Questions discussed in this category
Can you explain when would you consider light chain amyloidosis work up with fat pad biopsy?
Do you avoid using these agents only in patients with history of medullary thyroid cancer or pancreatic cancer? Are there other cancer risks we should...
Cell counts are normal. Bone marrow shows grade 3 fibrosis. Spleen size continues to enlarge.
Bone marrow biopsy does not meet criteria for MDS and no other identifiable cause of the cytopenias.
Is there a role for increasing the dose if not yet maximum? (Hb ~8)
Can you elaborate on reasons for a non-quantifiable SPEP and how does one follow the paraprotein?
For what duration and is there a preferred anticoagulation agent?
How would you sequence these therapies given approval for both?
What about if the patient has mediastinal disease and ISRT is not an option?
Would you change your radiation therapy treatment dose or volume if you needed to treat a chloroma? If a patient had a separate cancer (e.g., skin can...
Do next generation sequencing results influence diagnostic and therapeutic decisions for patients with MDS?
Most patients with PGNMID have no detectable disease in their marrow or blood and urine protein cannot adequately be monitored.
Is there a role for nelarabine and venetoclax in this setting?
USPTF and CMS guidelines differ in age criteria, and NCCN guidelines do not have an upper age limit.
Since ECHELON-1 trial showed an improvement in PFS (but not OS), are there any situations where you would replace bleomycin with brentuximab...
Do you discuss the risk of sickle cell crises with G-CSF? What about for patients with sickle cell trait?
Is there a role for non-myeloablative regimens?
Al-Ibraheem et al., PMID 33731050
Are there characteristics which could help identify whether a follicular lymphoma might behave more indolently vs aggressively and inform treatment se...
Have you encountered changes in prolactin, testosterone, etc?
Or would you sequence a different BTKi?
At the time of initial diagnosis, there was no clear CNS involvement. When it became clinically apparent disease was refractory to EPOCH, there was CS...
Does a certain level of free light chain ratio reassure you against the possibility of AL amyloid? Is there a certain level that makes you more concer...
Do the recently published IMROZ and BENEFIT trials inform maintenance treatment in transplant-in-eligible patients with NDMM?
What is your evaluation approach for RAI response? What cumulative dose do you use in practice for deciding a patient is RAI refractory?
Since free light chains are removed by dialysis and SPEP can also be impacted, is there a reliable way to monitor patients with ESRD and MM?
Is APLS a contraindication to using interferon?
No clear inciting etiology found.
Would you consider dexamethasone +/- cytokine blockade (IL-1, IL-6, or IFN-g)? What do you think about the data for...
E.g. frequency of Bortezomib, dosing of Bortezomib, length of cycles.
Assume thrombolytics are not indicated. Do you favor early DOAC transition after 24-48 hours of heparin gtt or do you favor LMWH for 10-14 days follow...
Given nationwide shortage in vinblastine, several of my patients under active therapy are facing delays in their therapies. Is it appropriate to subst...
How would you counsel the patient given the drug interactions present?
Do you do additional workup for venous obstruction or any other different testing/evaluation?
Do social or economic factors (i.e., relative cost of acquiring LMWH, the patient being injection averse) affect your decision to use DOACs?
Do you s...
WBC and Hb values are normal, and normal JAK2, CALR, BCR-ABL.
Are there other mutations/biomarkers in CLL which may specifically predict for response or resistance to pirtobrutinib?
Do you consider "bridging" therapy prior to transplant, and if so, what are your thoughts on the intensity of the chemotherapy?
In a patient with no evidence of bleeding, do you use a platelet cutoff? Do you utilize genomic testing (eg CALR, MPL, JAK2, etc.) to decide on cytore...
Ropeginterferon is now a preferred therapy for Polycythemia Vera (PV) as per a recent update to the NCCN guidelines.
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
Would portal hypertensive gastropathy or colopathy sway you away from using it?
Patient in their 60s with TP53 mutation by NGS, treated 12 years ago with FCR, then at first relapse 2 years ago started ibrutinib. Bone marrow biopsy...
How would your recommendation change if the patient has H63 homozygous mutation?
When would you consider a bone marrow biopsy?
Are there specific safety or efficacy benefits associated with prolonged infusion times in this population?
TRIANGLE study
Estimating blood loss from hemoptysis is not always reliable. The bleeding may be due to the PE itself. Is anticoagulation with any degree of hemoptys...
Confirmatory tests with DRVVT, hexagonal phase assay, and PNP are all normal. No bleeding history
What is the ferritin target that you would aim for? What would be your approach for a ferritin >500? When do you order an MRI liver for iron quanti...
Given pelvic RT is likely to induce ovarian dysfunction/menopause, would you consider systemic options?
What does it add beyond a serum electrophoresis or light chain testing?
Are there certain types of patients where monitoring immunoglobulins is parti...
Do you have a preference on the regimen or cycle number, and how and when do you assess response prior to transplant?
What criteria do you use to define steroid-refractory disease?
Does your management different by organ system involved - GI vs skin vs other?
Patient developed atrial fibrillation on Ibrutinib, severe fatigue and intolerance to Zanubrutinib and a maculopapular rash (grade 2) on Acalabrutinib
The patient presented with a numb chin, more to the right of his face; an MRI did report mandibular nerve opacity, which is non-specific per neuro-rad...
Does age influence your choice of regimen?
Aside from addressing the underlying case, is there a role for phlebotomy in secondary polycythemia such as in COPD or post-renal transplant erythrocy...
NCCN says "consider autologous HCT" while retrospective data seems to support SCT in most histologies like AITL
Have you changed your practice given BMT-CTN 1506/Morpho results?
