Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you consider aggressive presentation of multiple squamous cell carcinomas of the skin an indication for treatment of CLL?
In general, no. The reason is that the many squamous cell carcinomas are a manifestation of immune dysfunction. Historically, when all the treatments were chemo-based, immunity would be if anything, temporarily worsened. Then, even in people in CR, immunity wasn't always restored. For example, patie...
What is the best strategy after initial treatment with hypomethylating agents for high grade myelodysplatic syndromes, mainly for responders who became transfusion independent?
The hypomethylating agents (HMA’s, 5-azacitidine & decitabine) have important disease modifying properties in addition to relieving cytopenias for patients with high-risk MDS. They decrease the risk of progression to leukemia and improve overall survival. The randomized phase III Aza-001 study dem...
How would you treat a diffuse CNS myeloid sarcoma (aka chloroma/granulocytic sarcoma) without evidence of blood or bone marrow involvement?
Myeloid sarcoma prognosis is not good and treatment need high dose ARA-C based chemo As induction. Would consider IT chemo would consider Omaha as well. Patient will need after CR CS radiation inculded in the conditioning regimen to consolidate with Myeloablative transplant. HLA and donor activation...
What growth factor would you use with A+AVD, if any at all?
When treating patients with Hodgkin lymphoma with either ABVD or A-AVD I decide if their risk of febrile neutropenia is likely to be more than 20%, which, therefore, includes some patients on ABVD and most patients on A-AVD. For such patients I give GCSF (filgrastim, grastophil) on days 6-11 after e...
How do you treat a young woman of child bearing age group diagnosed with primary CNS lymphoma?
The first step is to check HIV serology to ensure that the patient is HIV negative as HIV+ve patients would need to antiretroviral therapy promptly along with chemotherapy or the prognosis is dismal. If patient is young and fit the initial approach is similar in both HIV +ve and -ve patients. Assumi...
How would you approach a Follicular grade 1-2 NHL found on a terminal ileum biopsy with otherwise negative EGD and colonoscopy and contrast enhanced CT scan?
At our facility, we have treated a significant number of patients with low grade lymphoma isolated to a single fixed site within the GI tract with excellent long term results. It is worth considering a dose of 2400 rads to the involved site.
What is your threshold for transfusing platelets in an asymptomatic patient after autologous stem cell transplant?
My thresold for transfusing platelets in an asymptomatic patient after autologous stem cell transplant is the same as with other patients - transfuse for plts<10 unless febrile or if any bleeding complications, at which time the threshold would be higher.
Do you have any concerns about enhanced radiation toxicity with any of the novel agents used to treat multiple myeloma?
We use radiotherapy in myeloma sparingly. Generally, ONLY for end stage patients for which there is few to any systemic treatment options.That being stated, I am not aware of overt radiosensitization by novel agents. On the rare occasion that we do incorporate radiotherapy, we also rarely add potent...
How do you approach CNS prophylaxis in double-hit lymphoma patients?
There is no consensus about the need for IT chemo for CNS prophylaxis in DLBCL. Factors such as IPI, the number and location of extranodal sites of disease, and LDH may be used to identify a group of patients with aggressive NHL who are at particularly high risk for CNS recurrence and might therefor...
What dose of radiotherapy do you use for low volume Castleman's disease?
Reports in the literature are varied in terms of radiation dose. For scenarios such as this with low volume disease, it is probably reasonable to consider the lower end of ranges reported by others to be successful, such as 30 Gy. Careful pathology review is important for these cases as well. One mu...