Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?
I am unaware of any published data to guide the decision-making for this topic. Empirically, I recommend low-dose aspirin in patients >50 who have to get long-term IVIG especially if there are a lot of underlying risk factors for thrombosis like diabetes, immobility, etc. Again, this is not an evide...
How do you approach an isolated T-cell gene arrangement found in the setting of persistent hypereosinophilia?
The lymphocyte variant hypereosinophilic syndrome (L-HES) is a rare form of reactive eosinophilic driven by clonal, phenotypically aberrant T-lymphocytes that secrete IL-5 and other eosinophilopoeitic cytokines. Diagnosis is based primarily on immunophenotyping (flow cytometry) of peripheral blood. ...
How do you utilize cytokine panels in your clinical practice?
It's become easier to order cytokine panels that get processed locally in my hospital. However, I think we're still far from knowing how to interpret these or make clinical changes as a result. While it's tempting to think, "If TNF is elevated, I will give the patient a TNF inhibitor, which will mak...
How would you approach a low risk patient <60 yo with platelets <600 K, JAK2 positivity and heterozygosity for factor 5 leiden mutation with no previous thrombosis?
First, some clarification is necessary with respect to the patient's MPN diagnosis because all three MPN can be caused by a JAK2 mutation, but the thrombotic risk is very different in each. Second, this is also a relevant concern because there is no correlation between the platelet count and thrombo...
How does one approach maintenance treatment in transplant ineligible patients with newly diagnosed multiple myeloma?
IMROZ and BENEFIT trials are interesting in that they are billed as for transplant-ineligible patients, yet frail patients were excluded, so I don't think they give us the answer for how to maintain a frail patient. The best answer for a frail patient is, I believe, the MAIA trial, which gives DRD t...
What is your approach to vaccinations and titers for patients with myeloma, who are immunosuppressed and do not have appropriate antibody responses to vaccines?
It depends on the vaccine and prior immunization history. Not all vaccines require an antibody response to be at least partially efficacious. In addition, with any immunocompromised host, reduced effectiveness for all vaccines is expected, but is not a reason to not vaccinate. Serologic testing is h...
Are you still recommending autologous stem cell transplantation (ASCT) for all eligible myeloma patients who achieve remission after induction with a quadruplet regimen?
Our institution still recommends upfront autologous transplant for most fit patients. We appreciate the recent results from CEPHEUS and BENEFIT, but if we believe that achieving MRD negativity is important, the addition of autologous transplant improves the rate of MRD negativity, which ultimately s...
What is your preferred first line treatment regimen for patients with untreated transplant-ineligible MM?
For transplant-ineligible patients, there are many excellent choices, including RVD lite and Dara Rd. My practice has shifted to Dara Rd for several reasons: The HR for Dara Rd v. Rd which is 0.56 appears to be better than the HR for RVd v. Rd in SWOG 0777, where it was 0.712 (though it should be no...
When, if ever, would you select a three-drug regimen instead of four-drug regimen in patients with newly diagnosed Multiple Myeloma?
Thank you for this question. For older, transplant-ineligible patients, there is no data that patients live longer or better (the true goals of treatment) with four drugs instead of three drugs. Yes, the responses are better, and we hope this may translate to longevity over time, but we do not know ...
How does one interpret an SPEP showing potentially obscured but non-quantifiable M-spike however an IFE showing monoclonal protein?
Not all patients with monoclonal gammopathies make a detectable paraprotein on SPEP, or, in some cases like IgA gammopathies, it may be 'hidden' in the beta-region of the SPEP, or the rare IgD and IgE gammopathies may be too low to detect on the SPEP. In addition, for the 15-20% of patients who have...