Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you approach recurrent migratory superficial thrombophlebitis in a patient with a negative malignancy workup and low-titer anticardiolipin antibodies?
With anticoagulation using a DOAC.
Would you evaluate for thrombophilia in patients with incidental splenic infarcts in the setting of known cirrhosis, portal hypertension, and splenomegaly?
When approaching splenic infarction, one question is to attempt to discern if the infarction is due to venous thrombosis (e.g., in the splenic vein) and subsequent congestion or due to arterial thrombosis (e.g. in the splenic artery), which is much more common. Talking with an expert diagnostic radi...
What is your approach to choosing a conditioning regimen for allogeneic transplant in AML?
Randomized trials in AML and to a lesser degree in MDS have shown that dose intensity is important for long term disease control. Following the guiding principle of trying to optimize the conditioning for each individual patient I use the following guidelines 1 patients less than 60 with HCTCI 3 or...
How would you treat suspected secondary HLH in patients whom etoposide is contraindicated?
Thank you for the interesting question. It would be helpful to understand why etoposide is contraindicated. My general approach for these patients is to first ensure that there is no evidence of malignancy as a trigger as you do not want to mask that with steroids (I strongly recommend obtaining a P...
Is there a risk of increased side effects with combined radiation and ibrutinib therapy?
It is increasingly common to see patients with various hematologic malignancies requiring palliative RT who are on small molecular inhibitors (such as ibrutinib) or other novel agents. There is often a dearth of information in the medical literature regarding the safety of combining RT with these dr...
How do different inflammatory markers like CRP and ferritin contribute differently, if at all, to the monitoring of CART neurotoxicity?
These markers are routinely monitored as they are seen in association with CRS (cytokine release syndrome). Not all patients with CRS will also develop neurotoxicity (ICANS), but most patients with ICANS have antecedent CRS, so in an encephalopathic patient post-CART who does not have significant el...
When would you use proximal complement inhibitors like pegcetacoplan over terminal complement inhibitors for initial treatment of paroxysmal nocturnal hemoglobinuria?
I use either iptacopan or pegcetacoplan as primary therapy for PNH these days. Since its release, I have used mainly iptacopan. Its advantages are 1) it is oral, 2) the side effect profile is very tolerable, 3) it only inhibits the alternative pathway, thus is likely to be associated with less risk ...
When MGUS is suspected in a patient with one risk factor and no evidence of end-organ damage, what additional workup should be done, if any?
My approach applies only for the scenario of thinking about monoclonal gammopathy -> myeloma spectrum. Monoclonal gammopathy -> amyloidosis or MGRS/MGNS, etc. I think of quite differently.Our VA pathways and other organizations have advocated for bone marrow biopsy in this situation. For example, in...
How would you manage recurrent migratory lower extremity thrombophlebitis that occurs despite being on therapeutic apixaban?
The differential diagnosis of Trousseau syndrome (migratory superficial thrombophlebitis) is relatively broad and includes both inflammatory states and undetected proximal DVTs. So I think the short answer about venogram is "maybe," based on how clear is the view by ultrasound. This isn't a typical ...
Now that ropeginterferon is approved for PV, how do you select patients for this therapy?
First, I have no conflicts of interest with respect to ropeginterferon (rPegIFN). rPegIFN is a long-acting version (once every two weeks administration) of pegylated interferon (PegIFN) as opposed to once per week, which has been used for decades for the treatment of CML and MPN patients, without ra...