Hematology
Questions discussed in this category
Is there a role for increasing the dose if not yet maximum? (Hb ~8)
Can you explain when would you consider light chain amyloidosis work up with fat pad biopsy?
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.
Family history is notable for CVA and early onset MI in nonsmokers, but no personal or family history of VTE. APLS testing is negative. Previously fou...
Can you elaborate on reasons for a non-quantifiable SPEP and how does one follow the paraprotein?
How would you approach anticoagulation in this situation? Does the presence of thrombocytopenia or hemorrhagic splenic infarcts change your manag...
For what duration and is there a preferred anticoagulation agent?
How would you sequence these therapies given approval for both?
The patient takes frequent flights, with no prior history of VTE, and has already been taking measures for prevention including frequent ambulation, h...
There seems to be a wide variety of palliative doses used in clinical practice (8 Gy x1, 2 Gy x2, and 20 Gy in 10 fx). Do you have a preferred dose? D...
Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...
What about if the patient has mediastinal disease and ISRT is not an option?
Per the NCCN guideline for HR HD, if treated per OEPA-COPDAC, you can omit ISRT. This patient received treatment per AHOD1331, which recommends ISRT f...
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...
I am not sure there is much efficacy for a regimen that does not include asparaginase. The patient received 2 cycles of P-GemOx, then was admitted for...
Do next generation sequencing results influence diagnostic and therapeutic decisions for patients with MDS?
Would you anticoagulate for a fixed or indefinite duration? Would you recommend changing her contraception method?
What would be your RT volumes and dose?
Would you label this as intermediate or high risk and treat with prophylactic or full dose AC? What duration would you treat for?
Assume the patient has infrequent bleeding events every few years, with use of FIX replacement for acute bleeds only.
Presuming good medication adherence.
Do you generally recommend anti-diarrheals, dietary modifications, or consider this an unacceptable side effect and move to other therapies?
No prior hx of DVT/SVT. Negative LE doppler. Would you consider anticoagulating and at what dose, or favor close observation?
Do you consider starting Ursodiol? Do you perform routine abdominal ultrasound to monitor for cholelithiasis?
UpToDate recommends Hydroxychloroquine for all SLE patients, but neutropenia is sometimes ascribed to HCQ rather than the underlying disease. What lev...
Is there a role for nelarabine and venetoclax in this setting?
Is parasitemia >10% and severe hemolysis with Hb less than 7 enough to initiate this?
After what time period would you consider adding a second iron chelator?
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?
Caplacizumab is not FDA approved in pregnant patients, but has been used safely in isolated case reports.
What do you think about the long term risk of AML with romiplostim with longer follow up studies? What about using other TPO agonists like eltrombopag...
When would you consider pomalidomide over bevacizumab?
Is there a role for non-myeloablative regimens?
Are there characteristics which could help identify whether a follicular lymphoma might behave more indolently vs aggressively and inform treatment se...
Thrombophilia testing, including JAK2 is negative. When would you stop anticoagulation?
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...
Would you consider testosterone therapy if he is otherwise asymptomatic?
Do the presence of gastric varices and use of anticoagulation change the way you think about using these agents?
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...
If not, has your practice changed to use vWF replacement therapy more routinely for perioperative or acute bleeding management? Do you still perform D...
The patient has a history of a lymphoplasmacytic lymphoma with a CR after chemotherapy but presented with a large frontal lobe mass that was biopsied ...
BMI>40
When do you stop luspatercept? How do you approach iron chelation therapy if the patient is currently on therapy?
Would you consider chronic RBC exchange versus HU?
Do the recently published IMROZ and BENEFIT trials inform maintenance treatment in transplant-in-eligible patients with NDMM?
E.g., a patient with newly diagnosed CIDP who is wheelchair-bound.
Are there specific guidelines for managing this patient population?
Assume patient requires anticoagulation in the setting of acute thrombosis, with no need for IVC filter, but is approaching the end of her third trime...
When do you determine SSRI therapy is unsafe to pursue in such situations?
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?
rWGS did not demonstrate any HLH definable or associated mutations.
qPCR for BCR/ABL was negative. FISH remained positive.
If a patient is unable to tolerate peginterferon, is there any reason to think they may do better with ropeginterferon?
Is APLS a contraindication to using interferon?
What is your preferred anticoagulation in patients with BMI >50?
Should some patients get 325 mg instead of 81mg at least for a certain amount of time, such as patients in the acute phase of ischemic stroke or patie...
For B12 levels >2000-4000.
Hb at goal of 9-10
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...