Would you utilize maintenance therapy in patients who achieve MRD- remission?
Would you continue R-CHOP or would you switch therapy?
From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated.
What is the role of SBRT versus microwave ablat...
For example, how do you address tendency to "over-order" these tests in patients with common aches/pains but no structural abnormalities on advanced i...
Is there a specific tyrosine kinase inhibitor that you would prefer to use?
At the time of count recovery or do you continue it throughout induction and consolidation?
Comorbidities: morbid obesity, diabetes, hypertension
The patient also has transfusion-dependent anemia secondary to the LGL leukemia.
Given CPX-351 was given to elderly patients ages 60-75 with a lower dose (60 mg/m2) Daunorubicin, can one generalize from this study to younger adults...
NGS results are pending
Would you transplant a patient over the age of 70 with newly diagnosed myeloma? Does the risk category impact your decision?
The patient was recently diagnosed with pre-B ALL and is on day 10 of CALGB 10403. He is expectedly neutropenic as he received daunorubicin and vincri...
Would you follow an algorithm such as the one proposed by Hall et al., PMID 29940062?How do you decide between intrathecal chemotherapy vs systemic th...
There are various formulations of intravenous iron; each with varying costs, test dose requirement, elemental dose, and number or time of infusions ne...
While follow up ultrasound is not usually recommended in provoked DVT, it often is done either for other reasons or by other physicians. Would this in...
E.g., for a patient with myeloma, s/p induction therapy, and high-dose chemotherapy, followed by autologous rescue with inappropriate antibody respons...
Or offer resection followed by adjuvant therapy?
Is there benefit to radiation on top of systemic therapy?
Is the therapeutic purpose of the proteasome inhibitor to maximize total dosage per week or number of infusions per week?
Work-up was performed for isolated anemia which resolved to >11 g/dl after the reversible cause was treated.
Are you concerned about cases where radiation has to be started urgently before leukapheresis?
In a patient who relapsed following 2nd line transplant, how do you select CAR-T vs bispecifics vs non-T-cell-mediated therapies as outlined in NCCN? ...
Do you speak to different expectations re: ability to achieve PR/CR and/or how this will impact ability to get to later therapies for a patient with p...
Presuming the patient is not a transplant candidate due to comorbidities, PS, and age.
If there are light chain deposits on the kidney, is that conclusive of MGRS?
If yes, how does that affect management?
If no, what are your indications for BM biopsy?
Per the new data from the COMMANDS trial, Platzbecker et al., PMID 37311468
Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?
What is the work up and what is the duration of anticoagulation if used?
Triplet v. Quadruplet? Do you opt for VRd, DaraRD, CyBorD, Dara-RVd or another regimen?
How would this change for a patient with high risk cyt...
Would you continue KEYNOTE-522 neoadjuvant therapy? The patient has a PMH of sarcoidosis with no stroke risk factors. No residual deficits.
Do you always avoid heparin/enoxaparin or rechallenge if antibodies are negative?
Specifically, asymptomatic subsegmental PE diagnosed within a month from planned bilateral mastectomy for breast cancer.
Is liquid biopsy helpful? Would you treat if this shows somatic mutation?
Will the results of the recently published randomized comparison of proton beam therapy (PBT) vs. transarterial chemoembolization (TACE) change the wa...
Such as in a patient with essential thrombocythemia with a CALR mutation, younger than age 60, no history of thrombosis, no bleeding or vasomotor symp...
How frequently and what type of testing/sample are you performing MRD assessment?
Does your approach differ between transplant-eligible and transplan...
Is the data sufficient to change your practice?
Does cumulative exposure to BTKi increase potential risk of cardiac toxicity?
Should pirtobrutinib be viewed as a bridge to CAR-T or transplant or a destination therapy?
How do you predict which patients may be in a high risk group and less likely to benefit from a second BTKi?
Is there a specific Ki67 percentage? P53-negativity?
How do you pursue fertility preservation in younger females with this presentation?
Are you more inclined to use non cytotoxic regimens such as R2 or PI3K inhibitors?
What XRT dose do you use? Does the location of the disease (e.g., mediastinum) affect your decision when taking toxicity into account? would you offer...
Would a negative NGS eliminate the possibility of MDS?
Is bone marrow biopsy indicated in a patient with pancytopenia with a negative NGS panel?
Several patients with inability to access oral cyclophosphamide or lenalidomide, have attempted assistance and grants to no avail.
Given recent retrospective study showing potential lack of benefit with bortezomib-based maintenance therapy (Bumma et al., PMID 37021929).High-risk a...
Which PI and at what dosing intervals? Dexamethasone or not?
Emory has now published data with VRd consolidation as well as KPd consolidation, while ...
Such as the case in which a patient is unresponsive to steroids, IVIG, TPO-agonist, rituximab, splenectomy, and even fostamitinib.
Do you re-challenge them? If so, what pre-medications do you give? Do you dose reduce the cytarabine? Or do you switch another regimen?
Would you consider low dose indefinite anticoagulation in any scenario? Any difference in approach between hematological malignancy and solid tum...
E.g. TET2 mutation at < 10% allele frequency
How is this entity distinct from other secondary HLH entities?
If so, would you do bone marrow biopsy or send for NGS panel in blood to look for high risk mutations? NCCN lists this as the risk criteria.
Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?
How do you use this information in clinical practice?
Assuming there is clear laboratory and/or imaging evidence of disease progression, and assuming FISH data is already available from a prior biopsy, do...
Are there any instances where you would prefer a biosimilar rather than the reference product?
