Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
When following current COG ALL protocols with the addition of two courses of blinatumomab to treatment for SR and HR patients, how frequently should surveillance bone marrow and MRD evaluations be performed?
With the caveat that I only treat adults, but the general concepts are similar:In our practice, we routinely do bone marrow exams with MRD assessment after the first cycle of blinatumomab. Assuming this shows no detectable disease, we typically will then perform the same before transitioning to main...
Do you use premedications (acetaminophen, diphenhydramine) before pRBC and plt transfusions to prevent febrile nonhemolytic transfusion reactions and allergic reactions?
I do not routinely premedicate patients. There is a recent meta-analysis that shows no benefit. I only premedicate those who have had a prior transfusion reaction. Old studies showed this was a common practice but those studies were performed before universal leukoreduction and other strategies aimi...
Is there a role for anti-fibrinolytic agents in patients with hyperfibrinolytic disseminated intravascular coagulation?
DIC is a complex clinicopathologic syndrome. There are no randomized trials to support evidence-based practice. The following principles apply: 1) antifibrinolytics should not be used in patients with organ failure or those that are asymptomatic. One could justify their use in this group of patients...
Would you offer TPO-RAs to a steroid-refractory chronic ITP patient with history of stroke?
Yes, if needed, though with a bit of trepidation, and it probably wouldn't be my first choice. Second-line chronic ITP treatment can include TPO-RA, rituximab, or splenectomy, and no one treatment is clearly better than the others (Neunert et al., PMID 31794604). Both splenectomy and TPO-RAs have in...
What treatment considerations do you make for elderly patients with relapsed/refractory follicular lymphoma?
Treatment options for R/R FL patients depend not only on the condition of the patient but what was received in 1st line and the duration of that line of therapy. Given that if a patient has received chemo-immunotherapy in the frontline setting and had a prolonged remission (> 5 years), then these ag...
What treatment do you recommend for marginal zone lymphoma in a patient who previously received bendamustine and rituximab for MALT?
RCHOP or a BITE; I would use cladribine + GAZYVA with curative intent.
How would you manage a patient with polycythemia and MPN symptoms (aquagenic pruritus, fatigue) that is JAK2/CALR/MPL negative but peripheral blood NGS positive for IDH2?
I would approach this through the framing of a polycythemia/erythrocytosis workup and then consider MPN-related interventions if a diagnosis is made! This is an excellent review that provides an overview of erythrocytosis investigation (Noumani et al., PMID 38695361). In brief, I would be thinking a...
How do you approach prophylactic antibiotics in patients who continue to have recurrent neutropenic fever following chemotherapy for solid tumors despite chemotherapy dose reduction and growth factor support?
This has to be individualized to the patient. It depends on the length of neutropenia, previous infections, and local antibiotic resistance. If the patient develops neutropenic fever after every cycle of chemotherapy and no obvious nidus of infection has been identified, a trial of a fluoroquinolone...
In older male patients with a history of underlying autoimmune disease, what clinical manifestations would prompt you to evaluate for VEXAS Syndrome?
Hello!!!Skin lesions, elevated MCV, elevated inflammatory markers.
How should community oncologists practically counsel patients with aggressive lymphomas on the potential treatment course as they move into 2L/3L therapies?
For those who relapse after first line therapy, treatment recommendations are dependent on the timing of relapse. For those who relapse within 12 months of completing first-line therapy and are fit, I would strongly consider referral to a center with CAR T-cell capabilities. As noted before, 5-year ...