Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your approach to the upfront treatment of anaplastic large cell lymphoma, ALK positive, with low IPI score in a young person?
ALK positive ALCL is the most responsive of the aggressive PTCL’s to chemotherapy, and the majority of young patients can be cured with an anthracycline containing chemotherapy regimen. Either CHOP or CHOEP (ie CHOP plus etoposide) are frequently used. In a young healthy patient I favor CHOEP based ...
How do you manage rituximab-induced neutropenia?
Rituximab induced neutropenia is a relatively rare but well known phenomenon and can occur in the immediate post treatment period as well as a late sequela of rituximab treatment. In my experience, patients often improve with administration of G-CSF. In cases where a patient's ANC remains <500, I co...
If a patient with myeloma develops a symptomatic DVT or PE while on an immunomodulatory drug such as lenalidomide, would you stop the IMiD?
In general I prefer using enoxaparin (most convenient LMWH in US) or apixaban (least renally dependent Xa inhibitor) in myeloma patients for IMiD-induced VTEs. I don't generally wait 7-10 days as the anticoagulant effect is rapid for these agents. While compliance is always challenging with injecti...
Is venetoclax expected to be useful in patients with refractory CLL/SLL who do not have Del(17p)?
Venetoclax is active in all types of CLL including those patients who do not have del(17p). In fact, the data thus far suggests that the durability of response will be better in this group of patients.
Are there any indications on advanced stage Hodgkins disease that one might consider stopping the bleomycin after first two cycles?
The specific question was studied and the results published in NEJM June 2016 Barrington et al- Adapted treatment guided by PETCT in Advanced Hodkins LymphomaThe results suggested non-inferiority from the standpoint of PFS when bleomycin was omitted after an interim PET/CT suggested no disease. Pati...
For elderly patients who cannot tolerate chemotherapy, is radiation alone an option for a stage IA favorable classical Hodgkin lymphoma?
In my experience, it has been extremely unusual that a patient with Hodgkin lymphoma is considered a non-candidate for chemotherapy. But I suspect that in community practice that situation may arise because very infirm patients are not referred to major centers and community oncologists may be a bit...
How would you treat stage 3 lymphocyte-predominant Hodgkin Lymphoma that is CD20 negative ?
First, I would verify the diagnosis with molecular testing of some sort. It is my opinion that nodular lymphocyte-predominant Hodgkin's lymphoma is universally CD20 positive. The disease is also rarely in stage III. Is it possible that the diagnosis is really another entity such as T-cell-rich B-cel...
What is your approach to a patient with an advanced stage diffuse large B-cell lymphoma treated with chemotherapy alone (with a PET CR) who then develops an isolated CNS relapse?
This is a challenging albeit relatively rare situation. First, I would make sure to complete systemic workup, including MRI of brain/spine, CSF cytology, and PET/CT. I would not consider radiosurgery even for a single brain lesion, as this is ultimately a more diffuse disease process. If patient has...
What chemotherapy regimen would you recommend for a patient with symptomatic cutaneous B cell lymphoma?
This would depend on the subtype and stage. If only cutaneous disease and marignal or follicle center histology then single agent rituximab is best studied. The literature is variable on the # cycles to give, but there is nearly a 100% RR with high CR with follicle center. PCDLBC-LT requires multiag...
Given the sensitivity and prognostic value of the serum free light chain ratio for light chain multiple myeloma, do you continue to check urine studies?
This is a very pertinent and timely question. In fact, there is finally data. Dr. Dejoie et al published in Blood a study comparing the performance of serum and urine measurements in 113 newly diagnosed light chain myeloma patients. Interestingly only 64% of these patients had a measurable urine pro...