Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?
The workup for a young adult with an upper extremity DVT differs for me in two ways: Venous thoracic outlet syndrome must be suspected and a careful history of repetitive overhead movements must be obtained. Consulting your vascular surgery team in these cases to ensure the anatomy does not put the...
In an elderly transplant ineligible IDH1-mutated patient with AML, who is in remission after 6 cycles of azacitidine and ivosidenib, would you discontinue azacitidine after cycle 6 and continue maintenance ivosidenib until progression/toxicity or continue both azacitidine and ivosidenib?
Our practice is to typically continue azacitidine + ivosidenib per the AGILE study (Montesinos et al., PMID 35443108) as long as the patient is not having excessive myelosuppression/toxicity and doesn't feel strongly about coming off azacitidine. That being said, there are data to support ivosidenib...
Do you recommend postoperative radiation for spinal cord compression DLBCL?
I would recommend postoperative RT, following completion of systemic therapy. I would restage with PET-CT prior to RT. If CR: 30 Gy would suffice.
How do you counsel patients who experience diarrhea from mycophenolate mofetil (Cellcept)?
I have them stop the drug, and when their bowels are back to normal (usually just a couple of days), I resume with 1 tablet bid of mycophenolate mofetil (MMF, CellCept), then a few days later go up to 1 tab tid, a few days later 2 tabs bid... etc. I instruct them to go down to the most recent dose ...
How would you approach management of a patient with ESRD on the transplant list who is found to have high titer APS labs (ACL, B2GP1, LAC)?
This is an excellent but rather complex question. Management of patients with ESRD on the transplant list who are found to have high titer APS labs (ACL, B2GP1, LAC) depend on the renal histology, underlying autoimmune disease history, and comorbidities. Patients with thrombotic manifestations resul...
In the post Covid era, could the ILROG hypofractionated regimens (published as "emergency guidelines" for lymphoma) be considered as standard of care for ISRT?
In palliative settings, we have utilized hypofractionated regimens in hematologic malignancies for decades. Examples include 4 Gy X 1 for follicular lymphoma, 4 Gy X 5 for myeloma, 3 Gy X 10 for DLBCL, and 4 Gy X 2 for mycosis fungoides. In select circumstances (both before and after COVID-19), I ha...
Do you check the Duffy-null phenotype before starting azathioprine and in which patients?
I personally do not check the Duffy antigen prior to starting azathioprine. I do check TMPT levels on all patients prior to starting it to help determine initial dosing.
How would you manage a patient with HbSS and severe pulmonary hypertension on home oxygen?
This patient should be referred to a specialist in pulmonary hypertension in sickle cell disease for right heart catheterization and aggressive management of the pulmonary hypertension. As described, the patient is not a good candidate for lung transplant or gene therapy.
How would you approach the staging and treatment of extranodal marginal zone lymphoma of left and right lacrimal gland?
This entity is described in literature as "ocular adnexal lymphoma". I usually screen those patients for Chlamydia infection and would empirically consider a 3-week course of doxycycline especially if the disease is indolent behaving clinically and there is prior serologic evidence of Chlamydia infe...
In which patients with MGUS do you recommend a kidney biopsy to evaluate for MGRS?
If a patient has unexplained renal disease, and this could be interstitial or glomerular, and an MGUS, I strongly consider it. I typically try to get heme to do a bone marrow biopsy first because their findings may obviate a renal biopsy if they find something (although sometimes they may find low-g...