Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you manage steroid-refractory acute GVHD following allogeneic transplant?
The short answer is to enroll the patient in a well-designed clinical trial, if available. If not, I would start with ruxolitinib based on the REACH2 trial (Zeiser et al., PMID 32320566) which was multicenter, randomized, open-label, phase 3 trial comparing the efficacy and safety of oral ruxolitini...
For multiple myeloma, is 8 Gy in 1 fraction an appropriate palliative dose, although this histology was excluded from trials examining a single fraction?
There was a randomized trial comparing 8 Gy/1 fx vs 30 Gy/10 fx for patients with multiple myeloma. There was no difference in analgesic response or recalcification, however patients with the protracted regimen seemed to have a benefit in terms of QOL. However, the the control arm (30 Gy in 10), th...
Would you start anticoagulation in a patient with a history of CVA 1 year ago and high risk APL profile who was never started on anticoagulation, but is now presenting for follow up and without recurrent thrombotic events?
This is a difficult question. The details here are important. Therapeutically, you can go either way in my opinion. Were the positive antiphospholipid antibodies checked again later? Did the patient have an infection when the APS labs were first done? Does the patient have diabetes or other CV risk ...
What additional testing besides LAC/APLS, factor V Leiden, prothrombin gene mutation, JAK 2 do you draw for unprovoked cerebral venous sinus thrombosis?
Cerebral venous sinus thromboses (CVST) are often put into the category of "thromboses of unusual sites,"--as opposed to the more common lower extremity thromboses or pulmonary emboli.Provoked causes of CVST include pregnancy or exogenous estrogen use, infection of the head/neck or CNS, head trauma,...
How do you approach autologous stem cell transplant in T-cell lymphomas/PTCL after induction chemotherapy with achievement of CR1?
Autologous SCT can be considered in PTCL in CR1 especially if the patient is MRD negative by PET and molecular testing (by checking for the persistence of clonal T cells, for example). Schmitz et al., PMID 33512419 If MRD positive CR or PR/SD, would consider allogeneic SCT instead. The main concern ...
Would you offer bridging radiation before or after leukapheresis?
We believe the ideal time for bridging radiotherapy is after leukapheresis but before CAR T-cell infusion to avoid a negative impact on T-cell collection. However, the clinical situation has to be considered, and if a symptomatic presentation necessitates urgent treatment before leukapheresis, treat...
What induction regimen do you choose for high risk newly diagnosed multiple myeloma in light of the recent high risk focused studies?
Two things are clear from the slew of high-risk enrichment studies and subgroup analyses that have been done. In the age of upfront quadruplet therapy with an anti-CD38 monoclonal antibody, outcomes for patients with one high-risk cytogenetic abnormality are very good, even in the absence of prolong...
Do you routinely prescribe PPI prophylaxis for myeloma patients who will be on low-dose aspirin and weekly dexamethasone?
Depends on the dose of weekly dexamethasone. If 40 mg weekly, would use PPI. If given along with cyclophosphamide as CyBorD, would use PPI regardless of dose of dex; if symptomatic gastritis on aspirin or dex, will use PPI even with lower doses of dex.
For otherwise transplant-eligible patients with myeloma, given developments of bispecifics and CAR-T, what is your age cutoff for consolidative autologous transplant?
For any lawyers reading this, there is no upper age cutoff for consideration of transplantation. For the physicians and other healthcare providers reading this, it's much more nuanced. As the question poster alluded to, this isn't 2010 and we have many more treatment options available. I have many p...
In a young female with severe osteoporosis due to congenital estrogen deficiency, can estrogen be prescribed if genetic testing for congenital disorders reveals a heterozygous Factor V Leiden mutation?
First of all, I don't think testing for inherited thrombophilia is warranted in a patient with no personal or family history of thrombosis. Given the multigenic nature of thrombophilia and our limited ability to test for it, it's difficult if not impossible to determine an individual's risk of throm...