Patient with stable disease on maintenance therapy with lenalidomide and dexamethasone
Data exists for imatinib Dasatinib and nolotinib
Normal CBC, CMP, SPEP, serum light chains, and FISH. Young otherwise fit patient.
Presuming there are no matched unrelated donors.
240-300 mg/m2 prior exposure. How would your management change in young fit/older individuals with comorbidities? Would you obtain interval TTE during...
Would you give a trial of IST first or immediately refer for SCT if the patient has matched siblings?
How do you decide between starting infliximab, MMF, or IVIG? If a patient presents in respiratory failure (nearing or requiring intubation), woul...
What would you want community oncologists to know when following these patients? Are there any other special issues to follow especially in AYA?
E.g. in a patient with tenuous cardiac function, would starting treatment several weeks earlier potentially improve outcomes?
Regimen currently 25 mg lenalidomide D1-21 of D28 day cycles, Daratumumab 16 mg/kg every 2 weeks.
The patient has also acquired mutations in BCR-ABL, namely p.Met244Val, (c.730A>G); 3.7%, which may confer resistance, and p.Phe359Cys, (c.1076T>...
Patient on JAK2i, ESA, transfusion dependent
How can these interactions be improved?
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
If so, what platelet count threshold would you use? Would age impact your decision? Would you do a bone marrow to rule out primary MPD in adults if th...
Would you continue ibrutinib even if they are placed on anti-platelet therapy such as clopidogrel or ticagrelor?
When do you switch to an altern...
Do you incorporate PEG-asparaginase or brentuximab vedotin (for CD30-expressing malignant cells) into anthracycline-based induction regimens? Do you c...
Would you biopsy another site or treat the patient?
Concordant low EPO level and bone marrow with megakaryocyte hyperplasia
How do you choose between CAR-T and autoSCT, for example?
This is a recently described entity with poor prognosis, so even with a CR after RCHOPx6 cycles, is your bias to push for ISRT due to EBV being poor p...
In your practice, what is the proportion of patients receiving neoadjuvant chemotherapy who are diagnosed with VTE? Does this differ from patients rec...
It is understood that the trial's experience was to keep on treatment indefinitely until progression or unacceptable toxicity. We are asking about rea...
How would your choice of therapy differ (if at all) for high vs low risk disease?
Would the specific anti-platelet agents used influence your choice ...
Are there specific clinical, patient, or disease factors you focus on?
Are patients with long standing malignant central airway obstruction poor candidates for central airway stents? What is considered to be an acceptable...
Given the substantial risks associated with transporting an intubated and ventilated patient to Radiation Oncology, is there any evidence to support t...
Does it assist in prognosis in any way?
There are conflicting reports whether it contributes to renal insufficiency. If you do switch, what is your preferred TKI in this scenario?
Since both pregnancy and cancer are risk factors for VTE, is there data to guide when or if we should prophylactically anticoagulate? If so, what shou...
If indefinite treatment is recommended, is there an optimal maintenance dose?
Would you intercalate HD-MTX with her CHOEP?
Does your treatment approach differ from Waldenstrom's Macroglobulinemia?
Does the presence/absence of a MYD88 L265P and/or CXCR4 mutation change you...
How do you generally think about sequencing treatment among available options?
Would your choice be affected by a patient's eligibility for transplan...
Do you have a certain immunoglobulin level which you would use to determine this?
Does your management change if symptomatic or asymptomatic?
What parameters/goals/targets do you use?
Do you treat PV, ET, and MF differently?
Would you use a trial of dexamethasone for a patient with thrombocytopenia?
If so, how do you incorporate GCSF into treatment of these patients?
What are indications to order gene mutation studies (e.g. ELANE) and how would it help the patient?
What is your preferred agent (DOAC, warfarin, enoxaparin), and is periprocedural bridging necessary?
What would you recommend within the first year after ATG and thereafter if still maintained on cyclosporine?
What VAF burden would be considered significant prognostically or for treatment decisions?
Would the checkpoint inhibitor still work if blocking only that portion of the inflammatory cascade as opposed to more global blockade with steroids?
What is the risk of pregnancy loss in absence of anticoagulation? What would you suggest if the patient had anticoagulation in prior pregnancies and r...
If not, how do you choose GVHD prophylaxis regimen? Is there a preference?
Are there agents (eg. bendamustine) or modalities to avoid?
Does washout times prior to collection vary between modalities?
Please specify your approach in elective and emergency surgical situations
E.g. would you dose-reduce or continue at same dose?
Baseline ANC was in the normal range
How do you sequence systemic treatment options for in patients with Child's Pugh B (or greater) in context of IMbrave150 and HIMALAYA?
When do you in...
E.g. a patient with monoclonal protein with mild light chain ratio elevation. Do we need to get a BM biopsy in all such patients?
i.e. similar to CKD anemia?
Will you be using the IPSS-M in place of the IPSS-R? How will you be using IPSS-M in practice?
Does your answer change based on clinical or molecular risk factors, and if so how?
Does your answer change if MRD status after induction is unknown?
Infection is not part of the criteria for starting treatment both in UpToDate and in NCCN guidelines.
How do you determine whether to add intrathecal chemotherapy in patients with +CSF? Would your approach change for primary vs secondary CNS lymphoma?
iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.
How do you assess if a patient may be a candidate for CAR-T cell therapy?
Does this differ for a patient who had a longer remission before relapse?
When is this discussed? What are the common/less common toxicities you advise patients on? Are there best practices for coordination with referring on...
Given the results of ZUMA-7, TRANSFORM, and BELINDA - how does this inform your current practice? What are the currently approved indications for CAR-...
