Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Do normal methylmalonic acid levels absolutely rule out vitamin B12 deficiency?
An elevated MMA is a good indicator of B-12 deficiency but a normal level does not argue strongly against B-12 deficiency. Normal MMA levels have been reported in 10-25% of patients with known B-12 deficiency (B-12 levels below 100). Testing for an elevated homocysteine level might help but this tes...
What is your preferred treatment for CML that presents with thrombocytosis?
In short, I do not change my TKI recommendations for patients with newly diagnosed CML who present with thrombocytosis. Prognostic scores demonstrate that thrombocytopenia is associated with poorer outcomes (Pfirrmann et al., PMID 26416462), but thrombocytosis does not seem to have any specific prog...
In addition to supportive transfusions, do you consider other interventions for symptomatic anemia and thrombocytopenia associated with chronic neutrophilic leukemia?
Assuming the CSF3R mutation that is seen is the T618I mutation, you can consider ruxolitinib. Dao et al., PMID 31880950, reported on a prospective trial of ruxolitinib in 44 patients with CNL or atypical CML. The overall response rate was 35%. However, responses were enriched in patients with CSF3R-...
What dose constraints do you use when treating gastric MALT or DLBCL with radiation therapy?
Treatment of the entire stomach is recommended for gastric MALT lymphoma. A dose of 24-30 Gy is recommended, generally in 1.5 Gy fractions to limit acute toxicity. I am starting to utilize 24 Gy more frequently though, most studies have used 30 Gy. Gastric MALT tends to be multifocal, is not well vi...
What is your surveillance protocol for patients with common variable immunodeficiency receiving chronic IVIG therapy?
No target IgG level per se- dose/interval should be titrated to clinical condition. In general, trough IgG on treatment should be higher than 500 mg/dL, or 500 mg/dL higher than baseline. Most patients will not be in optimal clinical condition (minimal fatigue, arthralgias, absence of chronic cough,...
Do you use MRD testing to guide maintenance therapy discontinuation in newly diagnosed non-high risk myeloma patients?
Patients with high-risk myeloma, whether defined by the IMS/IMWG or the somewhat controversial functional criteria, generally require ongoing treatment given the agents we have available; otherwise, they quickly relapse. It's easy to understand that there must be patients on the other end of the spe...
For patients with SLE, is there an ANC level for which you would hold or adjust hydroxychloroquine in an asymptomatic patient?
Leukopenia most often as lymphocytopenia, of course, is not unusual in lupus. Total WBC less than 4000 is an ACR classification criteria for the disease as is ALC less than 1500 on two occasions. SLICC disease classification requires ALC less than 1000. Total WBC < 3000 generates SLEDAI points. On t...
Is there any benefit to checking serum viscosity in patients with autoimmune disease and headaches/migraines to see if aspirin or clopidogrel may be beneficial?
The serum viscosity test measures the time required for the serum to flow through a calibrated capillary tube under controlled pressure. Clinically significant elevations in viscosity (≥2.5 centipoise, normal range 1.4 - 1.8 cP) can cause symptoms and are most commonly seen in hyperviscosity syndrom...
What is your preferred frontline treatment for CLL in young patients < 50 years old?
For younger patients, just like older patients with CLL, my preference for frontline treatment is based on genomic characteristics, fitness, and patient preference. I also prefer clinical trials over standard therapy, when available. For those young fit patients with IGHV mutated disease, the option...
Under which circumstances would you prefer ropeginterferon over hydroxyurea for patients with Polycythemia Vera?
The approval of ropeginterferon (Besremi) for the treatment of polycythemia vera (PV) without any restrictions was a welcome event for PV patients and their physicians. First, because this drug selectively targets the JAK2-mutated hematopoietic stem cell (HSC) responsible for PV and can produce comp...