Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you treat progressive Rosai Dorfman Destombes disease after initial limited radiation therapy?
To provide the best answer, we need a little more detail on this case. Also, is the patient symptomatic from the abdominal disease? If not, I would observe in the short term. If symptomatic, I would do PET/CT and consider a repeat biopsy, given the risk of the development of another process. Do you ...
How would you approach mantle cell lymphoma in very elderly patients?
For patients who are very elderly, my approach depends on the patient's performance status, other comorbidities, disease features/disease behavior, and indications for treatment. There are patients with MCL who can be observed at diagnosis (those with leukemic non-nodal disease but also those with l...
Would you extrapolate results from ELEVATE-RR study to favor use of acalabrutinib as first-line therapy in treatment-naive CLL?
The ELEVATE-RR study enrolled patients with a median of 2 prior regimens, with either deletion 11q or deletion 17p. I think one could debate whether selecting this patient population as compared to a less selected treatment naïve population would be more likely to find a difference between the two d...
How would you approach treatment for a R/R mantle cell lymphoma patient with a history of autoimmune hepatitis who has progressed on both a covalent and non-covalent BTKi?
Without the whole story, hard to know if this patient is a candidate for CAR T therapy. Presuming the answer is no, I would give venetoclax. Admittedly this is off label, but venetoclax can be very effective in this disease, both in my personal experience and in the limited available data (Davids et...
How would you treat a BTKi naive p53 mutated MCL in 1st relapse with disease noted both systemically and in the CNS?
This is a case where I would likely still use ibrutinib. We know from years of experience that it gets into the CNS, and it's an incredibly effective drug in MCL. Zanu and acala should get into the CNS, but the companies have limited PK data for CNS penetration. The harder question (I think) is whet...
Following the BRUIN data in mantle cell lymphoma, will you routinely treat with pirtobrutinib following a covalent BTKi?
Yes, this drug has demonstrated clear efficacy in a difficult-to-treat population and perhaps to date, the best safety data with a BTK inhibitor we have seen (low rates of cardiac, bleeding, and GI adverse events). There is a head-to-head study of pirtobrutinib versus covalent BTK inhibitors ongoing...
What is your approach to re-challenging BTK inhibitors for a patient who has had intolerance to several different agents?
This is a great question, and the answer is that I probably would not rechallenge with a BTK inhibitor. Many patients who develop an intolerance to a BTKi can remain on the drug with supportive care for the toxicity and/or dose reduction, which is not always effective. If someone truly had an intole...
What are your top takeaways from ASH 2023?
Gene therapy for sickle cell disease and beta thalassemia. This was the first approval of CRISPR/Cas-based therapy in humans. Ex-vivo engineering of isologous hematopoietic stem cells followed by their reinfusion after myeloablative conditioning led to induction of 40-50% fetal hemoglobin in patient...
What is your preferred salvage therapy for patients with follicular lymphoma who relapsed within 24 months of completing front-line chemoimmunotherapy (POD24) and will proceed to high-dose therapy with Auto-SCT?
There is no standard therapy for patients progressing within 24 months of 1L chemoimmunotherapy. If you have a well-designed clinical trial, I would do this 1st. Outside of a clinical trial, I would 1st try to biopsy a hot spot to r/o large B-cell transformation. If so, if the patient is a candidate...
What is your preferred second line regimen for follicular lymphoma that has relapsed four years out since receiving BR?
Many possible answers here, but I have been using zanubrutinib + obino in this setting as in the ROSEWOOD study. Zinzani et al., PMID 37506346 While not compared directly to rituximab + rev, it certainly looks better. Don’t want to repeat benda and impair T cell function for future CAR-T or bispecif...