Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do you do prophylactic LP/IT chemotherapy in high risk APML prior to starting consolidation?
Extramedullary disease such as CNS involvement is quite uncommon at diagnosis in acute promyelocytic leukemia (APL). However, it can be seen in patients with relapsed disease. Both isolated CNS relapse and CNS relapse associated with morphologic or molecular relapse can occur. Yet one has the impres...
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 recommend a workup for POEMS and/or amyloidosis for IgM monoclonal gammopathies associated with neuropathy?
While IgM monoclonal disorders, amyloidosis, and POEMS syndrome may all be associated with peripheral neuropathy, they are not often confused with one another. A patient with a peripheral neuropathy can be diagnosed most simply by a serum protein electrophoresis. The presence of a monoclonal IgM spi...
How do you work up patients with low level monoclonal lymphocytosis and adenopathy?
In the setting where the blood has a CLL-like clone but does not meet criteria for CLL, I would obtain a lymph node biopsy to confirm the diagnosis of SLL. Although this is most likely to be the case, MBL clones can be seen in the blood concomitantly with other cancers as well.
Would you use bone marrow MRD status to guide stopping daratumumab early at 1 year instead of the recommended 3 years of therapy per the AQUILA trial for high-risk smoldering myeloma?
I would venture to say that there is probably a 0% chance that MRD negativity would be achieved with daratumumab alone. The CR rate was 8.8%, but MRD was not assessed, and I would doubt that MRD negativity was achieved in any patient. That said, we can't really extrapolate whether 1 year and stoppin...
What dose of radiotherapy do you use for low volume Castleman's disease?
Reports in the literature are varied in terms of radiation dose. For scenarios such as this with low volume disease, it is probably reasonable to consider the lower end of ranges reported by others to be successful, such as 30 Gy. Careful pathology review is important for these cases as well. One mu...
After prior BTKi + venetoclax and subsequent progression, how do you then choose next line therapy for high risk CLL?
In a patient having clinical progression after a fixed-duration BTKi + venetoclax, I first rule out Richter transformation and check for the acquisition of TP53 aberration and/or resistance mutations. Although the latter is rare in fixed-duration targeted therapies, it is important to rule it out. T...
Does the lack of long-term data influence your consideration of utilizing zanubrutinib and venetoclax 1L in High-Risk CLL?
Not really. The CLL17 data showed essentially equivalent 3yr PFS between ibrutinib + venetoclax, ibrutinib monotherapy, and venetoclax + obinutuzumab. But even before those data were published, with the solid 36-month PFS data for zanubrutinib + venetoclax, it seemed clear that many of these patient...
Do you check IGHV mutation status in patients with newly diagnosed CLL?
Yes. In the targeted therapy era, there are three factors that continue to have prognostic and therapeutic significance and should be checked: IgHV mutation status p53 aberrancy - requires both FISH for del17p AND mutation analysis for p53 Complex karyotype - can be done on peripheral blood or marr...
In a patient who has been receiving 1L Ibrutinib for TP53+ CLL for years with complete hematologic response but detectable MRD, is there any role to switch to the novel BTKi agents given better PFS?
There are a couple of features to this question that need comment. First, the goal of therapy with a single-agent BTKi, regardless of ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib, is NOT to achieve undetectable MRD. Very few patients will achieve this milestone due to the drug's MOA. BTK...