Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you structure your monitoring for a low-risk leukemic TP53-negative mantle cell lymphoma with 5% MCL cells detected in both peripheral blood and bone marrow, mild splenomegaly, and no lymphadenopathy or B symptoms?
This appears to be the prototypical indolent patient for whom observation would be ideal. For these patients, there isn’t a truly validated period of monitoring. I have typically extrapolated from follow-up from other chronic diseases, with a plan to extend follow-up intervals over several years. In...
Do you use direct oral anticoagulants to treat port-a-cath related VTE in patients with an active malignancy?
The initial trials that established DOACs as effective and safe in most patients with cancer-associated thrombosis (Agnelli et al., PMID 32223112, Planquette et al., PMID 34627853) only included patients with lower-extremity DVT or PE but clearly showed equivalence to low-molecular weight heparin (w...
Do you screen for VWD in all women with menorrhagia severe enough to cause iron deficiency anemia?
Yes, testing vWF is needed in this situation of severe menometrorrhagia. Excessive menstrual bleeding, especially when severe enough to cause anemia, is a common presenting symptom of vWD in women. The testing should be done as part of a comprehensive workup for gynecologic etiologies and other coag...
What would your next line of treatment be for a patient with Hb SC with history of recurrent VOC and new bone infarct who is already on hydroxyurea and phlebotomy?
HbSC disease is the stepchild of sickle hemoglobinopathies with almost no studies of its treatment, so that any recommendation is not data based. One might consider adding crizanlizumab that blocks red cell-endothelial cell adherence. Each treatment group of the crizanlizumab study that led to its F...
Is it reasonable to treat a solitary plasmacytoma of the lung parenchyma with SBRT?
I have only treated one patient with solitary plasmacytoma of the lung over the past 15 years of doing lung SBRT. It is an extremely rare and unusual disease presentation for myeloma. Given the radiosensitivity of myeloma, I opted for 30 Gy in 5 fractions, which resulted in a completed response in t...
How do you approach recurrent migratory superficial thrombophlebitis in a patient with a negative malignancy workup and low-titer anticardiolipin antibodies?
With anticoagulation using a DOAC.
Would you evaluate for thrombophilia in patients with incidental splenic infarcts in the setting of known cirrhosis, portal hypertension, and splenomegaly?
When approaching splenic infarction, one question is to attempt to discern if the infarction is due to venous thrombosis (e.g., in the splenic vein) and subsequent congestion or due to arterial thrombosis (e.g. in the splenic artery), which is much more common. Talking with an expert diagnostic radi...
What is your approach to choosing a conditioning regimen for allogeneic transplant in AML?
Randomized trials in AML and to a lesser degree in MDS have shown that dose intensity is important for long term disease control. Following the guiding principle of trying to optimize the conditioning for each individual patient I use the following guidelines 1 patients less than 60 with HCTCI 3 or...
How would you treat suspected secondary HLH in patients whom etoposide is contraindicated?
Thank you for the interesting question. It would be helpful to understand why etoposide is contraindicated. My general approach for these patients is to first ensure that there is no evidence of malignancy as a trigger as you do not want to mask that with steroids (I strongly recommend obtaining a P...
Is there a risk of increased side effects with combined radiation and ibrutinib therapy?
It is increasingly common to see patients with various hematologic malignancies requiring palliative RT who are on small molecular inhibitors (such as ibrutinib) or other novel agents. There is often a dearth of information in the medical literature regarding the safety of combining RT with these dr...