Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Are there biomarkers or other factors to help predict which patients with MCL are most likely to benefit, or not, from pirtobrutinib following a prior covalent BTKi?
In the phase I/II BRUIN trial, responses with pirtobrutinib occurred across prespecified subgroups regardless of demographics, number of prior lines of therapy, or prior therapy. Responses were seen in patients with blastoid and pleomorphic histology, regardless of the number of prior lines of thera...
What subsequent therapies did patients receive after progressing on pirtobrutinib in the mantle cell BRUIN trial population?
Not all post-protocol therapy was reported; however, nearly 20% of patients who were treated with pirtobrutinib on trial went on to receive CAR-T therapy. Pirtobrutinib’s ideal use is dependent on patient and disease characteristics. In the BRUIN trial, the median PFS, DOR, and OS of MCL patients wa...
When would you consider treating an asymptomatic patient with follicular lymphoma?
The decision of when to initiate treatment of low-grade follicular lymphoma is, of course, part art and part science. It largely remains the standard of care to defer initiation of treatment when not required, but when is it required? The question identifies symptoms attributed to disease as a clear...
Would you consider replacing ibrutinib with acalabrutinib or zanubrutinib in the TRIANGLE regimen for MCL in a patient with atrial fibrillation or high risk coronary syndromes who is otherwise fit for aggressive induction therapy?
Generally, if a patient is significantly symptomatic or intolerant due to atrial fibrillation, or other arrhythmia or even heart failure, it is reasonable to consider a next generation BTKI (acalabrutinib or zanubrutinib). As a cardiologist, I will defer to my cancer colleagues on efficacy across ad...
What post-protocol therapies did patients on the BRUIN trial in CLL receive, and how did these therapies impact outcomes?
The patients with CLL enrolled in the BRUIN study were heavily pre-treated with a median number of 3 prior therapies. All the patients in the BRUIN study had prior exposure to covalent BTK inhibitors and 40% of them also had been treated with a BCL2 inhibitor. As expected for patients offered a phas...
How would you consolidate a patient with primary refractory double hit lymphoma with secondary CNS involvement?
Thiotepa-based transplants are particularly rough. We haven't had good outcomes with them in terms of relapse and mortality is much higher than BEAM or Mel autos.Having said that, this patient has chemo-refractory disease. The initial concern with CAR-T in primary CNS or secondary involvement was th...
Do you routinely offer fungal prophylaxis for patients on BTK inhibitors?
We do not use antifungal prophylaxis for patients on BTK inhibitors. The risk of invasive fungal infection in patients treated with BTK inhibitors in recent large single institutional series have been 2 to 3%, without routine antifungal prophylaxis. The risk of fungal infection increases in patients...
Do you routinely use higher-dose VTE prophylaxis in patients admitted with traumatic orthopedic injuries undergoing surgery?
Yes, at my institution, we have two separate order sets. One is for moderate-risk medicine patients, which recommends enoxaparin 30-40 mg daily depending on renal function (heparin for ESRD and low-weight patients). The other is for high-risk patients, which includes all orthopedic and trauma patien...
What is the role of radiation therapy in recurrent Rosai-Dorfman disease after surgical resection, which manifests as many cutaneous lesions on the arms and buttocks?
I agree with Dr. @Dr. First Last. When I was in training, we reviewed the cases at MD Anderson. Radiation was only used for 9 patients (infrequently), and local control was achieved in 4 patients. So very small numbers, with uncertain benefits. Median RT dose 36 Gy. In the setting of multifocal dise...
How do you start and manage therapeutic SC heparin for acute thrombosis in pregnancy as the patient approaches delivery?
This is an excellent question and my approach to such a patient has changed over time. In my experience, therapeutic subcutaneous UFH is incredibly unpredictable--women may come in in labor on therapeutic UFH thinking that they will be able to get an epidural, but despite waiting hours and hours, th...