Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
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...
How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?
Patients with metastatic lung cancer are at increased risk of thromboembolic events with an estimated frequency of 13.9% (Connolly et al., PMID 23026639). Preclinical data show that PD-1/PD-1 pathway blockade may lead to increased levels of pro-inflammatory cytokines and T cell driven progression an...
Would you recommend ISRT for an initially bulky nodular lymphocyte predominant Hodgkin lymphoma with complete metabolic response after 4 cycles of R-CHOP?
Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) is a rare subtype of Hodgkin lymphoma. Approximately 95% of Hodgkin lymphoma cases are classified as classic Hodgkin lymphoma, including the nodular sclerosis, mixed cellularity, lymphocyte-rich, and lymphocyte-depleted subtypes, all of which a...
Has your practice changed to PLEX-free initial therapy for iTTP?
I am not. The reason is that caplacizumab is not on formulary at my institution, and so implementing PLEX rapidly while obtaining caplacizumab (which typically arrives in 24-48 hours) is my current practice. If I had caplacizumab on formulary, I would utilize it as it was utilized in the MAYARI tria...
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
This happens all the time now. I tell them that those results were flagged as outside the reference range (I don't use the term abnormal) but that they are not clinically significant. It does not always work if there is a patient who is super anxious or hyper-focused. Typically, if they need a lot m...
Would you radiate the thoracic duct for bilateral chylothorax in a hematologic malignancy with no discrete adenopathy?
We have done for adenopathy, which relieves obstruction and thus helps with drainage, but we don’t know how it would help in this situation.
Do you offer enasidenib with azacitadine in AML with an IDH2 mutation for patients ineligible for intensive induction chemotherapy?
I typically do not give enasidenib with azacitidine upfront for patients with AML with IDH2 mutation and ineligible for intensive induction chemotherapy. Based on the results of the VIALE-A study (DiNardo et al, NEJM 2020), I usually give venetoclax with azacitidine to those patients. In addition to...