Are the INRs reliable? In what scenarios would you not recommend POC INR use for warfarin monitoring?
Are these typically covered by insurance? Are t...
E.g. frequency of Bortezomib, dosing of Bortezomib, length of cycles.
Considering the short half-life, at what point would it be deemed too late to administer any reversal agent, and to consider withholding it?
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...
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...
Is there a factor XI goal that you target? Would you consider FVIIa products instead?
For example, would you offer 4 Gy x 5 fx (vs 24 Gy/12 fx) in a patient with isolated recurrent follicular lymphoma of the breast after RCHOP and maint...
In light of ANNEXA-I RCT results: Connolly et al., PMID 38749032.
Additional risk factors could be family history of VTE or thrombophilia, such as antithrombin deficiency.
WBC and Hb values are normal, and normal JAK2, CALR, BCR-ABL.
Are there specific mass features that would influence your treatment decision?
Are there other mutations/biomarkers in CLL which may specifically predict for response or resistance to pirtobrutinib?
How often would you check labs during pregnancy or postpartum to monitor for worsening hemolysis?
Do you consider "bridging" therapy prior to transplant, and if so, what are your thoughts on the intensity of the chemotherapy?
Would you offer palliative (4 Gy) radiation therapy to the stomach mass vs. definitive doses (24 - 30 Gy) encompassing all of the disease?
Should adult hemoglobin targets be different than pediatrics?
In which situations or patient populations do you find this useful? How is it sterilized?
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...
Does this hold true when the patient has significant inflammation?
When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?
HFE gene mutations in C282Y and H63D are negative.
Despite distinguishing between the three MPNs, results may not change management. There is controversy over whether to follow WHO criteria for d...
Ropeginterferon is now a preferred therapy for Polycythemia Vera (PV) as per a recent update to the NCCN guidelines.
Is there utility when classic inflammatory markers (ESR,CRP) or disease specific markers (C3, C4, dsDNA) do not correlate with patients disease activi...
How would you consider anticoagulation vs antiplatelet therapy, or the addition of antiplatelet therapy for these patients?
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?
Thrombocytopenia is moderate (80-100,000 microL). No concomitant cytopenias present.
When would you consider using anticoagulation and for how long?
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...
Is there any evidence supporting the use of heparin boluses?
Is a BM biopsy a must when there is skin involvement?
If tryptase level is mildly elevated but less than 20 would you recommend a BM biopsy?
The ASH 2020 guidelines have "recommended that adults with HbSS or HbSβ0 thalassemia be screened at least once for silent cerebral infarcts even ...
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...
For example, if patients are unable to receive continuous infusion from home health agencies, or if prolonged hospitalization is cost-prohibitive.&nbs...
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...
In the setting of requiring anticoagulation for atrial fibrillation and bioprosthetic valve, but also having severe vitamin K deficiency, would you st...
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 consider observation following surgical resection with negative margins? Would you recommend WBRT and/or ISRT? What would be your preferred ...
Would you continue R-CHOP or would you switch therapy?
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...
Would you consider this de novo DLBCL (unable to assess for clonality)? How would you handle prior anthracycline exposure?
How does graft source, conditioning regimen, and indication for transplant affect your decision regarding G-CSF?
Complete response was achieved after cycle 3. What extent of bone would you include?
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...
Is it different than early mobility that we always encourage?
NGS results are pending
Would you still plan for lifelong anticoagulation in this scenario?
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...
Antifibrinolytic therapy alone +/- DDAVP?
E.g. young male, morbid obesity, with BMI >50
Ferritin >2200, TSAT >80%
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...
How would you counsel the patient if he/she wants to continue on steroids?
Common thought is that FVIII may be used for differentiating coagulopathy in liver disease (normal to increased, from reduced clearance of VWF/FVIII) ...
In what situations would you feel comfortable omitting RT to bulky disease in stage III/IV Hodgkin's lymphoma?
Initial tumor size:18 cm. Partial response was achieved after cycle 2 and cycle 6 of chemotherapy. Complete response (Deauville 2, size: 6 cm) was ach...
E.g., for a patient with myeloma, s/p induction therapy, and high-dose chemotherapy, followed by autologous rescue with inappropriate antibody respons...
I.e. platelet count <30. Would your management change if HIT were only suspected rather than confirmed?
Practice is variable in the community, with some hematologists frequently prescribing ESAs for severe anemia that is mostly inflammatory. Do the risks...
Anemia is secondary to menorrhagia. No gynecologic interventions were possible.
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?
In FRAIL-AF, switching VKA therapy to a NOAC was associated with higher risk of bleeding in elderly, frail patients.
