Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is the best radiation dose to treat primary cutaneous B cell lymphoma?
For a small (1-2cm lesion) of these subtypes, 30Gy is usually adequate. For larger/thicker lesions, consider 36Gy. Electrons with bolus or orthovoltage/superficial therapy.
How would you manage a patient with antiphospholipid syndrome in the setting of severe steroid-refractory thrombocytopenia?
Dr. @Dr. First Last answered the question of severe thrombocytopenia in a patient with APS and an acute thrombotic stroke. I agree with his approach. However, this “between a rock and a hard place” clinical scenario does also appear not infrequently during the chronic management of patients with APS...
What is the best dose to treat splenomegaly with pancytonenia in the setting of myelofibrosis?
I have treated occassionally and have recommended 20 cGy to 25 cGy alternate day x 3 or 4 fractions It works well as spleen is a very radiosensitive organ and does not require doses above 150 cGy
For AML patients, when do you stop antiinfective agents?
Our practice is typically to continue an anti-viral throughout induction/consolidation without stopping the agent. We typically utilize anti-bacterial and anti-fungal when the absolute neutrophil count (ANC) is under 500 and then stop them once the ANC recovers to above 500. Our preferred anti-funga...
Do you avoid ESAs in patients with anemia and chronic kidney disease who also have Factor V Leiden?
I personally do not. I think it is better to get the hemoglobin in the 10-11 g/dL range and avoid having to give blood transfusions potentially than the slightly increased risk of hypercoagulability.
When (if ever) do you check for anti-platelet antibodies for workup of thrombocytopenia?
Routinely available anti-platelet antibody tests have a sensitivity too high and specificity too low to be of much clinical use. A patient's response to first line therapy (steroids or IVIg) is most telling and if there is no response, a bone marrow is warranted as it would be atypical for ITP. Ther...
How would you adjust the steroid dose for steroid-induced psychosis in a patient being treated for secondary HLH with the HLH-94 protocol?
If disease status allows weaning, we slowly wean per recommendations in HLH94. If they need steroids because of significant hyperinflammation that is damaging, then we add risperidone, which generally works very well.
What dose and fractionation would you recommend for a localized primary bone marginal zone lymphoma?
This would be an unusual presentation for marginal zone lymphoma (MALT lymphoma) and not one I've actually encountered. In a large series from MSKCC, "soft tissue/bone" comprised 2% of cases treated with radiation therapy (IJROBP 2015;92:130). Case series from Princess Margaret (Cancer 2010;116:3815...
Would you anticoagulate a patient with splenic infarctions in the setting of CMV viremia?
Based on my general knowledge/experience, I would consider CMV viremia as temporary, short-lived risk factor for a thrombotic event on a part of other inflammatory conditions, and outside of other indications for anticoagulation (e.g., atrial fibrillation, etc), my inclination would be to conclude ...
Does the presence of asparaginase antibodies on Granger Genetics testing indicate need to switch asparaginase formulations?
I would rely on the serum asparaginase activity (SAA) assay rather than the antibody testing. SAA has proven to be a reliable predictor of asparagine depletion and is a widely acceptable method for therapeutic drug monitoring. On the other hand, asparaginase antibody testing has not been consistentl...