Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Is there a role for hydroxychloroquine for secondary prevention in patients with APS without SLE?
There are no prospective trials to answer this question. In one cross-sectional study (Erkan et al., PMID 12154210) there was a suggestion of a protective effect of hydroxychloroquine. However, patients were also on aspirin and it may be difficult to sort out which of these agents had the protective...
How do you manage the development of neuropathy in patients receiving bortezomib for multiple myeloma?
Bortezomib and thalidomide cause the bulk of the neuropathy in myeloma patients worldwide, although thalidomide is rarely used in the U.S. because of more effective immune modulating drugs (IMiD's) available such as lenalidomide and pomalidomide. Pre-existing peripheral neuropathy is the biggest ris...
How would you manage a patient with p53 mutated MCL who has progressed after a BTKi and CAR-T with a CD20 negative clone?
Venetoclax + CD19 or CD22 mab if available
Would you irradiate all borderline suspicious lymph node regions on PET/CT in stage IIA nodular lymphocyte predominant Hodgkin's lymphoma treated with ISRT alone?
ISRT fields for lymphocyte predominant HL when treating without chemotherapy should be more generous in the nodal chain region than if treated with chemotherapy. We conducted a survey of expert lymphoma radiation oncologists published in the IJROBP, which demonstrated some differences in opinion. Ho...
What is the best treatment volume and dose for a marginal zone orbital lymphoma?
It would depend on the location- retrobulbar, conjunctival or lacrimal gland. Imaging, including MRI, helps in evaluating the site of origin and extent of involvement. Some advocate treating the entire orbit for all orbital lymphomas to be comprehensive, as the total dose is low, and this away we av...
How do you follow patients after radiation treatment for orbital MALT lymphoma?
Local control is extraordinarily high after definitive RT (24 Gy) for orbital MALT lymphoma (>95%). It is not uncommon for patients with retro-orbital disease to have residual masses after RT that remain stable during follow-up. One should be cautious about pursuing additional therapy for presumed "...
Would you require biopsy of both orbits or is unilateral biopsy adequate for a patient with suspected bilateral orbital MALT lymphoma?
Biopsy of one orbit is sufficient if clinical findings and images of the other orbit are all consistent with marginal zone lymphoma (MZL). I’m a little surprised the question of how to treat bilateral MZL of orbit was not asked. Assuming disease is limited to the orbits, radiotherapy to both sites w...
What is your approach to management of chronic neutropenia in a patient with Sjogren’s who was recently diagnosed with metastatic endometrial cancer and plans to start chemotherapy?
With metastatic cancer, optimal treatment of the endometrial cancer is the priority. Heme/Onc consultant would likely be giving granulocyte stimulating products.Although neutropenia can occur in Sjogren's Disease (SjD), I rarely have found it to be clinically significant, and lymphopenia seems to oc...
Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?
Great question, with practical implications for the clinic: Azathioprine (AZA) is a prodrug that likely exerts its immunosuppressive effects against B- and T-cell function by interfering with purine metabolism through its metabolites (including 6-MP). Logically, many of the "classic" AZA side effect...
How do you approach the treatment of drug-induced thrombotic microangiopathy?
Typically, transplant-related TMA is due to sirolimus, tacrolimus, cyclosporine, or some combination of those drugs. The first step is to reduce the dose. Often keeping the drug at the lower end of the therapeutic level, the TMA will resolve or ameliorate. If, for instance, sirol and tac are used to...