Level >60%. No family or surgical h/o of bleeding but heavy postpartum bleeding.
Hb <11, low iron saturation (<10%), high ferritin (>900), and low reticulocyte hemoglobin equivalent.
Work-up was performed for isolated anemia which resolved to >11 g/dl after the reversible cause was treated.
Would your management be different in node + vs. node - patients? What would be your radiation volume and dose?
Are you concerned about cases where radiation has to be started urgently before leukapheresis?
Is it only done when heparin is used in an emergency?
No transfusion dependence but has hemoglobin in the 8-9 g/dl range.
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.
What is the best treatment management of low grade early stage follicular lymphoma of the mesentery?
If the mesentery is widely involved with small lesions would this change your management? What if the patient was symptomatic?
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?
In FRAIL-AF, participants were switched from VKA to dabigatran, rivaroxaban, apixaban, and edoxaban.
Per the new data from the COMMANDS trial, Platzbecker et al., PMID 37311468
Would you offer WBRT + boost vs WBRT vs focal treatment/SRS.
If so, would you start immediately or wait for the second set of labs to confirm before initiating blood thinners?
If so, for how long?
Is there an optimal bridging radiation dose for aggressive B-cell NHL undergoing CAR T-cell therapy?
What influences your decision to proceed with palliative vs. definitive, and standard vs. hypofractionation dosing regimens?
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.
E.g. Normal F8, VWF activity ~50%, VWF antigen ~100%, ratio 0.5 sent in a patient with positive bleeding history
Is there any clinical significance t...
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.
Do you give RT before or after systemic therapy?
Significant history of autoimmune diseases and DVT in family, recent PE/DVT for a month
Does the fact that the patient is on methotrexate alter your choice?
How many cycles of systemic therapy is recommended? is XRT needed and what XRT dose is recommended?
Provided that the platelet count is normal, do you usually consider this to be a potential erroneous result or do you pursue additional workup for RBC...
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?
Is patch or gel HRT with ASA prophylaxis a reasonable option after counseling? Or do you add a prophylactic DOAC?
Nonreliable INR, given hepatic coagulopathy
ANC <500
Is lifelong LMWH the anticoagulant of choice? Would DOACs be an option?
How would these expansions differ based on the anatomic site being treated?
How often do you see non transfusion-dependent thalassemia and how do you approach the treatment?
Although TIBC is negative acute phase reactant, would it be a better indicator of iron deficiency (in combination with ferritin)?
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?
What else would you consider in your differential?
How would the risk of VTE associated with crizotinib affect your decision? Should we consider using crizotinib in combination with brentuximab?
Several patients with inability to access oral cyclophosphamide or lenalidomide, have attempted assistance and grants to no avail.
Also how would you manage this perioperatively?
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.
Often see bariatric surgery ordering these tests, is there any clinical relevance?
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
No prior thrombosis; no family history of thrombosis. As per endocrine, the only useful therapy for the osteoporosis is estrogen.
How is this entity distinct from other secondary HLH entities?
The patient has no known history of autoimmune disease.
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.
Would it change your management if the thrombus was symptomatic? Or if larger >3 cm?
Is this considered a sanctuary site from systemic therapy?
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...
For example, a patient with a bone marrow biopsy that shows normocellular bone marrow. Prior management with leflunomide and HCQ with neutropenia attr...
What would your next line therapy be? If the patient had no matched related or unrelated donors, would you consider haploidentical transplant?
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
Any particular labs or imaging indicated?
Normal CBC, CMP, SPEP, serum light chains, and FISH. Young otherwise fit patient.
What can you recommend that might help keep them out of the hospital? Do you consider a program of exchange transfusions in this situation?
Presuming there are no matched unrelated donors.
Would you bridge with enoxaparin 0.7 mg/kg/day in an ESKD patient, as described in a previous retrospective study (Pon et al., PMID: 24718051)?
240-300 mg/m2 prior exposure. How would your management change in young fit/older individuals with comorbidities? Would you obtain interval TTE during...
If hydroxyurea modifies the course of sickle cell disease by increasing fetal hemoglobin, is there any benefit to using it in patients with fetal hemo...
Would you give a trial of IST first or immediately refer for SCT if the patient has matched siblings?
For example: In a patient presenting with left arm swelling and found to have a left cephalic vein occlusive thrombus on ultrasound
Should they be placed on routine EGD surveillance and if yes at what intervals?
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>...
This is an adult patient that is status-post orchiectomy and R-CHOP now requiring prophylactic contralateral testicular radiation. Would you recommend...
