Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How have the results of the SUNMO trial with mosunetuzumab/polatuzumab vedotin impacted your treatment choices for transplant ineligible relapsed/refractory DLBCL?
The SUNMO trial results have provided another option for patients with relapsed and/or refractory disease who aren't fit enough for more intensive therapy, whether it be salvage + ASCT for relapsed or CAR-T/bispecific + CIT for those with refractory disease. As well, the regimen is likely to have le...
How do you manage erythrocytosis secondary to sotatercept for patients with PAH?
I have not done that yet, but I have let Hgb drift up to 18-19 and monitor the patient closely. I lower the dose to 0.5 or even 0.3, if Hgb is high at baseline, then start and stay at 0.3 before I increase. I will consider phlebotomy if the above options are not available.
In an adult patient with asymptomatic, isolated neutropenia in whom you suspect a Duffy null phenotype, at what ANC or in what situations would you do a bone marrow to look for other etiologies of neutropenia?
What a great question! Happy to answer. As you know, as many as 60% of individuals who have the Duffy null phenotype will have an ANC that is lower than the lower limit of normal in many labs BUT as you also know, the total body (in circulation + in tissues) neutrophil count in such individuals is n...
When would you consider use of emapalumab for HLH/MAS?
The FDA has approved emapalumab for familial HLH. For secondary HLH/MAS, I typically begin with anakinra (100 mg q 6 hrs for those 40 kg or more). If this is not enough and if CXCL9 (I send on day one to have the data available) is notably elevated, then consider adding emapalumab. Alternatively, a ...
Would you administer adjuvant chemotherapy for extrahepatic cholangiocarcinoma that has received neoadjuvant therapy and achieved near CR?
If the regimen was well-tolerated and there is reason to believe that additional treatment could have been administered (preop tumor evaluation was not stalled out, suggesting ongoing response), I would favor additional therapy. You may also have a role for ctDNA monitoring but I know many are not i...
How would you approach a completely resected DLBCL of the appendix if PET scan and bone marrow biopsy suggest no other disease?
Resected limited stage DLBCL has relatively high risk of recurrence. A recent prospective phase II trial was reported (Yoon et al. Oncotarget 2017) where patients received 3 cycles of RCHOP post resection and had an excellent 2 year PFS of 95%. Another study (Sehn et al. Annals of Oncology 2008 abst...
What are your top takeaways in Hematologic Malignancies from ASH 2024?
Years ago, I was consulting with a patient who had moved to the Pacific Northwest after being diagnosed elsewhere with multiple myeloma. After engaging in initial pleasantries and just before I was about to peel away the specifics of her medical history, she stopped me in my tracks. “Did you go to A...
Do you use G-CSF for a patient with ALL admitted for febrile neutropenia with prolonged count recovery?
Acknowledging the lack of definitive data, in our group we use G-CSF as primary prophylaxis in adult patients with ALL treated with intensive chemotherapy and hardly ever need to re-administered if they develop FN subsequently. That said, for prolonged neutropenia despite prior G-CSF, we may adminis...
Do you commonly observe acute erythrocytosis in patients with ILD flares being treated with supplemental oxygen and high-dose corticosteroids?
Assuming that this patient does not have erythrocytosis at baseline, my experience is that acute erythrocytosis is not typical. Erythrocytosis caused by hypoxemia typically has a lag of several weeks, even though EPO increases within 48 hours. You commonly see a moderate acute leukocytosis with high...
What is your clinical threshold for treating a potential monoclonal gammopathy of thrombotic significance?
I strongly advise against routine screening for monoclonal gammopathy in patients with thrombosis. The incidence of MGUS, particularly in older patients, is relatively high and so the signal-to-noise ratio in this setting will be very low. In a patient with recurrent thrombosis and thrombocytopenia ...