ALC<200
- Dialysis catheter used for hemodialysis- RIJ thrombus in dialysis catheter was incidentally found- Patient asymptomatic with no prior history of VTE...
The CALGB regimen is quite complicated.
Does the safety profile impact your choice significantly?
Does your first choice vary by disease histology?
Given the rarity of this diagnosis (5-7% of all AL amyloidosis cases), and the prognostic and clinical differences when compared to non IgM-AL am...
Secondary MF such as post-PV, for example.
Do you apply the same prognostic scoring systems?
My experience has been that patients can be neurologically devastated years out from WBRT. In Medical Oncology practice at my institution, we do not r...
We know the longer we expose patients to lenalidomide, the harder collection will be. Would you collect now or switch to an alternative regimen to ach...
No evidence of palpable splenomegaly, normal hematocrit and platelet count
If so, what would you consider ordering?
The said patient has been on Imatinib for 2.5 years and is In MMR. Last rt-PCR was 0.04.
How does graft function play into your decision making? How do you utilize post allogeneic transplant chimerism in clinical practice? Do you obta...
Is there role for IVIG? Would you alter the dose or time course of steroid therapy?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
Presuming strong indication for ASA - eg history of NSTEMI
In the setting of no personal or family history and no other risk factors for thrombosis, is systemic anticoagulation warranted if local treatments (e...
eg. eGFR < 30 ml
If not, what instructions do you give to patients regarding checking temperature at home/return precautions?
If so, what regimen do you utilize?
Does measuring serum free-light chains make a 24-hour UPEP unnecessary?
What agents would have sufficient efficacy overlap to treat both?
ET is JAK2+
How are your teams effectively evaluating and counseling patients to ensure they are prepared for potential extended adjuvant treatment approaches? Is...
Do you have a preferred sequence of therapies for diffuse skin limited MF?
What would you consider as contra-indications to Cladribine?
What is the impact among patients and providers?
Has your documentation been adjusted now that patients can readily review?
Peripheral blood flow shows prominent NK cell population but marrow aspiration/bx shows normocellular marrow with trilineage hematopoiesis.
Would you avoid imid's given reported association with transplant rejection?
For pts w/ eGFR between 30-60
In the absence of a VTE would you consider prophylaxis after a surgical procedure? Often non-hematologists order this testing but we are consulted for...
Would pegylated interferon be preferred?
Does treatment with B-cell depletion and/or negative anti-spike antibody status despite COVID mRNA vaccination influence your decision?
i.e. treatment-refractory PV, prior to progression to PMF or AML
Are the early results of CASSIOPEIA (Abst 8003) from ASCO 2019 practice changing? What about the GRIFFIN results in 2020?
e.g. DITP from eptifibatide after a cardiac intervention
Do you modify the aspirin dose based off the lenalidomide dose? Do you ever use higher dose aspirin in lieu of an anticoagulant? The NCCN guidelines s...
How does cirrhosis and/or underlying thrombophilia affect your decision?
IVIG, TPO, or other agents?
Would you consider the immune suppressed status of the patient as a high risk factor to offer adjuvant therapy?
Conversion tables suggest starting the new drug with the next dose but do not seem to answer this question (i.e. if switching from rivaroxaban 20 mg d...
What about changing standard regimens for TCL with HLH?
e.g. IS < 0.002% by qPCR
CAR-T (any specific preference of product?) vs bispecific antibodies vs any other specific agents not previously utilized?
Given the POLARIX study data presented at ASH 2021, will this replace R-CHOP as the standard of care therapy in your practice? If not, how will y...
Is a repeatedly abnormal serum immunofixation all it takes for MGUS?
Does VAF <1% make you want to do a BM biopsy for confirmation?
This is in the setting of a patient who is now on ruxolitinib with rising leukocytosis and thrombocytosis, but cannot be on aspirin due to recent blee...
Is there any role for radiation therapy alone?
If the patient cannot tolerate methotrexate or further chemotherapy, how effective is radiation therapy (e.g. WBRT) in rendering the patient disease-f...
Would you continue with daratumumab maintenance per ANDROMEDA or switch regimen?
After 3-4 cycles of RVD, would you automatically take the patient to transplant if he has achieved at least a partial response, or is there any benefi...
For example, for outpatients or resource-limited settings with a moderate probability 4-T score (but low clinical suspicion), would you ever consider ...
Ki67 = 90% with multiple small nodes on PET scan and normal CBC
Would you offer indefinite anticoagulation if the event is unprovoked and the patient has low bleeding risk?
Please also discuss the type and duration of anticoagulation.
Can patients be re-challenged after developing ILD? Is the toxicity seen with T-Dxd a potential barrier to use?
Do you feel the dosing used in...
Also is there value in using voxelotor for the purpose of reducing hemolysis, and if so what parameters do you use to determine when to initiate voxel...
If you do recommend resuming carfilzomib, what dose and frequency would you use?
Patient in mid-30s with no major medical history presented with isolated left neck swelling. Incisional biopsy w/ HTLV1/2 associated ATLL, Ki67 of >...
Is there a particular sequence you would adjust contributing antirejection or antimicrobial medications? Is the use of G-CSF appropriate and at what c...
Can you expand on this by sharing exactly what this routine workup should include? What additional tests outside of evaluating for POEMS and amyloidos...
Hydroxyurea is demonstrated to reduce complications and improve long-term outcomes in severe genotypes HbSS and sickle beta0 thalassemia. What clinica...
Are there other supportive care interventions that would otherwise be covered by hospice?
Provoked or unprovoked VTE: Do you use D-Dimer (or even repeat imaging to reassess residual clot) in any capacity to guide anticoagulation duration? E...
