Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
How would you approach a patient with vitreoretinal lymphoma without CNS or systemic involvement?
The optimal treatment approach for primary intraocular lymphoma is debated. This is a rare disease with only small retrospective series guiding therapy. There is no clear superior treatment approach in the literature. In clinical practice, younger patients are often treated initially with high-dose ...
How would you treat AML in a pregnant patient at 12 weeks' gestation?
My answer is under the assumption that, after a multi-disciplinary discussion with the patient, oncology/leukemia team, and maternal fetal medicine, the objective is to initiate AML-directed therapy while maintaining the pregnancy. The highest risk of deleterious impact to the fetus from chemotherap...
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...
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...
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...
What is your approach to utilizing MRD-guided therapy in previously untreated CLL, particularly in choosing between continuous versus time-limited treatment?
The question of what to do relative to a patient receiving therapy for CLL in first line and being MRD negative in blood/bone marrow with a reliable test (NGS sequencing or high sensitivity flow cytometry) and also no enlarged lymph nodes on CT/exam greater than 1.5 cm is challenging. For ibrutinib ...
What are the best labs to trend improvement in HLH?
Unfortunately, there is not one specific laboratory test to definitively trend responses to HLH directed therapy. In general, our approach is to obtain baseline inflammatory labs including CBC with differential, ferritin, soluble IL2 receptor (sIL2r), triglycerides, coagulation studies (PT/PTT) incl...
Would you offer live vaccines (e.g., MMRV/measles) to patients on bispecific antibodies for multiple myeloma?
I agree with the answer here by Dr. @Dr. First Last. There are a lot of nuances, though. In regard to giving the vaccine safely and effectively, the best strategy is not to wait until patients have multiple relapses and are on bispecific therapy to vaccinate. Given the recent outbreaks of measles, i...
How do you determine the optimal duration for 1L doublet treatment in newly diagnosed High-Risk CLL?
Among patients with high-risk CLL and indications for treatment per iwCLL criteria (Hallek et al., PMID 29540348), treatment regimens can be broadly categorized into fixed-duration, MRD-guided, and indefinite therapies. Fixed-duration doublet regimens include acalabrutinib with venetoclax per the AM...