Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
In a newly diagnosed elderly patient with AML who harbors an IDH1 mutation, would you treat with upfront with ivosidenib/HMA or would you proceed with venetoclax and HMA as your first line treatment?
For me, the decision whether to treat this patient with IDH1 inhibitor monotherapy (ivosidenib) vs. venetoclax/HMA depends on how fit this patient is and his/her desire for aggressive therapy and inpatient vs ambulatory care. Prior data suggests very high response rates (90-100%) following venetocla...
How would you manage a solitary, painful, lytic bony lesion in a patient with negative PET/CT but bone marrow biopsy confirmation of multiple myeloma?
This is a palliative scenario, but the approach may differ based on the clinical circumstances. If Heme Onc is planning on administering systemic therapy, then a short course of palliative RT to expedite pain control would be appropriate. Treatment of many sites (e.g., femur) can be done very quickl...
How do you choose between liso-cel and axi-cel in patients with early relapse DLBCL for whom you are recommending CAR T-cell therapy?
Axi-cel and liso-cel are anti-CD19 chimeric antigen receptor (CAR) T-cell products approved for primary refractory or early relapsed (<1 year from initial chemoimmunotherapy) diffuse large B-cell lymphoma (DLBCL). Both products exhibit excellent efficacy (overall response rates >80%) and are potenti...
How would you manage relapsed DLBCL in a patient who received second line CD19 CART treatment?
With commercial CD19 CAR-T therapy moving into earlier lines of therapy, post-CAR-T relapses are now more common. There are still many options depending on what first-line/bridging therapy was given, CD19/20/30 expression, and patient preferences. I always get a biopsy if feasible to confirm relapse...
What is your approach to systemic anticoagulation for patients with hypoalbuminemia and nephrotic syndrome secondary to a non-membranous nephropathy condition?
Patients with nephrotic syndrome (NS) and hypoalbuminemia have a several-fold higher risk of venous thromboembolism (VTE) than the general population and also a somewhat higher risk of arterial thromboembolism (ATE), such as MI and stroke. This risk seems to be higher in membranous nephropathy (MN) ...
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...
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...