Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
When would you consider aspirin for long term management of unprovoked VTE after initial therapeutic anticoagulation?
The WARFASA trial randomly assigned patients with first unprovoked VTE who had completed 6-18 months of anticoagulation to 2 additional years of aspirin versus placebo. While the study demonstrated a 40% reduction in recurrent thrombotic events, the rates of VTE in those receiving aspirin were still...
For patients with recent post-delivery symptomatic ovarian vein thrombosis on anticoagulation, how would you approach periop AC management for upcoming procedures like D&C?
Nevertheless, I would first determine if the D&C needed to be performed so soon after diagnosis of the ovarian vein thrombosis or if it could be delayed. If it needs to be performed sooner, communicate with the proceduralist to determine if the anticoagulation needs to be interrupted. A number of in...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
What is your threshold to diagnose light chain MGUS with only a slight elevation in the light chain ratio, in a patient without other CRAB symptoms and no M spike?
Mild increase in kappa light chains can be a result of antigenic drift seen with the assay, in renal dysfunction both can go up but kappa may go up a bit more skewing the ratio. If a 24-hour urine with electrophoresis and immunofixation is negative and the rest of the work up is negative, would cont...
Would you consider a positive DAT and indirect Coombs test, persistent and consistent with IgG warm antibody, clinically significant in absence of hemolysis?
Up to half of patients with red cell auto-antibodies (i.e., true positive DAT/direct Coombs test) are not experiencing hemolysis. After iron repletion in this patient, the best way to determine the degree of hemolysis and whether treatment is needed is by the stability of the hemoglobin and the reti...
Would you include midostaurin in induction and consolidation for patients with good-risk AML with NPM1 mutation and FLT3-ITD (<0.5)?
Yes, in my practice I routinely include FLT3 inhibitor (midostaurin) in upfront 7 plus 3 chemotherapy for all younger fit patients with AML regardless of NPM1 status or FLT3 allelic ratio. The RATIFY trial validated the benefit of midostaurin in patients regardless of ITD allelic birder (both high a...
How would you treat progressive Rosai Dorfman Destombes disease after initial limited radiation therapy?
To provide the best answer, we need a little more detail on this case. Also, is the patient symptomatic from the abdominal disease? If not, I would observe in the short term. If symptomatic, I would do PET/CT and consider a repeat biopsy, given the risk of the development of another process. Do you ...
How would you approach treatment for a R/R mantle cell lymphoma patient with a history of autoimmune hepatitis who has progressed on both a covalent and non-covalent BTKi?
Without the whole story, hard to know if this patient is a candidate for CAR T therapy. Presuming the answer is no, I would give venetoclax. Admittedly this is off label, but venetoclax can be very effective in this disease, both in my personal experience and in the limited available data (Davids et...
How would you treat a BTKi naive p53 mutated MCL in 1st relapse with disease noted both systemically and in the CNS?
This is a case where I would likely still use ibrutinib. We know from years of experience that it gets into the CNS, and it's an incredibly effective drug in MCL. Zanu and acala should get into the CNS, but the companies have limited PK data for CNS penetration. The harder question (I think) is whet...
Following the BRUIN data in mantle cell lymphoma, will you routinely treat with pirtobrutinib following a covalent BTKi?
I have incorporated pirtobrutinib into my practice since its approval. I recommend this for treatment in patients who are progressing on covalent BTKi or who have had prior exposure to covalent BTKi with progression and received alternative therapies with further progression. I have used pirtobrutin...