Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you approach imetelstat therapy in MDS patients with baseline neutropenia or thrombocytopenia?
Given the fact that the major treatment-emergent adverse events noted on the phase III IMERGE study in the imetelstat-treated arm were neutropenia (68% Grade 3+ tox) and thrombocytopenia (62% Grade 3+ tox), it makes it somewhat difficult to utilize imetelstat (Platzbecker et al., PMID 38048786) in p...
How would you manage superficial thrombophlebitis of the great saphenous vein involving the knee and calf?
I would point you to an excellent algorithm created by Sherry Scovell on UpToDate, "Superficial Vein Thrombosis and Phlebitis of the Lower Extremity Veins" which has informed my practice. The highlights of the approach utilized are to perform imaging with Doppler ultrasound to determine the length o...
How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?
Patients with metastatic lung cancer are at increased risk of thromboembolic events with an estimated frequency of 13.9% (Connolly et al., PMID 23026639). Preclinical data show that PD-1/PD-1 pathway blockade may lead to increased levels of pro-inflammatory cytokines and T cell driven progression an...
How would you determine the safety of anticoagulation in patients with evidence of cerebral microhemorrhages who present with acute stroke secondary to cardioembolism?
This question assumes that the patient already had an MRI showing microhemorrhages. The Boston criteria provide guidelines for the number of microbleeds, associated superficial siderosis, or major hemorrhage to make the diagnosis of cerebral amyloid angiopathy. I would also assume that at least some...
Would you treat an early stage transformed DLBCL from indolent lymphoma in the same way as a standard, newly diagnosed de novo DLBCL?
To my knowledge, all studies in limited-stage LBCL excluded prior indolent lymphoma. Therefore, we do not have prospective data to support shorter courses of CIT. It will be an interesting subject of investigation. However, given that, in general, cell of origin or MYC double-hit status does not rea...
Do you routinely check serum phosphorus levels after IV iron therapy?
Only before and after FCM. I hold subsequent doses if phosphorus low. There is no need to monitor with the other formulations. For people needing multiple doses of IV iron (IBD, bariatric surgery, heavy uterine bleeding, angiodysplasia), I avoid FCM.
What is your approach for persistent and romiplostim-refractory thrombocytopenia after temozolomide with radiation in a patient with recurrent GBM?
Even if bone marrow does not show leukemia, I would consider checking for CHIP or CCUS variants. I would probably not have a high index of suspicion for immune-mediated thrombocytopenia related to TMZ in this context. Beyond transfusion, time, TPO-RA, and supportive care, I am not sure there are man...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
How would you treat an elderly patient with stage I/II unfavorable classic Hodgkin Lymphoma, who could only tolerate 2 cycles of chemotherapy and has a Deauville 1-2 PET/CT re-staging scan?
Assuming a patient is responding favorably to therapy by PET/CT, there are 5 regimens that are supported by randomized trials and included in national guidelines: Chemotherapy-alone regimens ABVD x 2 + AVD x 4 (RATHL) BrECADD x 4 (HD21) Combined modality therapy regimens ABVD x 4 + RT (30 Gy) (H1...
How do you manage anticoagulation/antiplatelet therapies with strong indications for uninterrupted therapy in the setting of urgent procedures?
If anticoagulation is absolutely contraindicated because of the bleeding risk of the procedure, then "bridging" will usually make the most sense, most of the time, with low molecular weight heparin such as enoxaparin. If dual antiplatelet agents are contraindicated, particularly in the first month a...