ADAMTS13 level <5%
Inhibitor level <1
Patient on JAK2i, ESA, transfusion dependent
How can these interactions be improved?
Good performance score, 7 cm in size, CSF cytology is negative, MRI complete spine is negative. Would you consider any additional systemic therapy mod...
Elderly patient with large fungating necrotic breast mass positive for high grade BCL and a solitary hypermetabolic ipsilateral axillary node. Medical...
For example, concerning throbocytopenia or neutropenia during anal cancer treatment with concurrent mitomycin/5FU, or other pelvic malignancies treate...
E.g. pulmonary embolism, portal vein thrombosis, cerebral venous sinus thrombosis
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...
What is the ideal approach for female adolescent athletes if they have complaints of fatigue and dizziness and are diagnosed with mild iron deficiency...
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?
Does history of miscarriage affect your treatment decision?
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?
That is, extra copy of one of the alpha genes resulting in an atypical alpha thalassemia for the patient, and beta thalassemia heterozygous carrier fo...
Does it assist in prognosis in any way?
Please comment on temperature recommendations and role of exchange transfusion.
Do you use anticoagulation in cancer patients who develop an unprovoked superficial vein thrombosis?
If so, do you treat for a limited period of time or indefinitely?
While L-glutamine has minimal side effects and would likely be added after hydrea, how do you decide between the use of voxelotor and crizanlizumab?
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?
Do you wait 12 weeks for confirmation to begin treatment if patient is declining?
Would you still go to auto or consider allo?
In the absence of concerning bleeding or thrombosis, family history of coagulopathy, current anticoagulant use, or malnutrition
Would you intercalate HD-MTX with her CHOEP?
Is SLE-related APLS managed differently in terms of anticoagulation?
MPN work-up negative
Specifically - patient who had mild aggregation defect with ADP which corrected in third trimester of pregnancy. Would it be appropriate or necessary ...
Although testing was not indicated, what do u do with these results?
Other hypercoagulability work up negative
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?
E.g. low dose DOAC
Would the answer differ if the index event was arterial vs venous?
She was on surveillance after lumpectomy. No prior radiation therapy. What dose/fractionation?
Previous provoking factors resolved (CVC, malignancy, etc)
If so, when do you think this might occur?
When it seems fairly certain that this is a drug effect is it something that can just be monitored or requires a change in approach?
Do you advise against combination OCPs?
If work-up is sent and the patient is found to have a persistently positive antiphospholipid antibody, particularly lupus anticoagulant, would you con...
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 type, dosage, and duration of treatment do you use? How does your practice change when there is an inhibitor?
What are indications to order gene mutation studies (e.g. ELANE) and how would it help the patient?
Currently on nonwarfarin therapeutic anticoagulation
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?
When would you treat the entire orbit versus partial orbit? One patient has medial rectus involvement and another has only conjunctival involvement. I...
Ferritin uptrending >1000, no additional lab abnormalities. HFE wildtype. Too young for age-appropriate cancer screening. Asymptomatic except fatig...
What VAF burden would be considered significant prognostically or for treatment decisions?
Is thrombotic risk too significant? Patient failed OCPs.
(Normal oxygenation and echo)
What are the differences in approach to B lymphoid/myeloid and T lymphoid/myeloid MPAL?
If so, is there one type of antibody that is more likely to cause this false positive test?
Imaging studies (MRI and PET) show bilateral disease
For example, if TSAT is less than 20% but ferritin is over 200.
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...
For instance, evaluation by primary care and GI without other etiology for splenomegaly
Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?
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?
Wu et al., PMID 34665865
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
If so, how long before/after radiation?
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?
Patient with high titer acquired FVIII inhibitor with no causative etiology. Bleeding is well-controlled on emicizumab, but inhibitor has failed...
81 mg vs 162 mg
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?
Other than in the setting of disease progression or significant treatment-related adverse event?
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.
The patient has no personal history of VTE, but has positive family history of VTE.
Any prophylactic anticoagulation options?
How would manage...
How do you determine whether to add intrathecal chemotherapy in patients with +CSF? Would your approach change for primary vs secondary CNS lymphoma?
For instance, if clonal hematopoiesis of indeterminate potential (CHIP) suspected
Do we prophylactically place patients on anticoagulation after one episode?
Besides MRI/MRV brain, are there other diagnostic imaging that should b...
iPET2 and iPET4 showed Deauville 5 response. CT biopsy after 4 cycles was negative. Patient is currently scheduled for 2 additional cycles of ABVD.
Would you treat as bulky or non-bulky? Is ISRT indicated? Biopsy was performed because there was concern for soft tissue sarcoma.
