Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you use aspirin 81 mg for VTE prophylaxis in patients on adjuvant tamoxifen/SERMs?
In a meta-analysis of over 30,000 patients, VTE was found in 2.8% of patients on tamoxifen and 1.6% of patients on AI. So, yes there is a higher risk of VTE on tamoxifen but the percentage is still very low. I would not use 81 mg aspirin as VTE prophylaxis in all patients on tamoxifen to rescue or p...
Do you discontinue anti-hormonal therapy if a high-risk ER+ HER2- localized breast cancer patient develops blood clots on anti-hormonal therapy?
Tamoxifen has been associated with an increased risk for venous thromboembolic events, but there does not appear to be any increased risk with the aromatase inhibitors in the placebo controlled studies. These include MA.17, MA.17R in the extended endocrine therapy setting and MAP.3 and IBISII in the...
What platelet threshold, if any, is your goal for cytoreduction in essential thrombocythemia?
An unusual feature of the myeloproliferative neoplasms (MPN) is that their driver mutations are gain-of-function, meaning that the basic MPN phenotype is the increased proliferation of normal circulating blood cells. This basic phenotype is modified by host genetic variation to create three genetica...
What is the optimal choice of therapy for a patient with Hodgkin variant of Richter's transformation from underlying CLL/SLL?
I treat it similar to denovo Hodgkins Lymphoma with Brentuximab AVD for high risk versus ABVD for standard risk. If EBER-positive lymphoma, then there is a role for rituximab use in addition to chemo. Gupta et al., PMID 35291669
Does a patient with known systemic mastocytosis need a bone biopsy of lytic vertebral lesions to rule out other etiologies?
Yes, as long as other etiologies have been ruled out, such as cancer, osteomyelitis, or other infections. Even though osteoporosis is more common in systemic mastocytosis patients, bone lytic lesions are not.
What is your standard diagnostic workup to confirm GVHD in a patient post-BMT with skin rash and jaundice?
I assume there is no diarrhea, so sigmoidoscopy would not be helpful. Gut and liver pathology are useful. Skin biopsy is less helpful. It can be fairly nonspecific, but we do it to rule out other diagnoses that have more definitive pathology. Ultimately, it is a clinical diagnosis. Liver biopsy woul...
How does triple-negative status influence your management of ET?
This is a fantastic question! First, I would ensure that the patient has triple negative ET (or pre-fibrotic PMF) and not a secondary cause for thrombocytosis. This requires a bone marrow biopsy and a careful examination with hematopathology to ensure there are morphologic features consistent with a...
What dose/fractionation do you like to use for palliation of bulky LAD from CLL/SLL?
I have treated patients with bulky mass(es) - mostly parotids of recent. Bulky mass(es) -> I like either 400cGy x1 but most use 200cGy x2 (mostly used by me) -> (Electrons for structures like the parotid, but photons for deeper stuff.) For example, when I treated a few parotids glands, they were swo...
Does the use of A+AVD versus ABVD affect your decision for consolidation RT for bulky Hodgkin lymphoma?
A+AVD is an acceptable regimen for advanced HL based on results from the ECHELON-1 study (Ansell et al., PMID 35830649) showing an improvement in both PFS (82% vs 75% at 6 years) and OS (94% vs 89%) compared with ABVD. Radiation therapy was not incorporated into this study.In advanced HL, regardless...
Do you routinely start anticoagulation for a patient with newly diagnosed hepatocellular carcinoma presenting with a portal venous thrombosis?
No. Anti-coagulation is generally not indicated. Anti-coagulation is usually only indicated for acute PVT causing symptoms. This is more common with underlying thrombophilia. PVT is very common in cirrhosis and anti-coagulation is not required. PV thrombus from tumor similarly is common and anti-coa...