Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you counsel a patient diagnosed with HTLV after an abnormal blood donor screening, especially in light of new data that dolutegravir may reduce uncommon but severe neurological outcomes associated with infection?
We actually do not see many individuals with HTLV disease at present in the US. Having said that, HTLV is a retrovirus, so it is biologically plausible that integrase inhibitors (like dolutegravir) could reduce viral spread in the body. However, the key counseling message is: evidence is still emerg...
How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?
Patients with metastatic lung cancer are at increased risk of thromboembolic events with an estimated frequency of 13.9% (Connolly et al., PMID 23026639). Preclinical data show that PD-1/PD-1 pathway blockade may lead to increased levels of pro-inflammatory cytokines and T cell driven progression an...
How do you decide between blinatumomab or traditional chemotherapy in combination with TKI for upfront treatment of adult patients with Ph + ALL?
This question is likely inspired by the recent publication of a "chemotherapy-free induction and consolidation first-line treatment" for adults with Ph+ ALL (Foà et al., PMID 33085860; GIMEMA LAL2116). The authors reported relatively high rates of MRD- remissions by bone marrow BCR-ABL1 RT-PCR and i...
When testing for patients with symptoms of MPN, do you prefer to do JAK2 cascade testing or a leukemia NGS testing panel?
Genetic testing with regard to the MPN can be usefully employed both diagnostically and prognostically. With respect to diagnosis, if an MPN is suspected based on symptoms such as aquagenic pruritis, ocular migraine, erythromelalgia, or the occurrence of an unexplained thrombosis, the first laborato...
What is your approach to managing iron overload in children with transfusion-dependent beta thalassemia who have adherence challenges or toxicity with standard chelation regimens?
I would divide the adherence issues into two populations. The younger children where a caregiver is responsible for administering the chelation, and adolescents where caregivers have passed on the responsibility to the patient. For the former, adherence is reinforced with an explanation of the possi...
Could patients with smIPI >1 and poor tolerability to R-CHOP be offered ISRT after 3 cycles of R-CHOP if interim PET showed 5-PS 1-3 response?
The revised NCCN guidelines largely reflect data from studies demonstrating excellent outcomes with four cycles of R-CHOP in patients with low-risk diffuse large B-cell lymphoma (DLBCL), including FLYER, LYSA/GOELAMS, SWOG S1001, and the most recent trial, LNH2009-1B. Although each of these trials e...
After prior BTKi + venetoclax and subsequent progression, how do you then choose next line therapy for high risk CLL?
The first question to ask goes back to patient preference: does the patient want to pursue fixed duration or continuous treatment? If they want another line of fixed-duration treatment, I think retreating with a venetoclax-based regimen is effective based on the available data we have. We know from ...
What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.
If using the triplet AMPLIFY regimen with ven/acala/obin upfront, what do you then plan to use in 2nd line treatment of CLL?
For patients who achieve a favorable response that lasts >1 year (or so, this is a ballpark estimate that may shift with more data), I would be very comfortable re-treating with a covalent BTKi (preferably after screening for BTK resistance mutations by NGS where available - with note of caution tha...
How do you approach deciding which patients with hemophilia B to recommend for gene therapy?
Those of us involved in the care of patients with hemophilia feel like” kids in a candy store” with all these new wonderful treatments, as just in the last year we’ve had 3 FDA approvals of rebalancing agents-fitusiran, concizumab, and marstacimab, and the FIX gene therapy product Hemgenix has been ...