Is it time limited since it may have been triggered by the pregnancy or is it indefinite since it is APLS associated?
I.e., what constitutes well-controlled cancer, IBD, nephrotic syndrome, etc. What other diseases do you put in this category (obesity, autoimmune dise...
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
i.e. long car rides or plane rides
- 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.
CRP 39 mg/L (normal < 10) and normal ESR
APLA syndrome, obesity, non compliance ruled out and prefers another oral anticoagulation. Is higher dose of rivaroxaban or apixaban an option?
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...
Do you use a cutoff of 10 cm? Do you measure the size of the largest node or measure the largest conglomerate or measure the total length of the entir...
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?
Bleeding disorder such as vWD
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...
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
Should we stop checking factor VIII levels as part of thrombosis workup?
In the setting of no personal or family history and no other risk factors for thrombosis, is systemic anticoagulation warranted if local treatments (e...
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
(e.g. beta 2 glycoprotein IgM > 20 but <40)
In this case, initial tumor was 9.5 cm craniocaudal but hardware spans the entire femur.
eg. eGFR < 30 ml
e.g. K, Fya, s, etc
If not, what instructions do you give to patients regarding checking temperature at home/return precautions?
Do you routinely check IgG levels during therapy, if not indicated by a study protocol?
If so, what regimen do you utilize?
How would the approach differ if the patient had a significant bleeding phenotype vs only minor bruising and mucosal bleeding?
Does measuring serum free-light chains make a 24-hour UPEP unnecessary?
This type of etoposide sparing therapy has been previously described in a case series at https://pubmed.ncbi.nlm.nih.gov/32725881/
Last rituximab 6 months ago
What agents would have sufficient efficacy overlap to treat both?
ET is JAK2+
How do you approach secondary stroke prevention for patients with ischemic stroke, atrial fibrillation, and signs of cerebral amyloid angiopathy/micro...
Does this change depending on stage?
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?
If so, how long after diagnosis do you do so?
Are there situations in which a Deauville 3 would cause you to escalate therapy?
Recurrent thromboses despite therapeutic enoxaparin. Other hypercoagulable work-up negative.
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?
FVL heterozygotes are often treated similarly to the general population. Aside from avoiding other VTE risk factors, are there situations where prophy...
Are there particular clinical scenarios that would affect your decision?
i.e. treatment-refractory PV, prior to progression to PMF or AML
Do you routinely check IgA anticardiolipin and beta-2 glycoprotein antibody IgA in your practice? And how would a positive result change your manageme...
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?
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...
Which systemic agents would you recommend holding during RT?
What dose/fractionation?
If re-irradiation, what dose would you use?
What about changing standard regimens for TCL with HLH?
i.e. obstretric APS without thrombosis or SLE
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?
In situations when we are waiting for insurance clearance or due to other logistical reasons.
Plasmacytoma of 6th rib s/p resection. Negative multiple myeloma work-up.
Please comment on bridging.
Does VAF <1% make you want to do a BM biopsy for confirmation?
What should be done with a high level?
Would the presence of JAK2 versus CALR versus MPL influence this decision? What if there are other risk factors for cardiovascular disease?
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 ...
Would chemotherapy be preferred over RT?
e.g. in the setting of using prophylactic heparin in the past but now requiring therapeutic anticoagulation
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.
NCCN only recommends palliative ISRT for non-transplant eligible patients with refractory/relapsed DLBCL
The dosing in the literature has a huge range.
What if there are no cardiovascular risk factors? Are VKAs preferred or can DOACs be used?
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?
If so, what dose and fractionation would you recommend?
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...
If so, what agent(s) do you prefer?
Can you expand on this by sharing exactly what this routine workup should include? What additional tests outside of evaluating for POEMS and amyloidos...
How does belumosudil now fit in your approach to steroid refractory chronic graft-versus-host disease?
Hydroxyurea is demonstrated to reduce complications and improve long-term outcomes in severe genotypes HbSS and sickle beta0 thalassemia. What clinica...
What is your duration of anticoagulation?
Are there other supportive care interventions that would otherwise be covered by hospice?
What if the patient is triple-positive or has continued seropositivity on repeat lab testing? What is the appropriate interval of monitoring and does ...
Would you move straight to second-line systemic therapy or first attempt consolidative ISRT/boost, or employ both? Assume node is biopsy-proven.
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...
Is an LP only recommended in the setting of particular subtypes of lymphoma or symptoms of CNS disease?
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?
Is there data that it actually helps?
