Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
What is your approach to a patient with an advanced stage diffuse large B-cell lymphoma treated with chemotherapy alone (with a PET CR) who then develops an isolated CNS relapse?
This is a challenging albeit relatively rare situation. First, I would make sure to complete systemic workup, including MRI of brain/spine, CSF cytology, and PET/CT. I would not consider radiosurgery even for a single brain lesion, as this is ultimately a more diffuse disease process. If patient has...
What chemotherapy regimen would you recommend for a patient with symptomatic cutaneous B cell lymphoma?
This would depend on the subtype and stage. If only cutaneous disease and marignal or follicle center histology then single agent rituximab is best studied. The literature is variable on the # cycles to give, but there is nearly a 100% RR with high CR with follicle center. PCDLBC-LT requires multiag...
Given the sensitivity and prognostic value of the serum free light chain ratio for light chain multiple myeloma, do you continue to check urine studies?
This is a very pertinent and timely question. In fact, there is finally data. Dr. Dejoie et al published in Blood a study comparing the performance of serum and urine measurements in 113 newly diagnosed light chain myeloma patients. Interestingly only 64% of these patients had a measurable urine pro...
In multiple myeloma patients on bortezomib and dexamethasone, who develop HZV reactivation while on HZV prophylaxis, do you stop bortezomib/dexamethasone permanently?
It is important to make sure compliance with the drug is good. If it is drug resistance may play a role and alternative approaches can be used. Permanent discontinuation is not really an option as many drugs used for myeloma carries the same risk of zoster and if the patient needs the treatment, the...
What is your preferred dosing and schedule for interferon in pregnant CML patients?
The ideal starting dose for interferon in pregnant patients is a bit of a challenge because of gaps in the evidence base. In the IRIS study, interferon alfa at a dose of 5 million units/m2 was administered on a daily basis (along with cytarabine) and the toxicities of this regimen are well known but...
How do you approach the development of an LGL clone in a NHL patient actively getting therapy?
Most likely, i would monitor the clone and continue with the ongoing treatment plan. This is assuming the size of the clone was relatively small and that the patient was asymptomic in this regard. The development of a T-cell or NK-cell clone isnt necessarily indicative of a separate disease, does no...
Is a CLL FISH panel sufficient to aid in treatment decisions in CLL or is p53 sequence analysis also needed?
At a minimum, patients should undergo IGHV mutation analysis as well as testing for deletion of 11q and 17p prior to treatment initiation. However, testing for a TP53 mutation is ideal. While many patients with TP53 mutations will have a concomitant deletion 17p, this is not always the case. Given t...
How would you qualify and treat a patient with neutropenia, anemia, and abnormal NK cell population with normal trilineage marrow maturation?
I would run a molecular test to confirm that the clonality does not show a CD8-positive clone, as that is more common in LGL. The findings of a clonal NK population by flow cytometry would be enough, in the setting of neutropenia and anemia, to consider a diagnosis of NK cell LGL.
For a MALT of the eyelid, do you treat the entire conjunctiva reflection as well, or just the eyelid?
can you clarify the question? Is the question whether to treat superior and inferior conjunctiva (eyelids) or whether to treat deeper and more laterally on either the sup or inf Eyelid?
How do you choose between azacitidine and decitabine when deciding to treat a patient with MDS with a hypomethylating agent?
The only agent to prolong overall survival in patients with MDS is azacitidine so this is always my first choice particularly in older individuals at higher risk for complications of myelosuppression occurring at a higher rate with decitabine. Other issues to consider include ease of administration ...