Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you manage bruising in patients on ibrutinib?
Bruising is quite common in patients treated with ibrutinib, and it seems to be a class effect that also is seen with the 2nd generation BTK inhibitors, such as acalabrutinib. It should be mentioned when consenting patients, and reassurance generally is all that is needed because the bruising is usu...
Can acalabrutinib be used after ibrutinib failure in relapsed/refractory mantle cell lymphoma?
Acalabrutinib binds to the same pocket as ibrutinib on BTK. Theoretically, if a patient is ibrutinib resistant, acalabrutinib would not be effective. Ideally, there should have been a small trial testing this hypothesis. However, because of the theoretic concerns, nobody wants to do this trial. As w...
What are the factors that convince you to not immediately treat mantle cell lymphoma and to follow a course of "active surveillance"?
A subset of patients with MCL have a significantly longer survival (often more than 7-10 years) and a more indolent disease course. Two separate groups have reported patients who did not receive up-front chemotherapy at the time of diagnosis but were instead actively monitored, the watch-a...
What is your preferred BTK inhibitor for patients with relapsed/refractory mantle cell lymphoma?
The majority of patients with relapsed/refractory MCL will respond to single agent BTKi therapy and this is my preferred treatment in patients at first relapse when a clinical trial is not available, and they have not been exposed to a BTKi (for example, on a frontline clinical trial). I often used ...
When would you use acalabrutinib in combination with obinutuzumab vs acalabrutinib alone in upfront CLL treatment?
I generally prefer acalabrutinib for treating CLL.When this is first-line therapy and there is a need to give “fixed-duration" treatment, I use obinutuzumab + acalabrutinib. If this is a single agent (monotherapy), I use Acalabrutinib alone.For 2nd or 3rd line, if the patient previously has had chem...
How would you treat a fit patient with a history of relapsed CLL who now presents with Richter transformation s/p autologous anti-CD19 chimeric antigen receptor (CAR) T-cells?
This is very challenging and essentially in a data-free zone. There are some data on off-label use of axi-cel for Richter, and liso-cel technically has a label for Richter. Results appear encouraging, but treatment and outcomes after CART failure are unknown. I would consider everything possible – c...
In light of the TRIANGLE data at ASH, how should we now approach a transplant-eligible patient with a new diagnosis of aggressive mantle cell lymphoma?
The TRIANGLE data presented by Dr. Dreyling on behalf of the European Mantle Cell Network are certainly provocative. Adding ibrutinib to induction pre-BEAM and maintenance post-BEAM (A+I) led to improved FFS compared to standard-of-care induction and maintenance (A). Not surprising, and doesn't tell...
What are your top takeaways in Hematologic Malignancies from ASCO 2023?
There was a time when those of us in the myeloma field could focus on ASH each year as our main source of updated practice-changing abstracts. No longer! Many exciting oral and poster abstracts were presented around multiple myeloma at the 2023 ASCO meeting in Chicago. Here are the top three that st...
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...