Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What treatment do you recommend for marginal zone lymphoma in a patient who previously received bendamustine and rituximab for MALT?
RCHOP or a BITE; I would use cladribine + GAZYVA with curative intent.
How would you manage a patient with polycythemia and MPN symptoms (aquagenic pruritus, fatigue) that is JAK2/CALR/MPL negative but peripheral blood NGS positive for IDH2?
I would approach this through the framing of a polycythemia/erythrocytosis workup and then consider MPN-related interventions if a diagnosis is made! This is an excellent review that provides an overview of erythrocytosis investigation (Noumani et al., PMID 38695361). In brief, I would be thinking a...
How do you approach prophylactic antibiotics in patients who continue to have recurrent neutropenic fever following chemotherapy for solid tumors despite chemotherapy dose reduction and growth factor support?
This has to be individualized to the patient. It depends on the length of neutropenia, previous infections, and local antibiotic resistance. If the patient develops neutropenic fever after every cycle of chemotherapy and no obvious nidus of infection has been identified, a trial of a fluoroquinolone...
In older male patients with a history of underlying autoimmune disease, what clinical manifestations would prompt you to evaluate for VEXAS Syndrome?
Hello!!!Skin lesions, elevated MCV, elevated inflammatory markers.
How should community oncologists practically counsel patients with aggressive lymphomas on the potential treatment course as they move into 2L/3L therapies?
For those who relapse after first line therapy, treatment recommendations are dependent on the timing of relapse. For those who relapse within 12 months of completing first-line therapy and are fit, I would strongly consider referral to a center with CAR T-cell capabilities. As noted before, 5-year ...
Which patients with relapsed/refractory NHL are appropriate for pre-CAR-T bridging radiation therapy?
Before answering this important question, I think that we, as Radiation Oncologists, should give serious consideration to moving past the terminology of "bridging radiation therapy" and instead refer to it as "pre-CAR-T infusion radiation therapy." Bridging therapy was initially an apt name; we were...
In addition to monitoring hemoglobin and supplementing folic acid, what is your approach to hereditary spherocytosis in pregnancy?
I use the same transfusion threshold for the general pregnant population but I do refer to maternofetal medicine/high risk pregnancy clinic for closer fetal monitoring. My personal preference is to obtain genetic testing to confirm the specific mutation responsible for hereditary spherocytosis as it...
How do you manage B12 deficiency refractory to subcutaneous replacement?
I tend to start with IM injections of B12 when patients are severely deficient. The most common mistake in replacing severely low B12 is to not load, or to check levels too early. I have not used SQ administration before. It should absorb, but if you are having issues I would go to IM and start week...
Would you give GO and/or a FLT3 inhibitor for patients with AML with t(8;21) and FLT3-ITD low in addition to 7+3?
First, in terms of risk stratification, core binding factor (CBF) AML [whether inv16 or t(8;21)] is considered to be favorable risk by ELN22 even if a FLT3 mutation is present (Döhner et al., PMID 35797463). The incidence of FLT3-ITD in CBF-AML is 5-10% (Faber et al., PMID 27798625). There are some ...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...