Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
When do you consider re-starting treatment for a patient with relapsed myeloma?
Do you start anti-myeloma therapy when patients have progressive disease (25% increase in paraprotein or new or worsening myeloma bone disease) or clinical relapse (CRAB criteria, hyperviscosity, new plasmacytoma)? The goal is to pull the trigger right before clinical relapse. How is this done in th...
Do you prefer a chemo-radiation combination or chemotherapy followed by sequential radiation approach for early stage NK/T-cell lymphoma?
If SMILE regimen is used here (the preferred regimen for NK/Tcell lymphoma), radiotherapy should be delivered sequentially (not concurrent) due to normal tissue toxicity and poor tolerance.
When do you choose to give CyBorD over RVd in a newly diagnosed myeloma patient?
I only use VCd when patients are going to be inpatient for a while or the patient is unable to afford an IMiD. For patients with renal insufficiency, where time is of the essence, I recommend Velcade 1.3 mg/m2 SQ days 1,4,8,11 + dex 20 mg days 1,4,8,11 with Revlimid 5-15 mg in newly diagnosed MM. L...
How would you treat a fit, newly diagnosed, high-risk multiple myeloma patient with multiple poor risk factors and circulating plasma cells?
So...on most iFISH, we see a deletion of p53, but we don't know about the mutation. Similarly on iFISH we see trisomies and tetrasomies of 1q23, often CKS1B, but not genetic amplification. Finally circulating plasma cells are often missed when less than 5% even at large academic centers, and while t...
Would you use alternative management in a chronic phase CML with a 3 way translocation between chromosome 9, 22 and 7?
Variant Philadelphia chromosome translocations that involve a third or fourth chromosome in addition to chromosomes 9 and 22 are seen in around 5% of patients with CML. They are considered simple translocations if involved chromosome 22 in addition to a chromosome other than 9, or complex if involve...
How do you approach small lymphocytic lymphoma that does not have a leukemic phase?
Patients with SLL very often (90-95%) have circulating tumor cells in the blood that are CD19, CD20, CD5, CD23, sig dim by flow consistent with CLL tumor cells. If not in the blood, these same cells evevn more often can be found in the bone marrow. If disease is in either site with nodal involvement...
What would you choose as a first line therapy for a patient with CLL who is asymptomatic with Rai Stage 4 with bulky adenopathy and organomegaly?
A big discriminating feature here would be based upon age. For a patient who is fit and <65-70 years, IGHV mutated disease may be curable with fludarabine, cyclophosphamde, and rituximab therapy, first piloted by Michael Keating's group at MD Anderson Cancer Center. At a median follow up time period...
What is your approach to treating early stage EBV-positive diffuse large B-cell lymphoma of the elderly after a CR to systemic therapy?
EBV+ diffuse large B-cell lymphoma of the elderly, which typically affects apparently immunocompetant individuals > 50 y/o, was a provisional diagnosis in the 2008 edition of the WHO classification system. EBV+ DLBCL has been recognized in younger patients which led to a revision in the 2016 classif...
Do you use absolute WBC count or doubling time to determine whether to start treatment for early stage CLL?
In my view, the pace of disease is a more relevant indicator of the need for treatment than any absolute WBC count. Observations over time usually make it clear when treatment is needed. Several studies have shown that early intervention is not associated with improved survival, though it must be ac...
When treating a patient with multiple myeloma with bortezomib, how do you decide between subcutaneous vs intravenous dosing?
Due to the markedly increased risk of of peripheral neuropathy, the standard of care worldwide is to utilize subcutaneous bortezomib. There really is no medical indication to prefer IV over SQ. The issue of weekly versus biweekly bortezomib is controversial. The FDA indication is for biweekly on day...