Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
For young patients with smoldering multiple myeloma who wish to be treated with lenalidomide, how do you go about harvesting their cells for an autologous transplant?
I have serious reservations with treating smoldering myeloma with lenalidomide and in general, discourage it. That is likely a discussion for another day, but my thoughts on this have been summarized here. In general, we are able to secure permission for 'collect and store', and so I would prefer t...
In a patient with progressive thrombocytosis but negative MPN mutations on peripheral blood, what are your diagnostic and treatment recommendations?
I agree with Dr. @Dr. First Last. A bone marrow biopsy is helpful in a case like the one described as morphology can be informative in distinguishing triple negative ET vs pre-MF vs MF and also CML. I agree with NGS panel to see if there are clonal markers identified, testing for BCR-ABL is critical...
How have you been counseling patients with sickle cell regarding a 3rd COVID vaccine?
The rationale for vaccination was presented previously. We urge all of our patients to get third doses.
How do you approach the initial dosing of carfilzomib for patients with relapsed multiple myeloma?
A great question and one without a uniform answer! I place a lot of focus on patient quality of life, and one of the recurring themes from patients is the number of visits to the medical center. A twice-weekly regimen of carfilzomib (or bortezomib for that matter), over the course of a year, results...
How would you manage a patient with acquired von Willebrand disease who requires DAPT for arterial disease?
Acquired vWF has many causes: lymphoproliferative disorders; MPN; autoimmune disorders; high flow disorders (Heyde syndrome) and drugs. Treating the underlying disorders would be the safest strategy because DAPT is going to cause bleeding per se in some patients and removing a second cause for bleed...
In the absence of symptoms would you still treat high risk myelofibrosis if transplant ineligible?
If a patient with high risk PMF is not a transplant candidate, any therapy is, by definition, palliative and in the absence of symptoms, the potential risks of therapy would theoretically outweigh its benefits (e.g., anemia, leukopenia, or thrombocytopenia). The presence of asymptomatic leukocytosis...
Would you treat iron deficiency in post PV myelofibrosis if anemia is the predominant concern?
Absolutely would treat with IV iron. I have discussed this with KOL's and there is unanimity. You may buy a protracted period with anemia control. Not giving it is ill-considered. Where there is disagreement, is in the P Vera patient in excellent control, not anemic but with symptomatic iron deficie...
Do you recommend COVID vaccination in patients with antiphospholipid antibody positivity or other prothrombotic states not on anti-coagulation?
There are hypothetical reasons that the COVID-19 vaccine might increase thrombophilia in individuals with APS/APLAs. However, the only controlled study I could find, Absence of hypercoagulability after nCoV-19 vaccination: An observational pilot study by Campello et al., PMID 34246010 did not show a...
How do you approach patients with underlying psychiatric disorders who refuse CML treatment due to not believing their diagnosis?
Importantly, having an underlying psychiatric disorder doesn't unto itself mean that the patient lacks the capacity to make their own medical decisions. Further information is necessary about the patient's understanding, their current status, etc., to make that determination. At many institutions, p...
Do you send an antiphospholipid antibody panel routinely for all patients with an unprovoked thrombus?
Yes. My own practice is to perform testing for antiphospholipid antibodies in all patients with unprovoked VTE and also in patients with arterial thrombosis. Testing should include assays for lupus anticoagulant, anti-cardiolipin antibodies (IgG and IgM), and anti-beta 2 glycoprotein I antibodies (I...