Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Can the presence of elevated ring sideroblasts (20%) on a bone marrow biopsy without dysplastic changes or suspicious molecular mutations still be indicative of an underlying MDS in a patient with unexplained anemia?
It is easy to forget that this clinical presentation was the rule not the exception in the pre-genomic era. We knew then that idiopathic sideroblastic anemia could be congenital or acquired due to drugs, toxins, or disorders of porphyrin or hemoglobin synthesis, or could rarely be clonal (using G6PD...
Do you think that home INR monitoring is a feasible option for elderly, frail patients with atrial fibrillation on VKA treatment, given variations in socioeconomic status and access to care?
Whenever possible, I prescribe home INR monitoring with appropriate equipment. This allows me to monitor my patients on a weekly basis, rather than on a monthly basis at best. Unfortunately, insurance reimbursement is not standard for this equipment, and many patients are unable to obtain it. The ab...
How do you interpret CSF pleocytosis in the context of significant leukocytosis on CBC?
There is no correction factor as there would be for CSF vs serum glucose, for example. A patient with leukocytosis in peripheral blood, for example, due to urosepsis would not always have elevated CSF WBC unless there were concomitant meningoencephalitis. I would consider 100 WBC abnormal for CSF re...
Under what circumstances would you consider omitting radiation in patients with early stage, unfavorable (bulky) Hodgkin Lymphoma?
We should first acknowledge that combined modality therapy improves progression-free survival in early-stage HL compared with chemotherapy alone. Stated more succinctly- if you give combined modality therapy, there is a lower risk of relapse; if you give chemotherapy alone, there is a higher risk of...
What is your strategy for optimizing hydroxyurea dosage in patients with symptomatic sickle cell disease, particularly for genotypes HbSS and HbS/Beta thal?
I am far, far more worried about underdosing than overdosing. Although HgF is the traditional lab parameter, it may not go up in all patients. I also look for a decrease in reticulocytes, LDH, indirect bili (less hemolysis), less inflammation (WBC and platelets), and a lowering of MCHC (i.e., fewer ...
How do you approach severe anemia and thrombocytopenia in an elderly patient whose bone marrow biopsy shows hypercellular marrow with mild dysplasia in erythroid and megakaryocytic lineage but normal cytogenetics and a negative NGS panel?
This is a really interesting case! Few things to consider: The presence of a small PNH clone suggests marrow injury however, the marrow is usually hypo rather than hypercellular in this scenario. It may be worthwhile to send HLA typing. The presence of HLA-B14:02, HLA-B40:02, and HLA-B07:02 alleles...
Which patients with smoldering myeloma do you treat?
Let me address the last comment regarding treatment of high risk smoldering myeloma. IF one thinks that the patient requires treatment for myeloma, why treat with a regimen that is NOT the preferred treatment for myeloma? For example, lenalidomide alone or lenalidomide/dexamethasone. If this were "a...
How do you evaluate a patient with MGUS and peripheral neuropathy?
When I see a patient with MGUS and peripheral neuropathy, I think about it in stages: Does the patient have an IgM-monoclonal gammopathy? If so, then I think about DADS-M. An EMG/NCS, anti-MAG antibody, PET scan, and bone marrow biopsy are generally all part of the workup. I try to do MYD88 testing...
How would you treat an elderly male with history of mantle cell lymphoma who relapsed after chemoimmunotherapy and cBTKi w/ multiple co-morbidities including CKD and CHF w/ low EF?
There's obviously a lot of additional information that would help in making individual patient-level recommendations here. What was the first line of chemoimmunotherapy, and how was it tolerated? How long was his duration of response? How was the response to covalent BTKi in depth and duration? What...
Based on the ASC4MORE trial, would you add asciminib to imatinib if patients do not achieve deep molecular remission at 1-year?
This is hard to justify. If you are using asciminib, the patient likely has had resistance to several prior TKI's. In this setting, treatment discontinuation is not recommended outside of clinical trials. Achieving BCR::ABL1 <=1% is an adequate response likely to improve survival, and about 40% of p...