Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you manage B12 deficiency refractory to subcutaneous replacement?
I tend to start with IM injections of B12 when patients are severely deficient. The most common mistake in replacing severely low B12 is to not load, or to check levels too early. I have not used SQ administration before. It should absorb, but if you are having issues I would go to IM and start week...
Would you give GO and/or a FLT3 inhibitor for patients with AML with t(8;21) and FLT3-ITD low in addition to 7+3?
First, in terms of risk stratification, core binding factor (CBF) AML [whether inv16 or t(8;21)] is considered to be favorable risk by ELN22 even if a FLT3 mutation is present (Döhner et al., PMID 35797463). The incidence of FLT3-ITD in CBF-AML is 5-10% (Faber et al., PMID 27798625). There are some ...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...
Do you hold maintenance lenalidomide or bortezomib for a patient who needs a surgery?
I'm not aware of any formal data to guide this recommendation. In general, I do not recommend holding maintenance lenalidomide or bortezomib for surgery. I do hold maintenance for treatment if/when: - the patient has cytopenias from treatment and would benefit from improved counts from a treatment b...
Have you utilized a dose-reduced approach for elderly patients receiving frontline Pola-R-CHP, similar to R-miniCHOP?
I have utilized a dose-reduced approach for Pola-R-CHP for patients who are elderly, whom I would normally treat with R-miniCHOP, based on the early safety data from the POLAR BEAR trial. This randomized trial compared pola-r-miniCHP to R-miniCHOP in patients >80 years of age or >/=75 with comorbid ...
What is your approach to cancer patients who inquire about alternative or complementary treatments?
It depends a little bit on what specifically they want to use, and if they are truly investigating alternative medicine or complementary medicine. For people seeking full alternative medicine without any conventional treatment, I tell them that a research study showed that people who pursued the alt...
Do you consider co-prescribing hormone therapy and anticoagulation in a patient with prior DVT and uncontrollable VSM uncontrolled by non-hormonal therapies?
While I agree that you need to be thoughtful about adding additional VTE risk to patients with a history of VTE, I am much less concerned when patients are already on full-dose anticoagulation. Especially when the medication is transdermal estrogen, which has the lowest effect on thrombotic risk. I ...
What is your approach to AYA patients with B-cell ALL who relapse after CD19 CAR-T?
This is a somewhat nuanced question based on when the patient relapsed after CAR-T, what CAR-T product they received, whether the patient prior received hematopoietic stem cell transplantation (HSCT), other salvage therapies that were prior received as well as number of prior relapses. Multiple stra...
Do you perform genetic testing when patients have persistent hypogammaglobulinemia after rituximab therapy?
I would not routinely perform genetic testing. Multicenter studies (Labrosse et al., PMID 33862010; and Otttaviano et al., PMID 35892275) show that genetic testing returns a low yield, <5%. Several authors suggest that the risk of persistent hypogammaglobulinemia due to PID is increased if there is ...
How would you work up a patient with cutaneous mastocytosis?
In adults, consider mastocytosis as being systemic until you prove it is not. A single normal or low-elevated tryptase does not eliminate the possibility of systemic mastocytosis. All patients should go to Heme/Onc for consideration of bone marrow biopsy and ideally high-sensitivity PCR to look for ...