Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you treat a BTKi naive p53 mutated MCL in 1st relapse with disease noted both systemically and in the CNS?
This is a case where I would likely still use ibrutinib. We know from years of experience that it gets into the CNS, and it's an incredibly effective drug in MCL. Zanu and acala should get into the CNS, but the companies have limited PK data for CNS penetration. The harder question (I think) is whet...
Following the BRUIN data in mantle cell lymphoma, will you routinely treat with pirtobrutinib following a covalent BTKi?
I have incorporated pirtobrutinib into my practice since its approval. I recommend this for treatment in patients who are progressing on covalent BTKi or who have had prior exposure to covalent BTKi with progression and received alternative therapies with further progression. I have used pirtobrutin...
What is your approach to re-challenging BTK inhibitors for a patient who has had intolerance to several different agents?
This is a great question, and the answer is that I probably would not rechallenge with a BTK inhibitor. Many patients who develop an intolerance to a BTKi can remain on the drug with supportive care for the toxicity and/or dose reduction, which is not always effective. If someone truly had an intole...
What are your top takeaways from ASH 2023?
Gene therapy for sickle cell disease and beta thalassemia. This was the first approval of CRISPR/Cas-based therapy in humans. Ex-vivo engineering of isologous hematopoietic stem cells followed by their reinfusion after myeloablative conditioning led to induction of 40-50% fetal hemoglobin in patient...
What is your preferred salvage therapy for patients with follicular lymphoma who relapsed within 24 months of completing front-line chemoimmunotherapy (POD24) and will proceed to high-dose therapy with Auto-SCT?
There is no standard therapy for patients progressing within 24 months of 1L chemoimmunotherapy. If you have a well-designed clinical trial, I would do this 1st. Outside of a clinical trial, I would 1st try to biopsy a hot spot to r/o large B-cell transformation. If so, if the patient is a candidate...
What is your preferred second line regimen for follicular lymphoma that has relapsed four years out since receiving BR?
I try to move away from chemotherapy in FL in the relapse setting, especially with the available options and CAR-T in particular. I would consider lenalidomide-rituximab in second line and zanubrutinib - obinutuzumab in 3L. Obinutuzumab seems to be a better CD20 antibody for RR so lenalidomide and o...
How do you manage bruising in patients on ibrutinib?
Bruising is quite common in patients treated with ibrutinib, and it seems to be a class effect that also is seen with the 2nd generation BTK inhibitors, such as acalabrutinib. It should be mentioned when consenting patients, and reassurance generally is all that is needed because the bruising is usu...
Can acalabrutinib be used after ibrutinib failure in relapsed/refractory mantle cell lymphoma?
Acalabrutinib binds to the same pocket as ibrutinib on BTK. Theoretically, if a patient is ibrutinib resistant, acalabrutinib would not be effective. Ideally, there should have been a small trial testing this hypothesis. However, because of the theoretic concerns, nobody wants to do this trial. As w...
When would you use acalabrutinib in combination with obinutuzumab vs acalabrutinib alone in upfront CLL treatment?
I generally prefer acalabrutinib for treating CLL.When this is first-line therapy and there is a need to give “fixed-duration" treatment, I use obinutuzumab + acalabrutinib. If this is a single agent (monotherapy), I use Acalabrutinib alone.For 2nd or 3rd line, if the patient previously has had chem...
What are the factors that convince you to not immediately treat mantle cell lymphoma and to follow a course of "active surveillance"?
A subset of patients with MCL have a significantly longer survival (often more than 7-10 years) and a more indolent disease course. Two separate groups have reported patients who did not receive up-front chemotherapy at the time of diagnosis but were instead actively monitored, the watch-a...