Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Does anyone utilize P2Y12 assays to determine if clopidogrel may be ineffective when used for DAPT?
Yes, I use P2Y12 assays in two distinct settings. Medical management: If a patient on clopidogrel mono/dual therapy has disease progression with ICAD or experiences a recurrent ischemic event, I obtain a P2Y12 assay to assess responsiveness. This helps guide the decision to switch to ticagrelor and ...
Can RT to non-bulky sites be omitted in an early stage (stage I or II) classical Hodgkin's lymphoma case with a CR by PET/CT?
Randomized studies have consistently demonstrated that combined modality therapy is superior to chemotherapy alone in regards to progression-free survival in early-stage Hodgkin lymphoma. The magnitude of the benefit varies across studies, but a relative risk reduction of ~50% can be expected which ...
Is it reasonable to treat a solitary plasmacytoma of the lung parenchyma with SBRT?
I have only treated one patient with solitary plasmacytoma of the lung over the past 15 years of doing lung SBRT. It is an extremely rare and unusual disease presentation for myeloma. Given the radiosensitivity of myeloma, I opted for 30 Gy in 5 fractions, which resulted in a completed response in t...
In a patient with cardiac light chain amyloid who has significant heart failure symptoms, including inotrope dependence at presentation, how much clinical benefit does treatment provide?
In patients with cardiac light chain (AL) amyloidosis who present with significant heart failure symptoms and inotrope dependence, the clinical benefit of treatment is a complex and nuanced issue. This scenario often reflects an extreme end of the disease spectrum. Historically, patients with advanc...
While using bridging therapy prior to CAR-T cells in myeloma, if possible, do you target a certain response prior to proceeding with cell infusion?
While CAR-T cell therapy was, of course, first studied and shown to be highly effective in heavily pretreated patients with active disease, experience and newer data show the following themes: CAR-T cell therapy in earlier lines of therapy appears to lead to more durable responses. Lower disease bu...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
Is there therapeutic relevance for FLT3-ITD mutation in relapsed APML?
FLT3-ITD mutations are seen in anywhere from 12-38% of APL cases, and there are conflicting data on the prognostic impact of the mutation on outcomes (Kuchenbauer et al., PMID 16029447, Beitinjaneh et al., PMID 20096459, Kiyoi et al., PMID 9305596, Kainz et al., PMID 12522450, Schnittger et al., PMI...
Would you consider TPO mimetics for chemotherapy induced thrombocytopenia that persists despite dose reductions?
The reported evidence on using a TPO-RA in chemotherapy-induced thrombocytopenia (CIT) is complicated but this seems like a situation where it is worth trying a TPO-RA. Repeated dose reduction and/or delay is not good for treatment of a cancer in general. It is very important to individualize the ca...
If Ianalumab + eltrombopag (VAYHIT2) gains regulatory approval, what would make you consider its use for second-line therapy after glucocorticoid failure/relapse, given its potential hematologic toxicity?
I would consider this in patients who have a more immunoinflammatory phenotype (perhaps with other autoantibodies or with a significant family history of autoinflammatory disease) or in patients who have significant bleeding symptoms and need rapid control of the disease.
How would you manage suspected MGRS in a patient refusing a kidney biopsy?
To diagnose MGRS, a biopsy is necessary. If a patient has M protein on serum protein electrophoresis (SPEP) but shows no evidence of paraprotein-mediated kidney disease, this indicates MGUS. In contrast, conditions like PGNMID are also paraprotein-mediated but can be caused by a small clone that is ...