Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
With the recent FDA approval of nipocalimab and the emerging LUMINA 2 data for rilzabrutinib, what is your approach to wAIHA refractory to or relapsed after steroids and rituximab?
Probably because of its rarity (1–3 new cases per 100,000 people), we often joke that there are more treatments at our disposal for the management of wAIHA than the number of cases any hematologist sees on an annual basis—or even during their lifetime. A partial list includes typical first-line trea...
Are there any alternative, hypofractionated RT courses for patients with DLBCL that can be used during the COVID-19 pandemic?
ILROG recently came out with guidelines pasted below: Synopsis of ILROG Recommendations for Administering Radiotherapy for Hematological Malignancies During Emergency Conditions of the COVID-19 Pandemic • We are facing an increased demand for RT to substitute or complement systemic therapy deemed i...
How do you counsel patients on the risk of clinically relevant bleeding or other complications with bone marrow aspiration and biopsy?
I counsel patients that, in general, bone marrow biopsies are a fairly safe procedure from a bleeding standpoint due to minimal tissue between the skin and the bone, and the superficial nature of the biopsy, such that if there is bleeding, pressure can be applied. That said, this depends on the abil...
In a patient with persistent, otherwise unexplained mild anemia (e.g., Hb 12 g/dL) and a pathogenic somatic mutation identified on peripheral blood myeloid NGS, when do you pursue bone marrow biopsy to evaluate for CCUS/MDS rather than monitoring expectantly?
In situations where a mild but otherwise unexplained clonal cytopenia is present, the decision to pursue a bone marrow biopsy can depend on the impact that the bone marrow results would have on clinical care and the likelihood of making a diagnosis. For example, a mild stable anemia in an older pati...
How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?
Patients with metastatic lung cancer are at increased risk of thromboembolic events with an estimated frequency of 13.9% (Connolly et al., PMID 23026639). Preclinical data show that PD-1/PD-1 pathway blockade may lead to increased levels of pro-inflammatory cytokines and T cell driven progression an...
Do you offer enasidenib with azacitadine in AML with an IDH2 mutation for patients ineligible for intensive induction chemotherapy?
I typically do not give enasidenib with azacitidine upfront for patients with AML with IDH2 mutation and ineligible for intensive induction chemotherapy. Based on the results of the VIALE-A study (DiNardo et al, NEJM 2020), I usually give venetoclax with azacitidine to those patients. In addition to...
How do you approach the second-line treatment for a patient with high-risk myeloma relapse early post-autoHCT after Dara-RVD induction?
Depending on the nature of the relapse, I would salvage with DCEP, or carfilzomib-based triplet (KCyD, KPd) with ciltacel as the next step.
What is your approach to bone imaging in MGUS?
Excellent question. For low-risk MGUS (M-spike <1.5 g/dL, normal serum free light chain ratio, and an IgG type protein), it is reasonable to forego any bone imaging in the absence of any relevant bone-related symptoms. The rate of bone involvement in patients with an M-spike of 1.5 g/dL was noted to...
For patients with newly diagnosed unmutated CLL how will you decide between BTKi alone vs Ven/BTKi vs Ven/Obin vs Ven/Obin/Acalabrutinib?
My usual practice has been Ven Obin for most patients, even unmutated, but if they have bulky nodes and are young/fit, I am now adding acala to that and giving the 3-drug regimen. Continuous BTKi in my practice is mostly reserved for the older or less fit patients, or those who really, really don’t ...
Would you give adjuvant radiation after complete resection of a small primary cutaneous follicular lymphoma of the scalp?
Not a lot of data, but here goes. First, one has to go back decades in the literature to find series of patients with lymphoma rx'd with surgical resection alone. In general addition of RT improved outcome even when ostensibly resected with neg margins. With today's technology risk of additional RT ...