Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you stop current immunosuppressive therapy or delay starting immunosuppressive therapy in a patient with aplastic anemia who has been infected with COVID-19?
Not much is known yet about this specific situation—but our growing experience here in New York City suggests it may be safe. We have had several post-BMT patients who were on immune suppression for GVHD become COVID positive who have not had significant problems. Also, we have now treated 8-10 pat...
If blood counts are being checked during concurrent chemoradiation, is there a number at which point you would recommend a radiation treatment break?
I’ll let the platelets go as low as 10K before stopping. I lean heavily on the rate of decline to intervene with a break sooner than the absolute numbers if heading for trouble and later if decline is slow and at reaching the end of treatment.
Would you recommend anticoagulation prophylaxis for a pediatric patient admitted with COVID-19?
COVID-19 disease in children seems to be less severe than adults based on the current literature and our personal experience at Children's Hospitals. Among adults, the coagulopathy is beginning to be described with elevated inflammatory markers and other markers of coagulation activation, including ...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
Have you changed your practice in treating CRAO with IV thrombolysis?
The recent THEIA trial had a limited sample size to draw conclusions, even though there was a non-significant trend of improved visual acuity initially in the thrombolysis group. Even the TenCRAOS trial had a small sample size with recruitment challenges, where subtle small differences cannot be acc...
Would you use bone marrow MRD status to guide stopping daratumumab early at 1 year instead of the recommended 3 years of therapy per the AQUILA trial for high-risk smoldering myeloma?
I would venture to say that there is probably a 0% chance that MRD negativity would be achieved with daratumumab alone. The CR rate was 8.8%, but MRD was not assessed, and I would doubt that MRD negativity was achieved in any patient. That said, we can't really extrapolate whether 1 year and stoppin...
What radiation dose do you typically use for relapsed DLBCL following 6 cycles of R-CHOP?
There are several potential scenarios, all with different answers, so I will illustrate a few.Historically, second-line chemotherapy (e.g., R-ICE) would first be pursued for relapsed DLBCL, and if the disease was still responsive to chemotherapy (CR or PR), then the patient would proceed with high-d...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...
How do you modify HMA treatments for a patient with high-risk MDS experiencing prolonged cytopenias after each cycle?
When using azacitidine for the treatment of MDS, I adjust the dose in case of cytopenia for cycle 2 onwards. If there was no baseline cytopenia (ANC >1.5, PLT >75K) but cytopenia developed with treatment, the subsequent cycle is delayed until counts recover, and the dose is based on the nadir and t...
Do you use anti-microbial prophylaxis when you prescribe ibrutinib?
Traditionally, H.Zoster and PJP prophylaxis was more routinely administered in CLL patients receiving chemoimmunotherapy as these regimens were typically more myelosuppressive as well as immunosuppressive. In the era of the novel BCR receptor agents with the approval of ibrutinib and idelalisib and ...