Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do CLL patients with downstream treatment-resistant mutations such as PLCG2 respond to pirtobrutinib?
In the BRUIN trial, among 222 patients with PLCG2 mutation data available, 18 had mutations and 204 did not. The overall response rate (ORR) was numerically lower in those with PLCG2 mutation (56% vs 84%) (Mato et al., PMID 37407001).The ORR was numerically higher in those with BTK C481 mutation com...
Does tolerance of prior BTKi therapy or specific agent used (e.g., ibrutinib, acalabrutinib) influence your starting dose of pirtobrutinib?
Not really. I generally start pirtobrutinib at the standard dose of 200 mg daily.
Would you consider IV thrombolytics in patients with acute ischemic stroke, with or without a large vessel occlusion, if they have a history of von Willebrand disease (VWD), regardless of its type?
I would still consider it unless the INR >1.7 or they are on anticoagulation for some clinical reason.
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...
How do you treat patients with T-cell ALL/T-cell lymphoblastic lymphoma who have pre-existing CKD with a CrCl of 30 mL/min or less?
In our experience, it requires very close coordination with our clinical pharmacists to ensure proper dose adjustments are made. By doing this, you will hopefully deliver comparable dose intensity without increased toxicity. This assumes you achieve the same level of drug exposure for the agents tha...
Do you routinely consider FDG PET/CT imaging for workup of fever of unknown origin?
The landscape of FUO and IUO and our clinical approach to diagnosing its cause has changed significantly over the past several decades. More sensitive microbiologic screening for infectious etiologies, including syndromic molecular panels and next-generation sequencing are now clinically available a...
Can a patient still have primary HLH even in the absence of any HLH associated genetic mutations?
Yes, a patient can still have primary Hemophagocytic Lymphohistiocytosis (HLH) even in the absence of identified HLH-associated genetic mutations.Primary HLH, also known as familial HLH, is typically linked to mutations in genes related to the immune system, such as PRF1, UNC13D, STX11, STXBP2, and ...
When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?
The number of antibodies is an important consideration.On the one end of the spectrum, I would not recommend any DOACs in a triple positive APLS (especially with arterial thrombosis). Having said that, I would not change treatment in a triple positive APLS patient if they were started on DOACs in th...
Do you always initiate hypercoagulable work up in a patient with recurrent stroke?
As always, this is a more complex problem than it appears. A history of both prior other thrombosis and family history of thrombosis is essential. Are there good reasons for the stroke and/or has it been worked out in past including carotid disease, atrial fibrillation, underlying malignancy, valvul...
How will you treat a young man with recurrent cryptogenic strokes with no identifiable cause, with MTHFR A1298C homozygous mutation and normal homocysteine level?
The genetic variant you report seems to be a SNP that, while it has been reported to be statistically associated with various diseases in GWAS studies, is not pathogenic. SNPs that are significant in GWAS studies have very small effect sizes that can be measured when considered in thousands of peopl...