While low-dose aspirin for primary thrombosis prevention in aPL without APS is not typically recommended outside cardiovascular prevention guidelines ...
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?
Would your recommendation change based on grade and/or location (weight-bearing vs non weight-bearing bone)?
There are multiple difficulties that could be seen: steroids can precipitate a sickle cell crisis, vasculitis and sickle cell can produce similar clin...
Would your recommendations change if the mass were significantly smaller, say 1-2 cm, and was completely excised with negative margins?
Patient with ferritin level <1000 ng/mL and no evidence of end-organ damage
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 ...
Are there major differences in standard conditioning and/or GVHD prophylaxis regimens utilized?
Does the non-relapse mortality different significantl...
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
Does transplant eligibility make a difference for management?
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?
With a strong family history
When do you consider initiating eculizumab?
What are your target goals during transfusion, either prophylactically or during acute complication? Does your management change between vaginal deliv...
The use of anti-fibrinolytics is typically contraindicated in DIC, but does it have benefit in DIC states characterized by hyperfibrinolysis?
Does the rate of progression of IgM influence your decision?
Does having a concurrent consumptive process e.g. DIC change your management?
While benefits outweigh known harms and limited data, do you worry about vaccination in patients with a history of or active autoimmune cytopenias (e....
Do you follow the 2019 EULAR Guidelines that SLE patients with asymptomatic, positive aPL should be on low-dose ASA?
Would you consider this type of patient as having polycythemia?
How long after eculizumab infusion would you wait before giving blood transfusions?
Are there any subsets of patients that you're more inclined to offer maintenance?
What is the potential differential diagnoses for low iron saturation?
AstraZeneca may cause PF4 antibodies leading to vaccine-induced prothrombotic immune thrombocytopenia (VIPIT).
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?
Especially in a triple-positive patient with an acute ischemic stroke who may have urgency for anticoagulation with high bleeding risk and severe thro...
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 ...
The patient who has not responded to steroids, rituximab/bendamustine, and splenectomy?
In a patient with severe factor XII deficiency with a baseline prolonged PTT, what is the best method to monitor their ACT or heparin levels when on c...
How do you approach systemic therapy options? What are your recommended volumes?
Would you consider high-dose dexamethasone (deliberating adverse effects of antenatal steroids) or move to next-line therapies?
Has your medical practice taken any steps either in community outreach or within the clinic to show support for this medically vulnerable population, ...
For a patient with low ferritin, but high TSAT?
Ref: EINSTEIN-CHOICE and AMPLIFY-EXT
Would you approach this differently in patients with inherited thrombophilias?
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?
Are most places administering oral iron as once daily or every other day dosing due to upregulation of hepicidin receptors following oral iron adminis...
There is no uniform guideline in the literature. AAP recommends until 5 years old or 1-year post-splenectomy. Some for 5 years post-splectomy.
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?
Given the high cost of eculizumab, are there patient characteristics that inform which patients, if any, should be on indefinite therapy versus a time...
How do you manage an uncomplicated DHTFR versus a hyperhemolysis?
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?
For instance, if the tissue came back SLL, Waldenstrom's, follicular lymphoma, or even nodular lymphocyte-predominant Hodgkin lymphoma, would any or a...
Such as a patient who cannot tolerate oral iron and has had a anaphylaxis to intravenous iron
For example, a patient with hypogonadism unless it matters which organ is involved. Are other markers of iron storage useful in guiding therapy?
For example, in a patient who is steroid-refractory, requiring regular transfusion, and has not had response to rituximab after several weeks.
For example, in a young patient where standard fields would be very large and you want to minimize toxicity
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?
If so, what additional testing do you send?
For example, a patient on cytoreductive therapy and aspirin BID, but suffers an arterial event, or a patient who is already on therapeutic anticoagula...
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...
If autoimmune neutropenia already suspected, is this test informative or unnecessary?
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...
Relapsed disease occurred 3.5 years after initial treatment
Do you go straight to TMPRSS2 genetic testing or what other lab testing (e.g. hepcidin) could be helpful?
If there are a low-risk patients who can be monitored, how would you do so?
If unprovoked, would you consider stopping anticoagulation?
Individuals with MPNs may be at higher risk for thrombosis and be placed on antiplatelet therapy or even anticoagulation because of prior thrombosis. ...
Should we use a different dose in critically ill patients in the ICU? When should we consider intermediate-dose anticoagulation?
What if it is a young patient?
Is there a preferred strategy of transfusional support versus reduced-dose anticoagulation during the duration of thrombocytopenia?
In this scenario, is systemic treatment better given bilateral involvement? In a patient who has already had cataract surgery and is not at risk for c...
