Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you routinely offer fungal prophylaxis for patients on BTK inhibitors?
We do not use antifungal prophylaxis for patients on BTK inhibitors. The risk of invasive fungal infection in patients treated with BTK inhibitors in recent large single institutional series have been 2 to 3%, without routine antifungal prophylaxis. The risk of fungal infection increases in patients...
Do you routinely use higher-dose VTE prophylaxis in patients admitted with traumatic orthopedic injuries undergoing surgery?
Yes, at my institution, we have two separate order sets. One is for moderate-risk medicine patients, which recommends enoxaparin 30-40 mg daily depending on renal function (heparin for ESRD and low-weight patients). The other is for high-risk patients, which includes all orthopedic and trauma patien...
What is the role of radiation therapy in recurrent Rosai-Dorfman disease after surgical resection, which manifests as many cutaneous lesions on the arms and buttocks?
I agree with Dr. @Dr. First Last. When I was in training, we reviewed the cases at MD Anderson. Radiation was only used for 9 patients (infrequently), and local control was achieved in 4 patients. So very small numbers, with uncertain benefits. Median RT dose 36 Gy. In the setting of multifocal dise...
How do you start and manage therapeutic SC heparin for acute thrombosis in pregnancy as the patient approaches delivery?
This is an excellent question and my approach to such a patient has changed over time. In my experience, therapeutic subcutaneous UFH is incredibly unpredictable--women may come in in labor on therapeutic UFH thinking that they will be able to get an epidural, but despite waiting hours and hours, th...
Would you use aspirin 81 mg for VTE prophylaxis in patients on adjuvant tamoxifen/SERMs?
In a meta-analysis of over 30,000 patients, VTE was found in 2.8% of patients on tamoxifen and 1.6% of patients on AI. So, yes there is a higher risk of VTE on tamoxifen but the percentage is still very low. I would not use 81 mg aspirin as VTE prophylaxis in all patients on tamoxifen to rescue or p...
Do you discontinue anti-hormonal therapy if a high-risk ER+ HER2- localized breast cancer patient develops blood clots on anti-hormonal therapy?
Tamoxifen has been associated with an increased risk for venous thromboembolic events, but there does not appear to be any increased risk with the aromatase inhibitors in the placebo controlled studies. These include MA.17, MA.17R in the extended endocrine therapy setting and MAP.3 and IBISII in the...
What platelet threshold, if any, is your goal for cytoreduction in essential thrombocythemia?
An unusual feature of the myeloproliferative neoplasms (MPN) is that their driver mutations are gain-of-function, meaning that the basic MPN phenotype is the increased proliferation of normal circulating blood cells. This basic phenotype is modified by host genetic variation to create three genetica...
What is the optimal choice of therapy for a patient with Hodgkin variant of Richter's transformation from underlying CLL/SLL?
I treat it similar to denovo Hodgkins Lymphoma with Brentuximab AVD for high risk versus ABVD for standard risk. If EBER-positive lymphoma, then there is a role for rituximab use in addition to chemo. Gupta et al., PMID 35291669
Does a patient with known systemic mastocytosis need a bone biopsy of lytic vertebral lesions to rule out other etiologies?
Yes, as long as other etiologies have been ruled out, such as cancer, osteomyelitis, or other infections. Even though osteoporosis is more common in systemic mastocytosis patients, bone lytic lesions are not.
What is your standard diagnostic workup to confirm GVHD in a patient post-BMT with skin rash and jaundice?
I assume there is no diarrhea, so sigmoidoscopy would not be helpful. Gut and liver pathology are useful. Skin biopsy is less helpful. It can be fairly nonspecific, but we do it to rule out other diagnoses that have more definitive pathology. Ultimately, it is a clinical diagnosis. Liver biopsy woul...