Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is the optimal antithrombotic management, if at all, in patients with incidentally identified findings of multiple silent embolic appearing cerebral infarcts?
It is important to confirm the pattern is embolic. If unsure, input from a specialized physician (such as vascular neurology or neuro-radiology, if available) can aid in confirming the diagnosis. Various white matter findings may mimic an embolic pattern, and distinguishing between unilateral...
How do you decide when to use andexanet (ANDEXXA) for intracranial hemorrhage associated with factor Xa inhibitors?
The ANNEXA-I trial presents a mixed perspective. The data demonstrated that Andexanet is superior to standard care in reducing hematoma expansion for intracerebral hemorrhage associated with factor Xa inhibitors. This conclusion is based on an imaging-based primary endpoint, supported by previous st...
How would you manage a patient who develops acute stroke during neoadjuvant chemotherapy with KEYNOTE-522 for Stage III triple negative breast cancer?
I will try to provide some data for discussion, but also welcome comments from other experts and opinions. I'm assuming this is a younger patient without known risk factors and that an assessment for things like A. Fib, PFO, and DVT have been performed.Chemotherapy has long been associated with thro...
Should you consider thromboprophylaxis, even for low-dose lenalidomide maintenance, post-autologous transplantation?
In the event there are no adverse contraindications for the use of thromboprophylaxis, yes, I recommend the use of a minimum of 81 mg of aspirin daily with a low dose of lenalidomide. In this meta-analysis (Chakraborty et al., PMID 31913498), the risk of venous thromboembolism was low with a low dos...
How would you approach a young person with JAK2 V617F positive essential thrombocytosis with otherwise low risk features?
The first question in this situation is what is the JAK2 V617F neutrophil quantitative allele burden (NAB)? It must be less than 50% for a diagnosis of essential thrombocytosis (ET). Second, are we dealing with a man or woman? Men with so-called "ET" are much more likely than women to develop myelof...
When do you consider cytoreduction in patients with Essential Thrombocytosis?
I consider cytoreduction for patients with ET if they are at high risk of thrombosis based on the R-IPSET score. For intermediate risk patients, I factor in medical comorbidities and symptoms to help decide to initiate therapy. I don't start cytoreduction based on a platelet count alone. If a patien...
How do you approach frontline treatment for an elderly patient with adult T-cell leukemia-lymphoma (ATL)?
More information is needed. As you know, there are four clinical variants of ATL that differ in clinical presentation, prognosis and need for treatment. Are you dealing with acute, lymphoma-type, or unfavorable chronic-type ATL? If so, for elderly patients (≥70 years), a CHOP or CHOP-like regimen, b...
What is your approach to CMML-MDS in an older patient with low risk disease who is becoming transfusion dependent?
The short answer is that we treat lower risk CMML much like we treat lower risk MDS, even though we don't have dedicated studies in CMML to support this approach. After addressing any reversible causes of anemia (iron or vitamin deficiencies, hemolysis, etc...), NCCN guidelines for MDS would recomme...
How would you approach transfusion-dependent anemia in an intermediate-risk MDS patient refractory to azacitidine?
An MDS patient with ESRD likely has multiple contributors to their anemia. It is surprising to see the EPO level >500, but this may reflect the use of ESAs. If so, I would make sure that the dose is appropriate for MDS (60,000 units at least weekly) and that it is not renally dosed. If the patient i...
How do you approach MDS patients with low/very low risk IPSS-R but high risk mutations on NGS?
This a great question and one that I think will become more frequent in clinical practice. As it stands in my practice currently, I have been managing my IPSS-R low/very low-risk patients as I always have, with either observation, ESAs, or lenalidomide (in the case of those with del 5q). Age and com...