Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What stage is bilateral orbital/conjunctival NHL (limited only to the bilateral orbit/conjunctiva)?
By the Ann Arbor staging system, this is stage IV disease because more than one extranodal site is involved at initial presentation. However, NCCN and other guidelines acknowledge that MALT lymphoma involving both paired organs (e.g., bilateral orbital/conjunctiva) is often best treated with RT alon...
How do you approach CNS prophylaxis in patients with DLBCL?
I think the NCCN-CNS-IPI based on the German data is a reasonable place to start when it comes to making decisions regarding CNS prophylaxis. We typically do IT MTX for patients on the lower end of the risk spectrum and high-dose IV MTX for patients on the higher end of the risk spectrum.
How would you manage a patient with a MALT lymphoma (H. Pylori negative) found incidentally in the surgical specimen at the time of sleeve gastrectomy?
MALT lymphoma tends to be a multifocal disease. Furthermore, imaging is often suboptimal in delineating the true extent of disease within many extranodal sites, including the stomach. For these reasons, the entire organ is typically treated during a course of radiation therapy. Historically, radical...
Why are hypomethylating agents as single agents not approved yet by FDA for treatment of AML (technically off-label)?
DNA hypo methylation gets agents are not approved as single agents for treatment of AML as Phase 3 studies with both azacitidine and decitabine vs treating physician choice of best alternative regimens failed to meet their primary end-point of statistically significant improvement over-all survival ...
What dosing schedule of cladribine do you use for newly diagnosed hairy cell leukemia in need of treatment?
Great question. For patients who meet criteria for treatment and have classic hairy cell leukemia, both the 7-day continuous infusion of cladribine and the 5-day daily dosing seem to have equal efficacy and toxicity. I think either is fine and patient preference can be considered. The 5-day scheme s...
How would you manage a patient with minimal residual disease (<1% of CD25 positive cells) six months after completing therapy with 2-CDA for Hairy Cell Leukemia?
This is a challenging question. Patients with HCL who have MRD after treatment with cladribine or pentostatin have shorter remissions than those who have pathologic remissions. Several studies have shown eradication of MRD with subsequent treatment with rituximab. Thus, utilization of rituximab afte...
How would you treat low grade follicular lymphoma with diffuse epidural involvement? Would you give intratheracal or high dose systemic methotrexate in addition to systemic chemoimmunotherapy?
This is a rare presentation of follicular lymphoma especially if its primary epidural lymphoma without presentation outside the epidural space. This entity was traditionally treated with combined chemotherapy and radiotherapy and associated with a poor prognosis of less than a year. I would conside...
Do you make diagnostic lumbar puncture part of routine work up for newly diagnosed AML if patient is asymptomatic?
Unlike acute lymphoblastic leukemia (ALL), central nervous system (CNS) involvement by acute myeloid leukemia (AML) occurs in less than 5% of patients at the time of diagnosis. Therefore, routine lumbar puncture is not recommended for asymptomatic patients. Certain clinical and biological features h...
How much later after starting a hypomethylating agent in an elderly patient with AML being treated in the upfront setting can venetoclax be started?
It can safely be started at that time, but the outcomes may not be quite as optimal as when used from cycle 1. There is not much data about this, but when used after patients have had progression with prior exposure to hypomethylating agents, responses are sometimes not as robust (see ASH abstracts ...
How would you approach therapy for a patient with newly diagnosed non-GC DLBCL with previous anthracycline exposure?
For fit patients with prior anthracycline exposure for non-lymphoma healthcare who are fit for chemotherapy and with preserved LV function, I would recommend considering daR-EPOCH. The history of the regimen was its original development as treatment of relapsed lymphoma after 1L bolus doxorubicin, a...