Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your approach to an infant (<12 mo) with new onset petechiae and thrombocytopenia, with labs consistent with ITP?
In an older (1-6 year old) child with apparent ITP, less work up might be needed. While many tests are possible, in this case, labs consistent with ITP, I would interpret as including a CBC otherwise normal for age without blasts on a smear (if this is not true, the differential is much wider). If i...
How would you approach treatment in an older (>65), but fit patient with intermediate-risk AML, but with MRD persistence after induction with 7+3?
The presence of measurable or minimal residual disease (MRD) after induction chemotherapy, before allogeneic transplant or after transplant is associated with risk of relapse. (Araki et al. J Clin Oncol. 34:329-36) The detection and measurement of MRD by flow cytometry requires specific expertise in...
For patients with VEXAS syndrome and good response to azacitidine, what duration of therapy do you consider?
The short answer: as long as azacitidine is controlling inflammation, reducing/eliminating steroid dependence, and/or improving cytopenias, keep using it. Don't stop (or if the patient is being bridged to alloSCT, continue until BMT).The long answer:VEXAS is an autoinflammatory disease wherein patie...
What is your approach to curative-intent therapy for a young, fit patient with newly-diagnosed monomorphic epitheliotropic intestinal T cell lymphoma (MEITL)?
If >= 10% of the cells express CD30 by IHC, I would treat with BV+CHP x 6 cycles rather than CHOP according to the ECHELON-2 trial (although this trial included only 3 patients with EATL). Historically, the 5-year OS rate with anthracycline-based chemotherapy alone is approximately 10 to 20%, so for...
Would you offer definitive radiotherapy for prostate cancer (or another solid organ malignancy) to a patient on maintenance Rituximab for lymphoma?
Good question and a somewhat increasingly common issue in the general sense of patients with overlapping hematologic and prostate malignancies. For starters, I would think hard about the risk group of this patient and competing risks. If this patient has an aggressive or relapsed lymphoma with favor...
What adverse events would make you switch off nivo + AVD therapy and to what second line therapy in patients with Hodgkin Lymphoma?
The question of how to handle severe IRAEs when using the N+AVD regimen is an important one. First, of course, is to hold CPI therapy, empirically treat as indicated to avoid ongoing or worsening organ injury, and concurrently ensure that there is no other cause for the observed event(s). But if you...
What radiation dose would you use to treat a symptomatic osseous lesion secondary to AL-amyloidosis?
Extrapolating from our tracheobronchial experience, we’ve used 20 Gy in 10 fractions to target the underlying plasma cells that produce amyloid production. We’ve also used this regimen for ocular and GU (ureteric and bladder) amyloidosis. If there are obstructive or symptomatic lesions, then surgica...
What is the role of anticoagulation in patients with septic thrombophlebitis?
The role of heparin anticoagulation in septic thrombophlebitis is controversial. There are limited to no randomized trials to document outcomes. A systematic review (Falagas et al., PMID 17222406) supported this practice, and the Infectious Disease Society also supports this practice. The role of or...
How do you interpret elevations in ESR and CRP in the setting of increased BMI?
Increases in BMI (overweight and obesity range) have been shown to be associated with elevated CRP and ESR, with stronger associations shown with CRP specifically. Interestingly, the association between elevated CRP and obesity seems to be stronger in female populations than in male patients.In the ...
How should one monitor for and manage CMV reactivation in patients receiving alemtuzumab?
Here's how I approach it: Baseline Testing: Perform CMV serology (IgG/IgM) and quantitative CMV DNA PCR before initiating alemtuzumab to establish baseline status. Frequency: Weekly PCR testing for 8–12 weeks post-infusion, focusing on the high-risk window (weeks 3–6). Extend monitoring ...