Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you treat an elderly patient with stage I/II unfavorable classic Hodgkin Lymphoma, who could only tolerate 2 cycles of chemotherapy and has a Deauville 1-2 PET/CT re-staging scan?
Glad this person had a good early response. If can't tolerate full course standard chemo, would treat with 20-30 Gy ISRT - treating only original sites of disease. The H10 (Federico et al., PMID 37967311) demonstrated a 13.4% benefit of RT at 10 years after ABVD x4 alone with a negative interim PET....
What approaches can we take to initiate therapy and improve survival rates in patients with HLH?
At our institution, we have comprised a multidisciplinary team to help treat these patients. The team or "HLH task force" as we like to call ourselves is comprised of a clinical immunologist, rheumatologist, dermatologist, critical care physician, hepatologist, BMT attending/hematologist, infectious...
In low-risk MDS patients with symptomatic anemia and a low EPO level, how does the presence of a high-frequency SF3B1 mutation influence your first-line choice between an ESA and luspatercept?
I would consider the SF3B1 mutation to be the relevant biomarker for the selection of frontline therapy (namely luspatercept) in this case. The correlation between SF3B1 mutations and the presence of ring sideroblasts in MDS is strong but not perfect. This could be for a variety of reasons, the most...
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
What is your treatment of choice for triple class refractory multiple myeloma?
To define triple-class refractory means the patient is refractory to FDA-approved IMiDs (up to Pomalidomide), proteasome inhibitors (bortezomib and carfilzomib), and CD38 naked antibodies (e.g. daratumumab or isatuximab). Refractory is defined as progression or within 60 days of the last dose. I ag...
What scenarios do you utilize CT venography in the workup of suspected DVT?
There are likely a limited number of scenarios in which a CT venogram should be ordered. My own approach is as follows: Bilateral deep venous thrombosis: to exclude IVC obstruction. Anecdotally, in the younger patients, we have made a diagnosis of IVC atresia. Suspected May-Thurner syndrome: typica...
How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?
Overall, evidence suggests that while SSRIs do increase the risk of bleeding. The absolute risk of a bleeding event remains low and is usually not serious. A 2017 meta-analysis by Laporte et al., suggested that overall bleeding risk is increased by at least 36% while other meta-analyses suggest that...
What are your practical considerations for incorporating bispecific antibody therapy into treatment of relapsed DLBCL?
In relapsed/refractory DLBCL, if the patient has not yet received bispecific antibody (BsAb) and/or CAR T-cells, and the patient is eligible and able to receive CAR T-cells, I favor CAR T-cells before BsAb, given extensive follow-up time demonstrating CAR T-cells are a potentially curative approach ...
How do you address logistic barriers related to blinatumomab when treating relapsed B-ALL?
This is a very challenging issue that speaks to an incredibly important aspect of delivering not only this drug but others like it. Despite the strong evidence that supports the use of blinatumomab in a variety of clinical scenarios for patients with B-cell ALL [e.g., Gökbuget et al., PMID 29358182;...
How do you incorporate CAR-T cell therapy for DLBCL in transplant-eligible patients?
The role of sequential therapy including CARs vs high dose chemotherapy + ASCT post primary induction failure/relapse in large cell lymphoma is a matter of active research. Given the present FDA indication of CARs is in relapsed/refractory large cell lymphoma after failure of at least 2 lines of pri...