Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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...
Are SCDs contraindicated in patients with acute DVTs?
SCDs can help prevent DVT but I'm not aware of any evidence of benefit when treating an established event. There are rare reports of pulmonary embolism following the application of SCDs in patients with asymptomatic DVTs. I don't think this constitutes an absolute contraindication, but in the absenc...
How would you manage a patient with SLE that has a remote history of positive anti-phospholipid antibodies with a current DVT and now completely negative APLs?
Assuming the reliability of the lab report indicating negative antiphospholipid antibodies (APL) and the absence of any other manifestations as per the latest APLS guidelines, I generally would not factor a distant history of APL positivity when determining the management of this patient.While the f...
Does the presence of osteoporosis change the extent of workup that should be performed for an older patient with otherwise serologically low-risk MGUS?
In brief - no, it shouldn't. While some previous studies have suggested that patients with MGUS are more likely to develop osteoporosis than those who don't, this is often related to confounders when MGUS is picked up clinically - in other words, patients with comorbidities that prompt a doctor to l...
How do you determine when to use a maintenance regimen vs continuous 3-drug regimen in a transplant-ineligible MM patient after response to first line therapy?
After completing initial therapy (which may or may not include high dose melphalan and auto SCT), I typically use maintenance lenalidomide. I consider “dual maintenance,” which is combining lenalidomide and a proteasome inhibitor, for patients with high risk FISH: t(4;14), t(14;16), and del17p. 1q g...