @Dr. First Last. Apologies for the delay in responding.Light-chain disease is not as clearly defined as heavy-chain disease.There is some guidance here based on current studies, such as Maeng et al., PMID 40295472, revised free light chain reference intervals enhance ri...
What are the factors that you would consider for the use of ESA in patients with anemia of CKD with a history of stroke or TIA?
Large clinical trials of ESA have indicated increased stroke risk with these medications with TREAT reporting the highest stroke incidence. In this study, "baseline history of cerebrovascular disease was a strong predictor of experiencing a stroke during follow-up; patients with a history of stroke ...
How would you treat an older patient with B symptoms and biopsy consistent with grade 3 follicular lymphoma but noted to have a PET scan with SUV readings of > 20?
If an adequate biopsy was performed of the most active (high SUV) mass/node and results as follicular grade 3 A, then can treat as you would a follicular lymphoma with BR. I have seen high SUVs with follicular lymphoma. Mir et al., PMID 31961926However, if it is follicular grade 3 B or has high Ki67...
What is your first line of therapy for refractory Hodgkin lymphoma in an AYA patient?
Our first approach in this setting is second line chemotherapy with the intention to achieve a complete metabolic remission (by PET) and then an autologous stem cell transplant. Our approach to the transplant includes total lymphoid irradiation followed by a conditioning regimen of Cyclophosphamide,...
How would you approach a patient with early-stage orbital MALT lymphoma with high proliferative index?
High proliferative index is uncommon in MALT lymphoma, seen more often with high grade histologic variants. For localized disease, it would not influence my management recommendations. For orbital MALT lymphoma, 24 Gy in 2 Gy fractions to the orbit. Efforts to shield part of the orbit should be unde...