Does your dose recommendation change if a patient has cord compression or has undergone surgery? There is a range of doses in the ILROG guidelin...
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?
Does recent iron intake affect the iron panel, and if so, do you often order fasting labs in practice?
Does your opinion change based on the specific underlying inherited thrombophilia? The original case was a central retinal artery occlusion in a patie...
Especially in a patient without hemophilia or thrombosis history?
Do you only give intrathecal chemotherapy or systemic therapy?
What are the scenarios in which a rebiopsy is warranted for follicular lymphoma?
Would you offer this routinely or only if specific complications arise, such as distal emboli?
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.
At what point would you recommend transfusion? At what point would you stop radiation?
In patients who are intolerant to hydroxyurea, anagrelide and interferon
Is there any benefit to getting it prior to starting cytoreduction?
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?
The patient received R-EPOCH followed by consolidative RT (36 Gy in 18 fractions) approximately one year ago and was subsequently salvaged with RICE.
Does acute leukemia sub-type affect your decision?
Assuming CBC w/ different and complete metabolic panel are within normal limits, what (if any) further evaluation or management is needed?
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?
If so, what dose would you recommend?
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?
The unfavorable risk factors for stage I-II Classic Hodgkin's Lymphoma differ depending on the cooperative group (GHSG, EORTC, NCCN), which criteria d...
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, ...
Or do you consider addition of this agent in the re-induction setting for refractory disease?
Guidelines indicate RCHOPx3 +RT as category I and RCHOP x 6 below that; long term f/u for SWOG 8736 showed similar PFS and OS. Do you have and approac...
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...
If so, what is your approach to laboratory and clinical testing?
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...
For a stage IAE DLBCL (in this case, of the oral cavity) that was completely excised, s/p R-CHOP, is the ISRT target volume just the preop volume plus...
(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?
How would your dose and/or volume change if the patient refuses chemotherapy?
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?
Any experience treating patients prone with openings for both breasts, no minimize breast overlap with axilla and mediastinum?
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?
The patient is not a transplant candidate due to multiple co-morbidities. Some of the sites in question have had a complete response and other have ha...
How would you handle high risk features (eg double hit) with the limitations of dialysis?
What dose and fractionation would you recommend for a localized primary bone marginal zone lymphoma?
The patient has no bone marrow involvement.
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...
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.
If the breast was previously radiated 15 years ago, would that change your decision?
If there was residual lymphoma on cytology of a chronic se...
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...
Would you recommend RCHOP x 3-6 or RCHOP x 3 + ISRT? If you end up doing ISRT, would your target be any different than the principles that guide...
Since some prior studies (eg. Eskelund et al. Blood 2017 130:1903-10.) have shown intensive chemoimmunotherapy does not overcome the ad...
Is your scoring based on SUV uptake vs the subjective interpretation of the radiologist? How do you go about reconciling Deauville scoring when there ...
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?
Repeat EGD and additional biopsies of the stomach were all negative for MALT lymphoma and H. Pylori. A CT of the C/A/P was done showing no evidence of...
Although the MMR vaccine is contraindicated in immunosuppressed patients on anticancer treatment according to CDC/ACIP and IDSA guidelines, data on sa...
For example, would you go ahead with 20 Gy of ISRT if medical oncology has already treated a stage I-IIA patient with 2 cycles of ABVD meeting all oth...
If they are symptomatic do you relax that time interval? Do you ever consider partial brain radiation instead of whole brain to minimize neurotoxicity...
In a patient who absolutely cannot receive chemotherapy due to impaired performance status, what dose would you use for WBRT and what dose would you u...
I have received inquiry from a patient's gastroenterologist regarding use of Entyvio or Stelara in such a situation.
Prior trials of systemic therapy including alkylating agents and rituximab have failed and the patient is medically inoperable with no history of Hepa...
The staging bone marrow biopsy was negative. The staging manual simply states "bone involvement is identified using appropriate imaging studies."...
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 you use a similar dose and fractionation as gastric MALT (30Gy in 1.5 Gy fractions)?
Should prechemo PET positive disease from bowel or other structures be carved out?
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?
Do you generally always boost the scalp and/or soles even if those sites are not involved with disease?
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?
The patient had a bilateral orchiectomy (pathology demonstrated no invasion of the tunica) followed by R-CHOP x 6 and IT Mtx with a PET CR in a para-a...
The patient is a 75 yo immunocompetent man who has a history of inverted papilloma of the sinuses and presented with a new lesion in the right maxilla...
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?
