Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How soon after CAR T-cell therapy can salvage radiation be delivered?
This is another important question. In our practice, the earliest we have treated patients is after their first post-CAR-T PET/CT at day 30. An abstract presented in an oral presentation at this year's ASTRO meeting by Dr. @Dr. First Last describes that radiation to sites of incomplete response at t...
Is there an optimal salvage radiation dose for relapsed post-CART disease?
While there is not enough data to definitively recommend a specific dose, we feel an EQD2 > 37.5-40 Gy is desirable for patients with limited residual or relapsed disease post-CAR T-cell. Our commonly recommended fractionations include 37.5 Gy in 15 fractions, 40 Gy in 15 fractions, and 40 Gy in 20 ...
Would you offer XRT as bridging for all patients with limited pre CAR-T disease or as consolidation for only those with residual PET-avidity on day+30 post CAR-T?
There are no studies comparing these 2 approaches. However, given the detrimental outcomes of post CAR-T relapses, I would consider maximizing peri-CAR-T treatments as much as possible as long as the toxicity profile is reasonable, and would not view these 2 approaches as mutually exclusive. I would...
Do you ever repeat screening for acquired von Willebrand in patients with essential thrombocythemia who have high platelet counts and very low risk disease not on cytoreductive therapy?
I generally check on a regular basis (i.e., yearly) to confirm no changes. Obviously, if there is bleeding I would check at that time.
How do you approach a persistently elevated mean platelet volume and immature platelet fraction in an otherwise healthy patient with a normal platelet count?
I am trying to understand the circumstances where this question might arise. Nowadays, when patients can readily see CBC results before their clinicians, they might notice the H or L designations and ask. In general, I would not think twice about "slightly out of range" CBC parameters in a single me...
For patients with solitary plasmacytoma of the ureter undergoing definitive XRT (40-50 Gy), what dose constraint do you use for the ureter?
Well, since this is a solitary plasmocytoma of the ureter, I presume that parts of the GTV encompass the OAR here. I do not think that you can set any meaningful constraint for the ureter, bearing in mind that this is a serial OAR. You can try to avoid hotspots in the ureter, but that's about it.
Are you now using luspatercept as your first choice for anemia management in patients with low-risk MDS otherwise appropriate for EPO initiation, regardless of presence of SF3B1 or ringed sideroblasts?
Only use luspatercept if the patient is transfusion-dependent. FDA approves luspatercept as first-line treatment of anemia in adults with lower-risk MDS (aabb.org). In patients with MDS who are candidates for epo and transfusion independent then epo is still my first choice.
What is your preferred third-line therapy for a fit patient with symptomatic, relapsed follicular lymphoma who has failed bendamustine-rituximab and lenalidomide-rituximab?
This sounds like the patient where a CART may make sense. If that's not an option for whatever reason, I may go to bi-specific over say, copanlisib at this point. I suppose if EZH2 mutated, tazamezostat might be an option, but less appealing in a young otherwise healthy person.
How long do you anticoagulate for cirrhosis patients who have portal vein thrombosis extending to the mesenteric veins?
I recommend indefinite anticoagulation for most patients with portal vein thrombosis, and at least 3-6 months if there are risk factors for bleeding. Once they complete anticoagulation for the first 6 months, I re-evaluate their risk of recurrent thrombosis vs bleeding, and if there is an underlying...
What is your approach to bridging anticoagulation in patients with history of recent HIT?
One should not re-expose patients with past HIT to heparins. Even with remote HIT, there is a high rate of serologic recurrence (eg, Warkentin and Anderson, PMID 27114458) and while the rate of overt HIT relapse may be low with proper precautions, I have seen and published a couple of fatal HIT recu...