Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
When do you opt to administer IV iron for patients with heart failure who may also have anemia of chronic disease or at risk for iron deposition disease?
I do not hesitate to administer IV iron in a patient with heart failure (chronic inflammation) if serum ferritin levels are <30 ng/ml and TSAT is under 20%. This is the only way, besides blood transfusions, to improve Hgb levels in this patient population.
How do you approach a patient with recurrent VTE who develops VTE again after reduction of apixaban to 2.5 mg bid?
Several factors play into this decision for me. Is the patient obese? Obese patients tend to give me pause for dose-reduction of DOACs. As such, half-dose apixaban may have been relatively underdosed for an obese patient and I would not call it DOAC failure, rather I would increase the dose to usua...
How do you counsel a patient diagnosed with HTLV after an abnormal blood donor screening, especially in light of new data that dolutegravir may reduce uncommon but severe neurological outcomes associated with infection?
We actually do not see many individuals with HTLV disease at present in the US. Having said that, HTLV is a retrovirus, so it is biologically plausible that integrase inhibitors (like dolutegravir) could reduce viral spread in the body. However, the key counseling message is: evidence is still emerg...
How do you decide between blinatumomab or traditional chemotherapy in combination with TKI for upfront treatment of adult patients with Ph + ALL?
This question is likely inspired by the recent publication of a "chemotherapy-free induction and consolidation first-line treatment" for adults with Ph+ ALL (Foà et al., PMID 33085860; GIMEMA LAL2116). The authors reported relatively high rates of MRD- remissions by bone marrow BCR-ABL1 RT-PCR and i...
When testing for patients with symptoms of MPN, do you prefer to do JAK2 cascade testing or a leukemia NGS testing panel?
Genetic testing with regard to the MPN can be usefully employed both diagnostically and prognostically. With respect to diagnosis, if an MPN is suspected based on symptoms such as aquagenic pruritis, ocular migraine, erythromelalgia, or the occurrence of an unexplained thrombosis, the first laborato...
Could patients with smIPI >1 and poor tolerability to R-CHOP be offered ISRT after 3 cycles of R-CHOP if interim PET showed 5-PS 1-3 response?
The revised NCCN guidelines largely reflect data from studies demonstrating excellent outcomes with four cycles of R-CHOP in patients with low-risk diffuse large B-cell lymphoma (DLBCL), including FLYER, LYSA/GOELAMS, SWOG S1001, and the most recent trial, LNH2009-1B. Although each of these trials e...
What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.
If using the triplet AMPLIFY regimen with ven/acala/obin upfront, what do you then plan to use in 2nd line treatment of CLL?
For patients who achieve a favorable response that lasts >1 year (or so, this is a ballpark estimate that may shift with more data), I would be very comfortable re-treating with a covalent BTKi (preferably after screening for BTK resistance mutations by NGS where available - with note of caution tha...
Would you perform a bone marrow biopsy in a patient who had systemic anaphylaxis with hypotension to a stinging insect?
I would start with checking a serum tryptase and D816V mutation. Also, apply a REMA score and do a good skin exam. With normal tryptase and copy number, still check for KIT mutation.
How do you manage perioperative anticoagulation for a patient with a history of recent, surgically provoked VTE?
In most cases, bridging is rarely indicated because the bleeding risk usually outweighs the risk of VTE recurrence during a short (1–2 day) interruption of anticoagulation. However, after a recent VTE (defined as <3 months), the estimated risk of VTE recurrence is high (>15–20% per year) (still low ...