Have you used anticoagulants other than coumadin? Or is that the only appropriate agent given monitoring is based on PT/INR?
Insurance won't pay for harvesting if the transplant is not done within a year.
Does this data change your preferred first line treatment regimens when considering other options such as mAb combos, cytotoxic chemotherapy?
Is the non-inferiority margin of 1.429 sufficient, how was this selected?
Is the open label (rather than blinded) study design of any concern?
Is th...
Can experts comment on fungal pneumonia risk with individual BTK inhibitors as seen in ELEVATE-RR and whether this impacts their management decisions?
Do you feel comfortable with BTK inhibitors in these patients?
In ELEVATE-RR patients on a/c were excluded, and rate of atrial fibrillation in the ac...
Such as patients with specific underlying cardiovascular risk factors or other medical comorbidities?
Is leukocytosis and thrombocytosis alone an indication for treatment?
Do you ever recheck JAK2/CALR/MPL/BCR-ABL? Would you recommend a bone marrow biopsy? Is cytoreductive therapy indicated?
Is there a role for aspirin or hydroxyurea? Do you perform phlebotomy, and if so, what goals?
In the case of subtle single lineage dysplasia with normal cytogenetics, do you routinely perform NGS testing for CHIP-type clonal mutations?
Do you ...
Recommendations in guidelines are discordant (ASCO vs NCCN vs UptoDate).
What if the patient is no longer responding to steroids?
Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...
Is there data that it actually helps?
Especially with the current drug shortage of nelarabine.
While building a trusting patient-physician relationship, what therapies could be discussed that may be aligned with naturopathic medicine? (i.e. L-gl...
Is it safe to challenge with other CD20 monoclonal antibodies such as obinutuzumab?
Would you get bone marrow biopsy periodically? Would your approach change based off specific age or platelet count?
Would appreciate expert opinion on when to reimage and when to restart anticoagulation depending on findings.
If yes would you delay initiation of antineoplastic therapy to allow time for the vaccine to start acting?
Is this a reason to start hydrea? Would you give oral iron after adequate control on hydrea?
How would you approach a patient who is intolerant of AI and develops thrombosis while on SERM?
While there are many factors involving:- type (DVT vs PE, unprovoked vs provoked) and severity of venous thromboembolism (VTE) size- duration of antic...
If all work-up including peripheral flow, bone marrow biopsy, PET-CT returns negative, what additional management (if any) would be recommended?
When do you start treatment in this case?
Does manipulation of blood products (leukoreduction, irradiated) affect your approach? There is growing evidence that routine premedication (at least ...
While this is a known risk factor for venous [Meijers et al NEJM 2000] and potentially arterial [Yang et al, Am J Clin Pathol 2006] thrombosis, it is ...
Would this change with someone who has a history of thrombosis (e.g. DVT/PE, MI, CVA)?
Would this change with someone who is more fit vs more frail?
Such as patients who are frail, elderly, renally impaired?
Would you consider sirolimus over cyclosporine or tacrolimus for safer nephrotoxicity prof...
How often do you monitor ADAMTS-13 levels off therapy?
For example, do we prefer one regimen over the other in patients with a bleeding history or who have relapsed after a lengthy remission?
How is this impacted by patient features, cytogenetics/disease biology, depth of response, or other factors? What would compel you to continue 3 drugs...
How do you factor in patient age, frailty, patients with underlying organ dysfunction, or other clinical features?
Do you still consider CyBorD or R...
e.g. a genetic mutation picked up through a family member
In your experience, do certain regimens have more cumulative toxicity, financial impact, or patient convenience factors?
Do you recommend therapeutic phlebotomy to a certain Hct goal? Any strong evidence for thromboembolic risk related to erythrocytosis or if this is mit...
In follow up to @Jacqueline Casillas presentation at ASCO 2021 regarding models of survivorship care delivery for AYA patients.
If given both options, which donor would one prefer: haploidentical related donor or 7/8 mismatched unrelated donor using post transplant cyclophospha...
Are there scenarios where you would use a higher dose of lenalidomide in a novel doublet or triplet (eg. relapse on lenalidomide maintenance)?
Given recent data in Blood (Moik et al, 2021), and the potentially overlapping risks with other clinical factors associated with NSCLC.
Will you alte...
Is there any difference between anticoagulants in this clinical context (e.g. anti-Xa inhibitors vs warfarin vs LMWH)?
Is there a role for empiric antibiotics if there is history of opportunistic infection?
Does the rate of progression of IgM influence your decision?
Does having a concurrent consumptive process e.g. DIC change your management?
Do you follow the 2019 EULAR Guidelines that SLE patients with asymptomatic, positive aPL should be on low-dose ASA?
Are there any subsets of patients that you're more inclined to offer maintenance?
Are there other regimens you employ for patients unsuitable for standard chemotherapy?
Do you always treat with the full 21-day treatment course, or can defibrotide be stopped if certain criteria are met sooner?
Assuming the patient is a candidate for all anticoagulation options (no mechanical valve, antiphospholipid syndrome, patient-specific contraindication...
Is Ommaya placement with CNS-directed therapy preferred to intrathecal or cranial irradiation? How do you interweave this therapy with systemic therap...
Excluding clinical trials
Do you prefer a cHL chemotherapy backbone or PMBL chemotherapy backbone?
While thrombophilia testing is not routinely recommended prior to starting OCPs, how about after the development of a VTE?
Would you use R-CHOP or a more intensive chemotherapy regimen? Would you consolidate with radiation therapy after 3 cycles or use systemic thera...
