Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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...
Do you hold maintenance lenalidomide or bortezomib for a patient who needs a surgery?
I'm not aware of any formal data to guide this recommendation. In general, I do not recommend holding maintenance lenalidomide or bortezomib for surgery. I do hold maintenance for treatment if/when: - the patient has cytopenias from treatment and would benefit from improved counts from a treatment b...
Have you utilized a dose-reduced approach for elderly patients receiving frontline Pola-R-CHP, similar to R-miniCHOP?
I have utilized a dose-reduced approach for Pola-R-CHP for patients who are elderly, whom I would normally treat with R-miniCHOP, based on the early safety data from the POLAR BEAR trial. This randomized trial compared pola-r-miniCHP to R-miniCHOP in patients >80 years of age or >/=75 with comorbid ...
What is your approach to cancer patients who inquire about alternative or complementary treatments?
It depends a little bit on what specifically they want to use, and if they are truly investigating alternative medicine or complementary medicine. For people seeking full alternative medicine without any conventional treatment, I tell them that a research study showed that people who pursued the alt...
What is your approach to AYA patients with B-cell ALL who relapse after CD19 CAR-T?
This is a somewhat nuanced question based on when the patient relapsed after CAR-T, what CAR-T product they received, whether the patient prior received hematopoietic stem cell transplantation (HSCT), other salvage therapies that were prior received as well as number of prior relapses. Multiple stra...
What induction regimen would you consider for KMT2A-rearranged AML in a young patient with multiple medical co-morbidities who is ineligible for clinical trials?
Given the mention of medical comorbidities and ineligibility for trials, I am going to assume that the patient cannot be treated with an intensive induction regimen. With this in mind, a lower-intensity approach such as azacitidine + venetoclax would be my recommendation. Survival outcomes in adult ...
What is the preferred approach for an AYA patient with VHR B-ALL with iAMP21 mutation with an isolated early CNS relapse?
For relapsed high-risk disease such as iAMP21, the recommended approach is to achieve remission followed by consolidation with allogeneic stem cell transplantation. However, in cases of isolated CNS relapse, I favor CAR T-cell therapy first to achieve and deepen CNS remission, as it has demonstrated...