Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Should testing for genetic causes of HLH be performed in all patients with MAS or secondary HLH regardless of the patient's age?
Familial HLH (fHLH) is a pediatric disease. Therefore, there is no place for genetic testing to establish a diagnosis of fHLH in adults, and treatment for HLH should not be delayed while waiting for genetic testing. However, there are hypomorphic polymorphisms in the fHLH genes that may be a contrib...
How would you counsel patients with personal or family histories of autoimmune disease on immune checkpoint inhibitor therapy for Hodgkin lymphoma?
This is also a tough question. I think patients with autoimmune endocrinopathies (especially Hashimoto’s or Type 1 DM) on stable, longstanding replacement regimens, as well as pre-existing vitiligo, are reasonable candidates for frontline PD-1 based therapies, although they certainly bear very close...
What is your approach to screening for malignancy in dermatomyositis patients who do not have a high risk antibody profile and whose disease responds well to treatment?
This is a great question and one that is very relevant to our clinical practice. Different myositis specific and associated antibodies seem to carry different risks in their associations with cancer. My colleague, Dr. Alexander Oldroyd, has written our current guidelines on cancer screening for pati...
What are your current recommendations for treatment of symptomatic splenomegaly in the setting of myelofibrosis when splenectomy is not an option?
I use low dose, typically 50cGy per fraction for 4-6 fractions, done in 2 fractions per week; need to check platelets each week during course.
When would you consider aspirin for long term management of unprovoked VTE after initial therapeutic anticoagulation?
The WARFASA trial randomly assigned patients with first unprovoked VTE who had completed 6-18 months of anticoagulation to 2 additional years of aspirin versus placebo. While the study demonstrated a 40% reduction in recurrent thrombotic events, the rates of VTE in those receiving aspirin were still...
For patients with recent post-delivery symptomatic ovarian vein thrombosis on anticoagulation, how would you approach periop AC management for upcoming procedures like D&C?
Nevertheless, I would first determine if the D&C needed to be performed so soon after diagnosis of the ovarian vein thrombosis or if it could be delayed. If it needs to be performed sooner, communicate with the proceduralist to determine if the anticoagulation needs to be interrupted. A number of in...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
What is your threshold to diagnose light chain MGUS with only a slight elevation in the light chain ratio, in a patient without other CRAB symptoms and no M spike?
Mild increase in kappa light chains can be a result of antigenic drift seen with the assay, in renal dysfunction both can go up but kappa may go up a bit more skewing the ratio. If a 24-hour urine with electrophoresis and immunofixation is negative and the rest of the work up is negative, would cont...
Would you consider a positive DAT and indirect Coombs test, persistent and consistent with IgG warm antibody, clinically significant in absence of hemolysis?
Up to half of patients with red cell auto-antibodies (i.e., true positive DAT/direct Coombs test) are not experiencing hemolysis. After iron repletion in this patient, the best way to determine the degree of hemolysis and whether treatment is needed is by the stability of the hemoglobin and the reti...
Would you include midostaurin in induction and consolidation for patients with good-risk AML with NPM1 mutation and FLT3-ITD (<0.5)?
Yes, in my practice I routinely include FLT3 inhibitor (midostaurin) in upfront 7 plus 3 chemotherapy for all younger fit patients with AML regardless of NPM1 status or FLT3 allelic ratio. The RATIFY trial validated the benefit of midostaurin in patients regardless of ITD allelic birder (both high a...