Would you use 10 Gy in 1 Gy per fraction as mentioned in a litterature review in Pubmed?
What factors influence your choice to treat as well as dose and target?
Once you decide to begin treatment, any special precautions you would use for protein levels starting that high.
The patient does have significant weight loss, drenching night sweats, but no evidence of other involved sites on PET, thorough skin exam, and has nor...
In the case of an excised groin node with no residual disease and no chemotherapy in a young adult patient, how large should the fields be? Is it requ...
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?
I have a patient with low volume disease of Castleman's disease with cervical lymphadenopathy and tonsillar hyperplasia that is suspicious but not bio...
If a patient has an increase in PET avidity between the PET/CT done after 2 cycles of ABVD and after completion of chemo, how would you proceed? Would...
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.
Does your follow-up differ depending on the dose you used (e.g. boom boom vs. 24 Gy)? Do you routinely image? If so, do you use MRI or PET...
If filgrastim, how many days would you give? Pegfilgrastim is often not covered by payers if given less than 14 days before chemotherapy.
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?
If the patient had a CR by PET/CT after 2 cycles of ABVD and received 6 cycles of ABVD would you recommended consolidating only the bulky disease and ...
Specifically, to you lean towards elotuzumab or a daratumumab-based regimen?
What technique do you use (IMRT vs direct electrons w bolus)?
The ILROG paper on extranodal NHL says "For tumors confined to the conjunctiva or...
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?
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?
For example: would you treat the entire Waldeyer's ring? For a stage II patient who also has cervical lymph node involvement on one side, do you...
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?
We often see young women with favorable, early stage disease in the mediastinum who have had a complete response to chemotherapy. With current smaller...
If so, do you use antivirals and/or antibiotics? Does it matter if the patient has mantle cell lymphoma, CLL, or Waldenstrom's macroglobulinemia?
How have the results of the UK RAPID study (Radford et al NEJM 2015) changed your practice?
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 is the best evidence to support or refute this?
Would you include one vertebral body above and below the involved vertebral body? Is IMRT appropriate in order to reduce dose to small bowel? What oth...
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?
If a patient had recently completed R-EPOCH x 6 cycles, would you change your dose for a low grade follicular lymphoma?
Is surgery an adequate treatment for Stage IE DLBCL of the cervix?
When treating with radiation therapy, what dose-fractionation do you typically utilize?
What is the utility of repeating FISH studies to evaluate for clonal evolution if FISH studies were done at diagnosis?
The NCCN guidelines recommend all patients receive 3 cycles RCHOP followed by ISRT unless they have bulky disease greater than 7.5 cm. However, are th...
With the field moving more toward ISRT/ INRT, and conformal radiation, would you generate separate PTV for initial nodal involvements that are within ...
If so, what data should be presented to insurance companies to cover the cost?
What dose do you recommend?
When nodal regions not amenable to biopsy but are enlarged without significant SUV uptake, should they be treated as involed and recieve RT?
After ABVE-PC X4 and Ifos/vinorelbine x 2 per AHOD 0831 (and is unable to have these sites biopsied), what dose would you treat to and what volume wou...
Is there a preferred low dose splenic irradiation regimine?
When radiation therapy is utilized, what should the radiation therapy treatment fields include and what imaging studies should be completed to assist ...
If so, should involved site radiation thearpy (ISRT) or involved field radiation therapy (IFRT) be used for the radiation therapy treatment fields? Wo...
Are the results of AHOD0031 practice changing?
When the disease (in this case, lymphoma) involves almost all of the entire muscle compartment of the distal lower extremity, what is a safe dose? I'm...
In drawing the lung blocks approximately 1 cm in from the chest wall, diaphragm and mediastinum, should the blocks stop underneath the clavicle o...
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...
Specifically for marginal zone or follicle center?
Is it necessary to treat the whole orbit or is conformal treatment ok?
After a nerve sparing parotidectomy, would you offer postoperative radiotherapy? If so, what volume and dose? Would it change your management if the p...
In a patient with Stage IE DLBCL, is your treatment volume postchemo ISRT or whole breast? Would you consolidate if a lumpectomy was performed prior t...
Hoskin et al (Lancet Oncology 2014) suggest 24Gy/12fx is more effect RT dose compared to 4Gy.
Is there a benefit to IMRT when we treat to relatively low doses (as compared to squamous cell cancers of the head and neck)?
Or is it more appropriate for certain sites/stages/histologies?
Specifically, for a diffuse large B cell lymphoma of the femur?
It seems that with the arms up, you get better lung blocking but with arms akimbo, you might have a lower dose to the humeral head.
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