Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What radiation doses and subsequent treatment monitoring would you recommend for multiple myeloma patients with multifocal bony lesions who decline chemotherapy?
Systemic therapy is the cornerstone of treatment for multiple myeloma, and the vast majority of patients initiate an appropriate regimen upon diagnosis. Occasionally, patients will have very limited disease and will be referred to Radiation Oncology for consideration of local therapy to delay the ne...
In a pregnant patient with cyclic neutropenia who has ANC nadirs <500/µL but no history of significant infections or other neutropenia-related complications, would you initiate G-CSF during pregnancy?
Understand that I am not an expert, but no, I would not. As long as she is asymptomatic, I would manage expectantly. If an expert recommends otherwise, I would defer without question.
If tafasitamab/lenalidomide plus R-CHOP (frontMIND) is approved/utilized for frontline treatment, how would you approach second-line therapy in transplant-ineligible patients with relapsed/refractory DLBCL?
I do not think my approach to transplant-ineligible R/R DLBCL will significantly change, other than not using Tafasitamab-Len. I will still consider CAR-T cell therapy as a treatment option, as Tafa does not seem to affect the efficacy of CD19 CAR-T (Sakemura et al., PMID 37879074, and also Bastos-O...
What therapy do you usually choose in patients with previously treated follicular lymphoma who experience early relapse (<2 years)?
My approach to POD24 patients is to first ensure there is no evidence of transformed disease. According to a retrospective analysis led by @Dr. First Last at Memorial Sloan Kettering, as many as 40% of the POD24 patients have evidence of transformed disease if a biopsy is pursued. Clinical indicator...
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...
Do you routinely evaluate patients with collagen disorders or Ehlers-Danlos for platelet defects?
Yes, I routinely carry out a full hemostasis evaluation, including platelet aggregation and release studies, in patients referred to me with easy bruising and hypermobility with an increased Beighton score suggesting EDS and in those already diagnosed genetically with EDS. EDS patients typically hav...
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
Do you perform genetic testing when patients have persistent hypogammaglobulinemia after rituximab therapy?
I would not routinely perform genetic testing. Multicenter studies (Labrosse et al., PMID 33862010; and Otttaviano et al., PMID 35892275) show that genetic testing returns a low yield, <5%. Several authors suggest that the risk of persistent hypogammaglobulinemia due to PID is increased if there is ...
Would you offer lung SBRT in a patient with Pulmonary Langerhans Cell Histiocytosis (PLCH)?
Langerhans cell histiocytosis (LCH) is a clonal proliferation of Langerhans cells (dendritic cells), part of the mononuclear-phagocytic system. Some patients present with unifocal disease, often in bone. A variety of treatments are acceptable for unifocal disease, including radiation therapy. Very l...
How do you approach CNS prophylaxis in patients with DLBCL?
Given the overall risk of CNS relapse for DLCL in our current era of chemoimmunotherapy is around 5%, the key to an algorithm for CNS prophylaxis is based on risk to avoid the risks of overtreatment. There are several methods of prognostication that have been published, which can identify groups wit...