While the CKD population is at high thrombotic and bleeding risk, would you consider anticoagulating a patient prophylactically if they had a history ...
Would you consider high-dose dexamethasone (deliberating adverse effects of antenatal steroids) or move to next-line therapies?
Ref: EINSTEIN-CHOICE and AMPLIFY-EXT
Would you approach this differently in patients with inherited thrombophilias?
Would you try atezolizumab/bevacizumab or switch to a TKI?
Does your recommendation differ between autologous and allogeneic transplants?
Does your recommendation differ in allogeneic transplant recipients wh...
For example, in cold agglutinin disease or AIHA, antibodies can be detected via DAT, but are often not observed on assays for monoclonal gammopathies.
Would you offer refractory doses (40-50 Gy) to the RPnodes and send for splenectomy? Or would you offer refractory doses to both RP nodes and spleen?&...
During the Stimate recall, how are we performing DDAVP challenges for newly diagnosed hemophilia A or von Willebrand disease?
In low-risk patients (age < 40) or patients with very obvious causes of blood loss or iron deficiency (menorrhagia, pregnancy), do you routinely pe...
Are there effective therapy options that do not include steroids?
When do you consider splenectomy? Is there a role for splenic radiation in non-surgical candidates?
Specifically, are there strategies you use to 1) empower patients to participate in decision-making and 2) reassure patients who may be skeptical?
Are there particular mutations (eg SF3B1) or syndromes (eg MDS/MPN overlaps such as MDS/MPN-RS-T) where you are more apt to using lenalidomide?
Presented at ASH: FLIGHT trial
An otherwise healthy patient with spleen only diffuse large B cell lymphoma with mild spleenomegaly, Spleenectomy plus Rchop or Rchop plus RT?
For example, a patient on cytoreductive therapy and aspirin BID, but suffers an arterial event, or a patient who is already on therapeutic anticoagula...
For example in a patient with a history of PE?
In a patient with a medical or personal indication to induce oligomenorrhea/amenorrhea, how would you manage OCP therapy if a patient develops a VTE d...
What is the lowest level you have seen with uncomplicated or complicated crises?
Can results from emerging AML data be extrapolated to high risk MDS populations?
Is there data to guide the choice of continuing the HMA in combinati...
i.e. EGD surveillance for varices?
Relapsed disease occurred 3.5 years after initial treatment
For T2bN0 or T3N0 disease, you consider radiation alone, sequential radiation followed by chemotherapy, or concurrent chemoradiation?
Do you go straight to TMPRSS2 genetic testing or what other lab testing (e.g. hepcidin) could be helpful?
ex. VEGFR2 expression, inflammatory signature, PDL1, etc.
Do you continue atezolizumab alone? Would you avoid anticoagulation?
After initiation of anti-TB treatment and 3 negative AFB smears, would you initiate concurrent chemoRT? Would you give sequential RT then chemo to giv...
In light of the SIRveNIB trial results and now IMbrave150, what is the role of intra-arterial therapy now?
If there are a low-risk patients who can be monitored, how would you do so?
If unprovoked, would you consider stopping anticoagulation?
Do you screen even asymptomatic patients?
Is there a preferred strategy of transfusional support versus reduced-dose anticoagulation during the duration of thrombocytopenia?
Is there any data justifying the use of systemic therapy over localized therapy (e.g. radiation or surgery) in this situation prior to a progression e...
Rituximab has entered the treatment algorithm in the first-line setting for the initial treatment of TTP. However, in remission, the role of adjuvant ...
What if this was "triple-negative" antiphospholipid syndrome?
Do you only give intrathecal chemotherapy or systemic therapy?
What are the scenarios in which a rebiopsy is warranted for follicular lymphoma?
Does the absence of an OS benefit in the AG221-AML-005 presented at ASCO 2020 deter you from this strategy?
CT scans show omental and pelvic disease.
In patients who are intolerant to hydroxyurea, anagrelide and interferon
Would you consider “bridging” therapy with something like an HMA?
Would it make a difference if the VTE diagnosis occurs during bevacizumab therapy or whether it preceded the cancer diagnosis?
Is it at neutrophil recovery, at documentation of CR on bone marrow biopsy, or is there a different point in time?
Does acute leukemia sub-type affect your decision?
Do you offer adjuvant chemoimmunotherapy after IFRT for Stage I to II low grade follicular lymphoma?
TROG 99.03 showed nearly 20% improved PFS at 10 years with chemoimmunotherapy despite 31/75 patients assigned R-CVP vs 44/75 assigned CVP without ritu...
For example, for joing replacement surgery? Do you hold the revlimid for certain about of time before and after?
Is there a preference for obinutuzumab over rituximab in early relapsed DLBCL, or in primary refractory disease?
Would your approach change based on the type of reaction (eg. Stevens-Johnson syndrome vs DRESS)?
How would you address maintenance (if any) post-tra...
For instance, would you discontinue when there is resolution of adenopathy and normalization of counts? If so, do you overlap ibrutinib with other the...
The NCCN recommends both regimens.
At what age would you treat an early stage hodgkins lymphoma patient with ABVD + RT (adult treatment) vs OEPA x 2 or AV-PC x 3 (pediatric paradigm)?&n...
How do you decide between WBRT, maintenance chemotherapy, or stem cell transplantation?
Risk of CNS relapse in a reported series is less than 5%.
Given the rarity of DLBCL with MYC/BCL2/BCL6 rearrangements, do you approach this disease differently than DLBCL with MYC/BCL2 or BCL6 rearrangement, ...
Should staging and treatment decisions be made based on imaging alone?
Or do you consider addition of this agent in the re-induction setting for refractory disease?
