Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How would you treat a stage I fully resected double hit DLBCL?
In patients with fully resected DLBCL, I still give chemotherapy. That also applies to double-hit lymphomas. Limited-stage DHL does not seem to have a poorer prognosis than non-DHL, and intensive regimens do not make a difference. I would treat with RCHOP x 3-4 cycles. Torka et al., PMID 31945157 Lu...
Has the data for the ENRICH study changed your practice for the initial treatment of mantle-cell lymphoma?
While the information presented was intriguing, it has not yet caused any change in my approach to initial therapy for MCL. I say this due to the fact that the IR arm did not seem better than BR, save for those with a P53 mutation. I have routinely avoided CIT in this patient population, so this inf...
In light of data from TRIANGLE, ECHO, and ENRICH, what is the best strategy to treat newly diagnosed patients with the blastoid variant MCL?
The management of MCL for almost 2 decades was driven by extrapolated data from aggressive B-cell lymphoma. However, aggressive chemotherapy and stem cell transplantation have failed to produce a plateau on overall survival curves, and patients inevitably have relapsed. It is now clear that MCL, par...
What is your approach to treatment of mantle cell lymphoma in someone with a mutated gene downstream of the BTK receptor, such as mutated CARD11?
For those with primary refractory MCL after a cBTKi, I would still not proceed with chemotherapy, given the limited data to support benefit after a patient progresses on a cBTKi. Only data thus far is with a bendamustine/cytarabine-based regimen, which, if/when they relapse, would potentially impact...
Would you give adjuvant radiation after complete resection of a small primary cutaneous follicular lymphoma of the scalp?
Not a lot of data, but here goes. First, one has to go back decades in the literature to find series of patients with lymphoma rx'd with surgical resection alone. In general addition of RT improved outcome even when ostensibly resected with neg margins. With today's technology risk of additional RT ...
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
What is your approach to the management of chronic GI bleeding from AVMs in an elderly patient on DOAC for atrial fibrillation?
I would definitely strongly consider the left atrial appendage occlusion device in these patients. While usually these devices (such as Watchman) do require anticoagulation for about 45 days until the device has an endothelial layer form on it (we usually confirm with a CT scan or TEE), there are so...
Do you routinely use antifibrinolytics for patients with heavy menstrual bleeding who are already on hormonal therapy?
Yes. Counsel patients about theoretical increased risk, but more recent studies do not support increased thrombotic risk with antifibrinolytics. Ker et al., PMID 39461793 Meschino et al., PMID 40680937 Muradashvili et al., PMID 41139079
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
Do you routinely screen and replace Vitamin D in patients with ITP?
I do not generally screen for vitamin D deficiency in ITP patients, but do recommend that all patients undergo routine screening as recommended by the American Academy of Pediatrics (pediatric provider) and have vitamin D deficiency identified and managed as appropriate for age in general, regardles...