Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
For patients with intermediate or lower risk essential thrombocythemia with plt >1000 but no symptoms, do you favor aspirin only therapy or aspirin and cytoreduction?
First, the wrong question is being asked. The correct question is, what is the proof that the low-risk, intermediate-risk, or high-risk ET classification has any validity? My answer would be that this classification has no validity. Whether it is based on the IPSET scoring system or one of the other...
Do you consider thrombocytopenia a contraindication for fibrinolytic therapy for a massive PE?
If one has access to mechanical thrombectomy devices and operators, they should be considered before systemic thrombolytics unless the massive PE is causing imminent danger to the patient/patient is going to code/die, in which case the risk of dying from said PE is higher than potential bleeding eve...
What is your target Hgb/Hct for women who are pregnant and have sickle cell disease in whom you are doing scheduled transfusions?
Assuming that the patient is truly transfusion-dependent, the usual target range is a Hb of 9.5-10.5.
What is your approach to initial management of patients with suspected or confirmed primary cutaneous CD8+ positive aggressive epidermotropic T- cell lymphoma (PCAECTCL)?
PCAECTCL is an exceptionally rare and clinically aggressive subtype of cutaneous T-cell lymphoma, characterized by a rapidly progressive course, ulcerated or necrotic skin lesions, and early dissemination to extracutaneous sites. Due to its rarity and lack of standardized guidelines, management is l...
In a newly diagnosed elderly patient with AML who harbors an IDH1 mutation, would you treat with upfront with ivosidenib/HMA or would you proceed with venetoclax and HMA as your first line treatment?
For me, the decision whether to treat this patient with IDH1 inhibitor monotherapy (ivosidenib) vs. venetoclax/HMA depends on how fit this patient is and his/her desire for aggressive therapy and inpatient vs ambulatory care. Prior data suggests very high response rates (90-100%) following venetocla...
How would you manage a solitary, painful, lytic bony lesion in a patient with negative PET/CT but bone marrow biopsy confirmation of multiple myeloma?
This is a palliative scenario, but the approach may differ based on the clinical circumstances. If Heme Onc is planning on administering systemic therapy, then a short course of palliative RT to expedite pain control would be appropriate. Treatment of many sites (e.g., femur) can be done very quickl...
In an adult patient with asymptomatic, isolated neutropenia in whom you suspect a Duffy null phenotype, at what ANC or in what situations would you do a bone marrow to look for other etiologies of neutropenia?
What a great question! Happy to answer. As you know, as many as 60% of individuals who have the Duffy null phenotype will have an ANC that is lower than the lower limit of normal in many labs BUT as you also know, the total body (in circulation + in tissues) neutrophil count in such individuals is n...
When would you consider use of emapalumab for HLH/MAS?
The FDA has approved emapalumab for familial HLH. For secondary HLH/MAS, I typically begin with anakinra (100 mg q 6 hrs for those 40 kg or more). If this is not enough and if CXCL9 (I send on day one to have the data available) is notably elevated, then consider adding emapalumab. Alternatively, a ...
Would you administer adjuvant chemotherapy for extrahepatic cholangiocarcinoma that has received neoadjuvant therapy and achieved near CR?
If the regimen was well-tolerated and there is reason to believe that additional treatment could have been administered (preop tumor evaluation was not stalled out, suggesting ongoing response), I would favor additional therapy. You may also have a role for ctDNA monitoring but I know many are not i...
How would you approach a completely resected DLBCL of the appendix if PET scan and bone marrow biopsy suggest no other disease?
Resected limited stage DLBCL has relatively high risk of recurrence. A recent prospective phase II trial was reported (Yoon et al. Oncotarget 2017) where patients received 3 cycles of RCHOP post resection and had an excellent 2 year PFS of 95%. Another study (Sehn et al. Annals of Oncology 2008 abst...