Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is the recommended initial treatment for spinal cord compression due to non-Hodgkin lymphoma (e.g. diffuse large B-cell lymphoma)?
The answer depends greatly on clinical circumstances, such as stage of disease, degree of neurological impairment, prior treatment if any, etc. First, I would argue there is seldom a role for surgical intervention ( other then biopsy to establish diagnosis) since lymphomas are uniquely radiosensitiv...
What is your approach to treatment of infection-triggered HLH that does not respond to treatment of the underlying infection?
The algorithm our center follows is to Recognize hyperinflammation (see answer to question above -- in addition to baseline labs, we obtain an infectious disease consult) Look for and treat the trigger. A concern, if the patient is responding, is that we are missing a trigger (HLH does not occur sp...
Would you anticoagulate an SMV thrombosis caused by malignant obstruction in the setting of metastatic colorectal cancer?
Superior Mesenteric Vein Thrombosis is a rare phenomenon, within the category of Splanchnic thrombosis. While portal vein thrombosis is most often associated with cirrhosis (though also seen in many patients without cirrhosis), SMV thrombosis is more commonly seen in the context of either local prov...
For a patient with ENKTL nasal type (nose/sinus involvement) who has hepatic toxicity with pegasparaginase but a CR after 2 cycles of chemotherapy with a plan for "sandwich" radiotherapy - what, if any, chemotherapy would you resume after completion of radiation?
This is an interesting situation as there is not much data. The cure rate is high for early-stage disease after chemoradiation, even with VIPD and no asparaginase regimens (see de Pádua Covas Lage et al., PMID 36446856). Nature reviews which show in Table 2 survival curves similar for asparaginase r...
Would you start anticoagulation in a patient with RCC and related (tumor) thrombus with extension to renal vein and further?
Tumor thrombus is an intraluminal extension of tumor mass, rather than a true thrombus. There is no evidence that anticoagulation improves outcomes in tumor thrombus (Marcoux et al., Blood 2019). Primary management is surgical resection, typically as part of radical nephrectomy for localized RCC or ...
How are you utilizing vibratory devices for reducing pain associated with injection or procedures?
Specifically for intra-articular/bursal/tenosynovial/carpal tunnel injections: Our office purchased the vibration distraction devices over a decade ago based upon the promising use from the pediatric literature. Our providers were underwhelmed with their use in our adult patients and we all stopped ...
What chemotherapy, if any, would you offer for an elderly patient with congestive heart failure with completely excised Stage I classical Hodgkin lymphoma?
Radiation is a curative option here.
Would you include the entire hardware as part of ISRT for a patient with Stage IE DLBCL of the distal femur treated with upfront prophylactic nailing for impending fracture, who had a CR to chemotherapy?
Quite uncommon to encounter such a patient, but based on data for non hematologic tumors, no. Treat just the involved site with a generous margin, the latter never precisely defined, but depends on the tolerance of surrounding normal tissue. Parenthetically, it's often difficult to determine a CR to...
What dose and fractionation do you use to palliate mycosis fungoides lesions?
I will admit that I utilize a wide range of fractionation schedules, depending on the clinical circumstances when treating mycosis fungoides. The data suggests that 2 Gy x2 is not an effective palliative schedule, with a CR rate of only ~30% with almost all lesions requiring re-treatment (Neelis et ...
How do you manage MPN patients with acquired VWD in the perioperative setting?
The greatest risk of a very high platelet is bleeding not thrombosis, and it is fair to say that this appears to apply to myeloproliferative (MPN) thrombocytosis as opposed to reactive thrombocytosis (there is no correlation between the platelet count and thrombosis with either cause of thrombocytos...