Would you treat with chemotherapy (carboplatin/etoposide) vs anti-pd-1 monotherapy vs combination chemoimmunotherapy vs supportive care?
To me, the recent NEJM study is flawed in that the control arm did not have maintenance treatment while the experimental arm used maintenance Dar...
Would you proceed to autologous transplant, or switch to an alternate regimen (eg. daratumumab-based) first?
Would the type or degree of organ involv...
Does the degree of PD-L1 expression weigh into your decision?
If so, what is your approach to laboratory and clinical testing?
If so, for what platelet count threshold and do you have a preference as to which agent?
Once a tissue biopsy has confirmed light chain amyloid, what additional tests do you perform as part of a standard workup?
In whom should treatment b...
Do these events mandate discontinuation of lenalidomide therapy or switching to a different agent? Can appropriate therapy for these skin cancers be r...
(ie Deuvelle criteria 1-3) Is it appropriate to discontinue brentuximab like you would with bleomycin?
Specifically, do you consider repeating maintenance therapy after second line therapy if a patient had already received 2 years of maintenance rituxim...
Would you still proceed to high-dose therapy and autologous SCT?
Would you incorporate radiation pre- or post- transplant? Or offer additional salvag...
If the patient has not experienced significant infectious complications? If so, what agent?
Specifically, do you utilize 3 cycles of chemo with ISRT or 6 cycles? Do you use R-EPOCH or R-CHOP in these cases?
For instance, do you ever start with dasatinib 50 mg daily? Are there any titration schedules that you follow?
Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...
Given the PFS benefit seen in the most recent ECOG-ACRIN, and the prior study of Rd showing an OS benefit, is your practice to put any high-risk SMM p...
e.g. mixed indolent/aggressive NHL, mixed NHL/HL? Is there a definitive way to discern composite from transformation? NCCN does not list recommendatio...
if so, are there specific cytogenetic, molecular, clinical, or hematologic factors that you take into consideration?
Have you changed your practice based off the FLYER trial presented at ASH 2018?
How would you handle high risk features (eg double hit) with the limitations of dialysis?
Although not approved, for example, are you every using AVD-nivolumab?
Would you give 3 cycles of RCHOP followed by consolidative IFRT or 6 cycles of R-mini CHOP? Is there a role for 3 cycles of R-mini CHOP followed by IF...
Assuming the patient has an indication for treatment.
Thrombosis was ruled out and no etiology was found. Would you start ponatinib back at a lower dose, transition to omacetaxine or begin transplan...
Do you recommend or make any modifications in the PACIFIC regimen for patients > 75 years of age?
Assuming there are no other indications at the moment.
Some specific questions:
Would you recommend repeat biopsy to confirm residual disease?
How would your recommendations vary if the patient had pre...
Would this affect your decision regardless of the stage and symptoms?
Do you await molecular and cytogenetic results prior to initiating therapy, or does age and function status primarily drive your choice?
NCCN does not list any preferences for the TKIs in their guidelines.
I.e., Can day 2 Rituximab (RCHOP) or day 6 Rituximab (DA-EPOCH, Hyper CVAD) be given? Or should only Day 1 Rituximab be used with chemoimmunotherapy i...
Since some prior studies (eg. Eskelund et al. Blood 2017 130:1903-10.) have shown intensive chemoimmunotherapy does not overcome the ad...
Is IO related pneumonitis in the radiation field or more diffuse?
For example - Would you offer tandem transplantation in a young, fit patient in a CR after first transplant, but with MRD detectable?
Pathology is clear this is not a concurrent DLBCL and is indeed transformed CLL
FDA package insert lists posaconazole as strong cyp3A4 inhibitor and states to consider other therapies.
Can it be added after 2 or 3 cycles of HMA?
Does presenting total white blood cell count affect your decision? Does myeloid subtype affect your decision?
How might your decision change if the patient had a suitable 10/10 donor? How about if the patient had a targetable molecular mutation such as IDH2?
Although the MMR vaccine is contraindicated in immunosuppressed patients on anticancer treatment according to CDC/ACIP and IDSA guidelines, data on sa...
Arterial events have clear instructions to permanently discontinue on the FDA label. Especially in HCC without many other treatment options, giv...
I have received inquiry from a patient's gastroenterologist regarding use of Entyvio or Stelara in such a situation.
Given the recent results presented from the Griffin trial, would you choose a daratumumab-based regimen (eg. D-VRd) over other salvage options (V...
Would the site of disease relapse play a role in your decision (i.e. isolated lymph node recurrence versus failure at primary site of disease)?
Has the recent data presented at ASH affected your choice of regimen?
Would your choice differ between transplant-eligible and transplant-ineligible ...
Shanafelt et al. recently presented results from the phase III E1912 study at ASH 2018. Will you still utilize FCR as first-line or now use Ritux...
Would MRD assessments affect your clinical decision making for MM patients outside of a clinical trial?
Do you use etoposide-based regimens such as R-CEPP? How about substitution with liposomal doxorubicin?
Specifically, what regimen would you choose in a patient with new renal failure but not requiring dialysis?
What factors influence your decision (patient/disease characteristics, additional agents added to induction chemotherapy, CR1 or later, etc)?
If a patient obtains a PR or less to front line cladribine, what factors help you chose between a second course of cladribine, an alternative pur...
How about if disease is found in the CSF?
When is it warranted to utilize targeted therapies for known mutations (eg. midostaurin or an alternative TKI for FLT3 mutations, ivosidenib for ...
Does the choice of initial induction regimen affect your decision for when to employ lenalidomide maintenance?
Are there situations where you would c...
