Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Given the data from SWOG 1826 suggesting that Nivo-AVD is likely the preferred regimen for advanced Hodgkin lymphoma patients, are there scenarios where alternative regimens may still be preferred?
Unless there was a contradiction to nivolumab (e.g., an active autoimmune disease), I would always favor N-AVD over BV-AVD- particularly in older patients.
Do you omit consolidative RT in pediatric patients with intermediate risk, non-bulky Hodgkin lymphoma who have a rapid early response to chemotherapy?
Yes, if the patients meet the rigid requirements for response, which include a rapid early response (Complete response or very good partial response) after 2 cycles of ABVE-PC chemotherapy AND have a complete response at the end of treatment then the data suggests similar outcomes whether or not the...
Have you seen CD30+ lymphoproliferative skin lesions with Upadacitinib treatment of atopic dermatitis?
I have seen this occur in the setting of atopic dermatitis in one instance with a patient on dupilumab who developed head and neck CD30+ disease. It is certainly possible with upadacitinib but I think most if not all cases of CTCL in the setting of AD were always CTCL from the beginning and just mis...
In massive transfusion protocol from suspected hemorrhage, is it worth obtaining a TEG to guide transfusion?
There really is no evidence (except expert opinion) on massive transfusion protocols and outcomes. There are a few trials showing that TEG or other viscoelastic tests reduce transfusion and even improve survival or other important outcomes in hemorrhage. So given the choice, if rapid point of care T...
How would you manage a Stage IV NLPHL that has residual hypermetabolic disease involving the bilateral neck/SCV following RCHOP x 4 cycles?
Nodular lymphocyte predominant Hodgkin lymphoma is an unusual disease, developing in ~450 patients each year in the United States. While the WHO classification still categorizes this entity as a Hodgkin lymphoma subtype, the International Consensus Classification refers to this disease as "nodular l...
Should testing for genetic causes of HLH be performed in all patients with MAS or secondary HLH regardless of the patient's age?
Familial HLH (fHLH) is a pediatric disease. Therefore, there is no place for genetic testing to establish a diagnosis of fHLH in adults, and treatment for HLH should not be delayed while waiting for genetic testing. However, there are hypomorphic polymorphisms in the fHLH genes that may be a contrib...
How would you counsel patients with personal or family histories of autoimmune disease on immune checkpoint inhibitor therapy for Hodgkin lymphoma?
This is also a tough question. I think patients with autoimmune endocrinopathies (especially Hashimoto’s or Type 1 DM) on stable, longstanding replacement regimens, as well as pre-existing vitiligo, are reasonable candidates for frontline PD-1 based therapies, although they certainly bear very close...
What is your approach to screening for malignancy in dermatomyositis patients who do not have a high risk antibody profile and whose disease responds well to treatment?
This is a great question and one that is very relevant to our clinical practice. Different myositis specific and associated antibodies seem to carry different risks in their associations with cancer. My colleague, Dr. Alexander Oldroyd, has written our current guidelines on cancer screening for pati...
What are your current recommendations for treatment of symptomatic splenomegaly in the setting of myelofibrosis when splenectomy is not an option?
I use low dose, typically 50cGy per fraction for 4-6 fractions, done in 2 fractions per week; need to check platelets each week during course.
When would you consider aspirin for long term management of unprovoked VTE after initial therapeutic anticoagulation?
The WARFASA trial randomly assigned patients with first unprovoked VTE who had completed 6-18 months of anticoagulation to 2 additional years of aspirin versus placebo. While the study demonstrated a 40% reduction in recurrent thrombotic events, the rates of VTE in those receiving aspirin were still...