You Make the Call: Readers’ Response
We asked, and you answered! Here are a few responses
from this month’s “You Make the Call” questions.
For the full descriptions of the clinical dilemmas, and
to see how experts responded to each dilemma, turn to
pages 99 and 100.
TRAINING
You Make
elevated
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is 12 weeks
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aparin sodiu
she be on enox
Colleague
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ASH
Through is a service for ASH
Medicine
eldorp, MD
of Vascular
Saskia Midd
AMC
Department
Medicine,
ers, Location
Professor of
Medical Cent
University
Amsterdam
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REFERENCE
al. Low-molecula with antiphospholipid antibodi
Pampus M, et
in women
Hague W, van
set pre-eclampsia
van Hoorn M,
:168-73.
recurrent early-on Reprod Biol. 2016;197
prevention of
Eur J Obstet Gynecol
the FRUIT-RCT.
while
node
clinic
I have a 22-ye
presented
increasing
nted her case
to a fertility
pelvis who
ed slightly
have prese
ity. I sent her
en.
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nodes in the
t CT scan show because of her fertil
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but a recen
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ing slowly,
ed and “will
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cycles
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oncologist
patient refus
was for six
add an LHRH
eggs, but the the recommendation
would you
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logy.org. ●
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inica
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Email us at
What woul
you respond?
How would
l News
at
Due to the positivity of the lupus anticoagulant test
and risk factors, the patient should receive anticoagula-
tion with enoxaparin. In addition, a new determination
of lupus anticoagulant, anticardiolipin, and anti-β2GPI
antibodies should be made in 12 weeks.
Flor Armillas, MD
Instituto Nacional De Ciencias Médicas y Nutrición
Salvador Zubirán
Mexico City, Mexico
I would also use a prophylactic dose of enoxaparin sodium.
Anastasia Skandali, MD
Hygeia Hospital
Athens, Greece
Yes.
recommend
ASH does not
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tests, physi
any specific
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or endorse
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nty, or
products, proce
tion, warra
representa
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disclaims any
same. Relian
the
to
as
is solely
guaranty
this article
provided in
information
risk.
at your own
DISCLAIMER:
December
Sajida Kazi, MBBS, FRCPath, MRCP
University Health Network
Toronto, Canada
Hyper-CVAD.
d to a
a request relate
listed here,
*If you have
to
c disorder not
mendation be
hematologi
your recom
.org so it can
please email
hematology
.
ashconsult@ addition in the future
for
considered
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involving lymp
progress-
Aubrey A. Lurie, MD
Overton Brooks VAMC
Shreveport, LA
topenias
dilemma?
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more
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at
Submit a ques Colleague volunteers
spx
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prescribe LMW
The patient should be on low-dose heparin until delivery.
Lothar B. Huebsch, MD
University of Ottawa
Ottawa, Canada
eagues”) will
teers (“coll
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Assigned volun ries within two busin
inqui
respond to
phone).
by email or
days (either
kin lymphoma
ASH Clinica
I have a 31-year-old female patient with HELLP
syndrome who is 12 weeks pregnant with her second
child. APL: DRVVT (+) not corrected with 1:1 mix and
DRVVT confirmed (+); anticardiolipin antibodies and
beta-2 glycoprotein (β2GPI) antibodies are normal.
She is taking low-dose aspirin daily. Should she be on
enoxaparin sodium as well?
s
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s
• Leukemia
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myel
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mma: 2a lymphocyte-predominant a healthy child.). Her disea
tion
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has since deliv needs to begin thera
le patient
mended
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100
What induction regimen would you choose for a
patient with Philadelphia chromosome–negative (Ph–)
precursor B-cell acute lymphocytic leukemia (ALL)
and ischemic cardiomyopathy with a left ventricular
ejection fraction of 35 percent?
