Hematology
Clinical discussions on blood disorders, coagulation, transfusion medicine, and hematologic malignancies.
Recent Discussions
How do you approach the treatment of HSCT-associated thrombotic microangiopathy?
TMA can be due to multiple insults: If the patient is on tacrolimus or cyclosporine, the dose should be reduced. These drugs cause the renal afferent arterioles to spasm, and RBC fragmentation can occur on that basis. It typically responds to a dose reduction If the patient was conditioning with TB...
In a patient with high risk acute promyelocytic leukemia, when do you consider ATRA+ATO with GO vs ATRA+ATO with idarubicin?
Given the recent publications with ATRA/ATO and GO in high risk patients or low risk patients who develop leukocytosis (Blood 2017) and the long term follow up of the comparative study form the NCRI AML Working Group (Blood 2018), GO is my preference in all cases unless there is hepatic toxicity or ...
How would you treat a patient with two concurrent plasmacytomas whose bone marrow showed no evidence of multiple myeloma and has no other MM defining features?
This is by definition Multiple Myeloma and I would treat it as such with systemic induction chemotherapy followed by transplant. These patients do better than the standard MM oftentimes. IMWG Criteria for the Diagnosis of MM | Inl Myeloma Fn
What is your escalation strategy for chronic GvHD?
There are now several available options for steroid resistant cGVHD. The old standbys - ECP and rituxan are useful in about 30% of patients. Ibrutinib was the first new drug to get FDA approval. Unfortunately, I don't think the real-world experience is anywhere near as good as the trial (Chin et al....
Will you use vadadustat in place of an ESA in treating anemia of chronic kidney disease?
Vadadustat is approved by the FDA only for patients who have been on dialysis for at least 3 months. It is not approved for patients with CKD not on dialysis. Its efficacy and safety are comparable to that of ESAs. I would consider using vadadustat in two patient populations: those on home dialysis ...
How would you approach an asymptomatic older female patient with eosinophilia to 17,000, present for years, and normal eosinophilia workup including marrow and negative FLIP1?
Interesting case. Eos have been in the 17K range for years? Was it incidentally noted? Could just be idiopathic HES. I would worry about cardiac infiltration in an older patient, but if there have never been cardiac issues and no evidence of a myeloid variant, I would probably defer to the patient a...
After induction therapy for acute promyelocytic leukemia with arsenic trioxide and ATRA, at what point do you start consolidation?
During induction, I wait for count recovery (ANC above 1000, transfusion independent- typically around Day 30, but +/- 5 days) and perform a bone marrow biopsy at that point. Patients routinely are still (but not always) + for PML-RAR at this biopsy, but that doesn't matter. As long as the marrow is...
How would you approach choosing a regimen for a patient with multiple myeloma refractory to Daratumumab and Lenalidomide, with severe neuropathy from Bortezomib?
That's an excellent question with many answers. Ideally, CAR-T therapy is a strong option, particularly based on the findings from the CARTITUDE-4 trial. If the patient is uncertain about CAR-T, then carfilzomib-based therapy is a viable alternative. This option can be effectively combined with eith...
How do you approach the second-line treatment for a patient with high-risk myeloma relapse early post-autoHCT after Dara-RVD induction?
Depending on the nature of the relapse, I would salvage with DCEP, or carfilzomib-based triplet (KCyD, KPd) with ciltacel as the next step.
How would you manage a CVST secondary to a traumatic brain injury with the presence of intracranial hemorrhage?
When dealing with CVST after TBI, the mechanism of injury is not the same as a spontaneous CVST. There is often direct injury to the vein or the area overlying it. Given that these patients often have other traumatic injuries, and given the lack of clear evidence to support one therapy or another, I...