Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
Would you require biopsy of both orbits or is unilateral biopsy adequate for a patient with suspected bilateral orbital MALT lymphoma?
Biopsy of one orbit is sufficient if clinical findings and images of the other orbit are all consistent with marginal zone lymphoma (MZL). I’m a little surprised the question of how to treat bilateral MZL of orbit was not asked. Assuming disease is limited to the orbits, radiotherapy to both sites w...
What is your approach to management of chronic neutropenia in a patient with Sjogren’s who was recently diagnosed with metastatic endometrial cancer and plans to start chemotherapy?
With metastatic cancer, optimal treatment of the endometrial cancer is the priority. Heme/Onc consultant would likely be giving granulocyte stimulating products.Although neutropenia can occur in Sjogren's Disease (SjD), I rarely have found it to be clinically significant, and lymphopenia seems to oc...
Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?
Great question, with practical implications for the clinic: Azathioprine (AZA) is a prodrug that likely exerts its immunosuppressive effects against B- and T-cell function by interfering with purine metabolism through its metabolites (including 6-MP). Logically, many of the "classic" AZA side effect...
How do you approach the treatment of drug-induced thrombotic microangiopathy?
Typically, transplant-related TMA is due to sirolimus, tacrolimus, cyclosporine, or some combination of those drugs. The first step is to reduce the dose. Often keeping the drug at the lower end of the therapeutic level, the TMA will resolve or ameliorate. If, for instance, sirol and tac are used to...
How do you treat primary refractory diffuse large B cell lymphoma in elderly patients with good performance status?
In general, age (by itself) is not a limitation for most of the available therapies for DLBCL elderly patients. Comorbidities and performance status are what drive the decision of what to use as next therapy. I usually recommend all the approved therapies for RR DLBCL. My limit for autologous transp...
When can abdominal surgery be safely performed for presumptive ovarian cancer in a patient with recent pulmonary emboli?
In general, the standard approach is to try to wait as long as possible after the thrombotic event, at the very least three months. This may not be possible, we then reduce that time interval to one month. Given the urgent nature of the surgical intervention, one approach is to wait one month and co...
What is the indication for phlebotomy in compound heterozygous hemochromatosis?
The indication for phlebotomy is proven or strongly suspected iron overload. The likelihood of expression in these individuals is low. An elevated ferritin is often due to reasons other than iron overload such as fatty liver or alcohol intake. I usually do a liver ultrasound in this circumstance. If...
How would you work up and manage persistent lymphopenia in an asymptomatic patient?
Simple answer: refer to an immunologist, as this degree of lymphopenia is quite likely to represent a serious immunodeficiency. I would also send a next generation sequencing panel of immunodeficiency/immunoregulatory genes to be in process while awaiting the immunology consultation. Long answer (fr...
How would you manage a patient pre-operatively with a prolonged PTT that does not correct on mixing, with lupus anticoagulant testing that is abnormal by LA-PTT only?
Not all reagents/assays exhibit the same sensitivity (aka responsiveness) to lupus anticoagulants (LAC). In this case, there is evidence of LAC based on one assay, LA APTT. Often we see prolongation/inhibition in other assays e.g. APTT, but the phospholipid neutralization (PNP) step is not always di...
Do you screen adults in your practice with sickle cell disease for silent cerebral infarcts?
The details of the ASH guidelines regarding adults are complex. It was not my practice to screen all patients. More than 50% of adults have silent infarction. Screening requires MRI and this, according to the guidelines, needs careful attention to many details before it is reliable. There are no pro...