nge
ague
tate the excha
Consult a Colle
helps facili
ists
members that between hematolog
on
bers can seek
of informati
. ASH mem
fied
and their peers clinical cases from quali
n on
consultatio
:
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in
rts
expe
• Anemias
oietic cell
• Hematop
ation
transplant
inopathies
• Hemoglob
osis
is/thromb
• Hemostas
inion
Expert Op
y
(“late pregnanc
syndrome
of HELLP
ive lupus
The presence
with two posit
) combined
12 weeks apart
morbidity”
tests at least
nts fulfills the
anticoagulant
that your patie
syndrome
would mean
olipid
antiphosph
the time to
criteria for
have not had
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not officially
g, she may
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repeat testin
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shou
meet the defin
nsus that she
in
there is conse
low-dose aspir
be treated with rent preeclampsia
recur
to prevent
rious
delete
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or other poten
herself or the
outcomes to
ry.
on her histo
nate based
olecular-
low-m
Regarding
the
in (LMWH),
tive
weight hepar
Although narra ts often
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exper
renowned
reviews by
in (in the
use of hepar
),
suggest the
thrombosis
ort
a history of
absence of
data to supp
ty
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are
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ledge, there
there are no
To my know
preg-
H improves
this approach.
data that LMW with late pregnancy
no reliable
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This is
mes in
preeclampsia.
nancy outco
not
HELLP or
as
trials have
such
as well-sized
morbidity
d con-
randomize
nce-free zone,
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lation was
in in this popu (n=32)
been conducted
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aturely becau
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Complications) antibodies, and LMW
olipid
antiphosph
Clinical Dilemma:
It is probably not possible to cure the disease or obtain
longevity unless you are very lucky. Start slowly with
weekly vincristine and prednisone/dexamethasone and
low-dose imatinib. Avoid severe neutropenia initially
to reduce issues around sepsis and the clinical/cardiac
stress of tumor lysis syndrome. The ALL may be very
sensitive to such therapy at the beginning. I would take
the time initially to confirm that left ventricular func-
tion is optimally medically managed.
If the disease is responding hematologically and
holding together clinically, you could increase treatment
intensity (perhaps after about three weeks) and might
switch to Part B of hyper-CVAD.
If the patient cannot tolerate chemotherapy-
induced thrombocytopenia (if he or she is fragile not
just from a coronary point of view), you might switch
to a monoclonal antibody.
the Call
P
ment of HELL
discusses treat
eldorp, MD,
Saskia Midd
.
t) syndrome
platelet coun
Clinical Dilemma:
2018
Depends on the patient’s age and other comorbidities.
If in poor condition and over age 65, I’d use steroids,
vincristine, and maybe add other ALL drugs such as
cyclophosphamide/methotrexate and cytarabine as
tolerated.
Michael Pidcock, MBBS
Canberra Hospital
Canberra, Australia
Pediatric regimens focus on the Berlin-Frankfurt-
Münster backbone of ALL therapy: glucocorticoids,
vincristine, asparaginase, early and frequent
central nervous system prophylaxis, and prolonged
maintenance therapy.
Jesús Alcaraz Rubio, MD
Hospital Quirónsalud Murcia
Murcia, Spain
Roberto Velazquez, MD
Ponce, Puerto Rico
There are some pieces of the puzzle missing in the
information provided. Did she have any history of
thrombosis or prior miscarriages? How severe is her
thrombocytopenia due to HELPP?
In a 31-year-old female that has at least three
potential hypercoagulable problems (pregnancy, HELLP
syndrome and (+) lupus anticoagulants), I would recom-
mend subcutaneous enoxaparin 40 mg daily for the rest
of her pregnancy, as opposed to aspirin alone.
The tricky part is how to do this based on her
platelet count. If her thrombocytopenia due to HELPP is
severe, it may pose a safety concern.
Alejandro Calvo, MD, FACP
Kettering Cancer Center
Kettering, OH
See more reader responses at ashclinicalnews.org/training-education/
you-make-the-call.
8
ASH Clinical News
December 2018