Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is the risk of radiation therapy to an abdominal aortic aneurysm infiltrated by lymphoma?
I have no personal experience treating an AAA infiltrated with lymphoma. I believe, however, it is appropriate to draw an analogy with treating stomach or bowel involvement with lymphoma. In this situation, chemotherapy may well result in perforation due to rapid tumor shrinkage, whereas fractionate...
How would you manage a patient with sickle cell disease who is infected with COVID-19?
We have limited knowledge about this management. The Sickle Cell Disease Association of America's Medical and Research Advisory Committee has issued a provider advisory. Also, Dr. Julie Paniepento has created a registry that can be viewed in real time here: https://covidsicklecell.org/ In general, t...
How would you manage a patient with primary CNS lymphoma who received R-MTX followed by autologous transplant with systemic relapse 5 years later for which R-Pola-CHP was given now followed by CNS relapse?
Dr. @Dr. First Last - certainly an interesting and unusual scenario! I'm presuming that the patient is fit for intensive approaches. This is a patient whom I would consider for CAR-T as a treatment of multiply relapsed DLBCL. Depending on the symptomatic and anatomic burden of the CNS disease, debul...
In patients with early-stage follicular lymphoma undergoing definitive RT, do you approach grade 3a disease any differently than grade 1-2 (radiation dose, fields/margins, systemic therapy)?
Our philosophy is based on whether it is grade 3A or 3B. If it is 3A, then we treat like low grade lymphoma with RT (similar dose and principle) but if it is 3B, then treat with chemotherapy +/_ RT like diffuse large B cell lymphoma.
Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?
The workup for a young adult with an upper extremity DVT differs for me in two ways: Venous thoracic outlet syndrome must be suspected and a careful history of repetitive overhead movements must be obtained. Consulting your vascular surgery team in these cases to ensure the anatomy does not put the...
In an elderly transplant ineligible IDH1-mutated patient with AML, who is in remission after 6 cycles of azacitidine and ivosidenib, would you discontinue azacitidine after cycle 6 and continue maintenance ivosidenib until progression/toxicity or continue both azacitidine and ivosidenib?
Our practice is to typically continue azacitidine + ivosidenib per the AGILE study (Montesinos et al., PMID 35443108) as long as the patient is not having excessive myelosuppression/toxicity and doesn't feel strongly about coming off azacitidine. That being said, there are data to support ivosidenib...
Do you recommend postoperative radiation for spinal cord compression DLBCL?
I would recommend postoperative RT, following completion of systemic therapy. I would restage with PET-CT prior to RT. If CR: 30 Gy would suffice.
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
How would you approach management of a patient with ESRD on the transplant list who is found to have high titer APS labs (ACL, B2GP1, LAC)?
This is an excellent but rather complex question. Management of patients with ESRD on the transplant list who are found to have high titer APS labs (ACL, B2GP1, LAC) depend on the renal histology, underlying autoimmune disease history, and comorbidities. Patients with thrombotic manifestations resul...