Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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?
Yes, this drug has demonstrated clear efficacy in a difficult-to-treat population and perhaps to date, the best safety data with a BTK inhibitor we have seen (low rates of cardiac, bleeding, and GI adverse events). There is a head-to-head study of pirtobrutinib versus covalent BTK inhibitors ongoing...
What is your approach to re-challenging BTK inhibitors for a patient who has had intolerance to several different agents?
This is a great question, and the answer is that I probably would not rechallenge with a BTK inhibitor. Many patients who develop an intolerance to a BTKi can remain on the drug with supportive care for the toxicity and/or dose reduction, which is not always effective. If someone truly had an intole...
What are your top takeaways from ASH 2023?
Gene therapy for sickle cell disease and beta thalassemia. This was the first approval of CRISPR/Cas-based therapy in humans. Ex-vivo engineering of isologous hematopoietic stem cells followed by their reinfusion after myeloablative conditioning led to induction of 40-50% fetal hemoglobin in patient...
Would you extrapolate results from ELEVATE-RR study to favor use of acalabrutinib as first-line therapy in treatment-naive CLL?
The ELEVATE-RR study enrolled patients with a median of 2 prior regimens, with either deletion 11q or deletion 17p. I think one could debate whether selecting this patient population as compared to a less selected treatment naïve population would be more likely to find a difference between the two d...