Are you routinely using letermovir as CMV prophylaxis in high-risk patients?
Any special considerations with its use versus other antiviral agents?
...
Would you consider switching regimens?
Would you treat differently for de novo disease vs disease arising from large cell transformation of an indolent NHL?
Given the rarity of this in MF, is it still predictive of response to lenalidomide therapy?
Does their candidacy for autologous HSCT affect your decision to use maintenance lenalidomide?
Would you change to an alternative triplet therapy, or switch to maintenance therapy?
Are there variations in depth of response short of CR that woul...
Does the more recent data regarding the continued utility of brentuximab vedotin and the utility of PD-1 inhibitors factor in to your reasoning at all...
Do you have experience administering these agents in the outpatient setting?
Could one make a case for addition of Rituxinab frontline to increase the chances of a complete remission and even maybe achieve MRD-negative status ?
Does it differ from the treatment of other relapsed peripheral T-cell lymphomas?
Are there any clinical trials or case series focused on SPTCL?
Is t...
Do we continue the hypomethylating agent indefinitely?
Technically, you can have up to 55% of larger cells circulating and still be called CLL.
Would you observe until progression or would you place the patient on maintenance?
Once you decide to begin treatment, any special precautions you would use for protein levels starting that high.
Assuming that the involved area is too widespread for RT. Would you try single agent rituximab first? Or obinutuzumab? What if rituximab alone gave on...
The recent NEJM phase II trial http://www.nejm.org/doi/full/10.1056/NEJMoa1715519?query=featured_home looked at a small cohort of 24 patients and show...
How do you choose between 3 and 4?
the MZL was untreated in the past prior to transformation.
Do these patients have a higher risk of recurrence post CR as opposed to patients with de ...
Do you follow treatment guidelines for indolent lymphoma or CLL? How do you get 17p testing on someone with only lymphadenopathy?
Specifically, in patients that had progression or developed toxicity on ibrutinib? Idelalisib is very toxic and venetoclax a labor-intensive drug to g...
Even though Venetoclax is not FDA-approved yet, assuming you can get it off label?
1. Gemtuzumab: What dose/schedule and which HMA?
2. Venetoclax: W...
Would you consider resection? Or maybe anti-CD20 monoclonal antibody?
My practice had always been to transfuse for plts < 10, but the recent ASCO guideline change suggests that in the post-autoSCT setting it is ...
In the absence of any other classic CLL indications for treatment.
If filgrastim, how many days would you give? Pegfilgrastim is often not covered by payers if given less than 14 days before chemotherapy.
Would you ever considering re-starting immunotherapy before completing the taper?
According to the new guildelines on managing immunotherapy related ...
The patient has no medical problems and no history of leukemia/MDS. Biopsy of the filum terminale and arachnoid confirmed a myeloid sarcoma and MRI sh...
Subq has been shown to have lower risk of neuropathy. Is there any reason to use weekly IV still?
Would it change your management if patient if IgVH mutated?
In a patient with multiple poor risk features including TP53 mutation, 1q amplification, stage III, and circulating plasma cells, would you consider a...
For example, how significant does the M protein have to increase for you to begin a conversation about new therapy?
Are you using ctDNA blood tests for targetable mutations at the time of diagnosis, at the time of disease progression, or not at all?
Specifically, to you lean towards elotuzumab or a daratumumab-based regimen?
If a patient will receive a total of 4 cycles ABVD and has a CR by PET/CT after cycle 2, can RT be omitted to non-bulky sites to avoid toxicity?
When there is biopsy proven mediastinal disease, do you offer definitive chemoradiation and monitor, or do you try to prove the presence/absence ...
Specifically I am thinking if a PET scan shows complete response, would it be reasonable to stop bleomycin and continue AVD?
What dose and volumes would you use?
Drug information indicates a patient may need 3-4 months off TKI. This seems like a long time off drug. Would a MMR of a certain duration make it less...
Would you ever give another IMiD?
Specifically when given as a single agent. Any role for G-CSF?
PET/CT/bone marrow biopsy negative for evidence of distant disease. Following 4 cycles of combination chemotherapy with no evidence of progressive dis...
With the advent of many new agents, any thought to initial therapy different from CHOP or CHOEP?
Do you incoprate Ki67% or mitotic rate into your treatment decision, and is there any use for somatostatin based imaging such as octreoscan or gallium...
At what point is the neuropathy a contraindication to further bortezomib therapy?
Although bendamustine + rituximab is a standard option for advanced follicular lymphoma when treatment is required, does the regimen rituximab + lenal...
Specifically, can you rechallenge after the effusion has resolved (e.g. therapeutic thoracentesis)? If so, how long do you wait to rechallenge (especi...
Imatinib, or a second-generation TKI? Are there specific factors that make you choose one over the other?
If so, do you use antivirals and/or antibiotics? Does it matter if the patient has mantle cell lymphoma, CLL, or Waldenstrom's macroglobulinemia?
Specifically, do you just wait for count recovery? Do you check for morphologic or molecular remission at all during this time?
Specifically, is there still a role for dd RCHOP followed by ICE, or do you recommend DA-R-EPOCH for all patients?
What about patients who are still on steroids for radiation pneumonitis?
NCCN guidelines suggest XRT as standard of care for this stage of disease. However, occasionally patients have their tumors completely excised when un...
What re-induction regimen without cytarabine or an anthracycline is likely to be most effective?
What is the utility of repeating FISH studies to evaluate for clonal evolution if FISH studies were done at diagnosis?
What dose do you recommend?
If a patient with stage I, low grade follicular lymphoma achieves a complete response after rituxan and treanda is there any role for consolidative ra...
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