Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
For patients with recent post-delivery symptomatic ovarian vein thrombosis on anticoagulation, how would you approach periop AC management for upcoming procedures like D&C?
Nevertheless, I would first determine if the D&C needed to be performed so soon after diagnosis of the ovarian vein thrombosis or if it could be delayed. If it needs to be performed sooner, communicate with the proceduralist to determine if the anticoagulation needs to be interrupted. A number of in...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
What is your threshold to diagnose light chain MGUS with only a slight elevation in the light chain ratio, in a patient without other CRAB symptoms and no M spike?
Mild increase in kappa light chains can be a result of antigenic drift seen with the assay, in renal dysfunction both can go up but kappa may go up a bit more skewing the ratio. If a 24-hour urine with electrophoresis and immunofixation is negative and the rest of the work up is negative, would cont...
Would you consider a positive DAT and indirect Coombs test, persistent and consistent with IgG warm antibody, clinically significant in absence of hemolysis?
Up to half of patients with red cell auto-antibodies (i.e., true positive DAT/direct Coombs test) are not experiencing hemolysis. After iron repletion in this patient, the best way to determine the degree of hemolysis and whether treatment is needed is by the stability of the hemoglobin and the reti...
Would you include midostaurin in induction and consolidation for patients with good-risk AML with NPM1 mutation and FLT3-ITD (<0.5)?
Yes, in my practice I routinely include FLT3 inhibitor (midostaurin) in upfront 7 plus 3 chemotherapy for all younger fit patients with AML regardless of NPM1 status or FLT3 allelic ratio. The RATIFY trial validated the benefit of midostaurin in patients regardless of ITD allelic birder (both high a...
How would you treat progressive Rosai Dorfman Destombes disease after initial limited radiation therapy?
To provide the best answer, we need a little more detail on this case. Also, is the patient symptomatic from the abdominal disease? If not, I would observe in the short term. If symptomatic, I would do PET/CT and consider a repeat biopsy, given the risk of the development of another process. Do you ...
What clinical or logistical factors influence your choice of anti-CD38 antibody in first line treatment of Multiple Myeloma?
I generally use daratumumab, because subcutaneous is more convenient for patients, and we go to once-a-month dosing much quicker with daratumumab compared to isatuximab. Once isatuximab subcutaneous is available, this advantage of daratumumab may be lost, but given comfort and familiarity with darat...
How would you approach mantle cell lymphoma in very elderly patients?
For patients who are very elderly, my approach depends on the patient's performance status, other comorbidities, disease features/disease behavior, and indications for treatment. There are patients with MCL who can be observed at diagnosis (those with leukemic non-nodal disease but also those with l...
Would you extrapolate results from ELEVATE-RR study to favor use of acalabrutinib as first-line therapy in treatment-naive CLL?
The ELEVATE-RR study enrolled patients with a median of 2 prior regimens, with either deletion 11q or deletion 17p. I think one could debate whether selecting this patient population as compared to a less selected treatment naïve population would be more likely to find a difference between the two d...
How would you approach treatment for a R/R mantle cell lymphoma patient with a history of autoimmune hepatitis who has progressed on both a covalent and non-covalent BTKi?
Without the whole story, hard to know if this patient is a candidate for CAR T therapy. Presuming the answer is no, I would give venetoclax. Admittedly this is off label, but venetoclax can be very effective in this disease, both in my personal experience and in the limited available data (Davids et...