Leukemia&nbsp;&nbsp;&nbsp;

In patients with CML on imatinib and newly diagnosed breast cancer now requiring radiation therapy, should we hold imatinib?

The said patient has been on Imatinib for 2.5 years and is In MMR. Last rt-PCR was 0.04.

How do you choose which BTK inhibitor to use in NHL?

Does the safety profile impact your choice significantly? Does your first choice vary by disease histology?

Would you include midostaurin in induction and consolidation for patients with good-risk AML w/ NPM1 mutation and FLT3-ITD (<0.5)?

What is the benefit of cytoreduction with Hydroxyurea for patients with newly diagnosed chronic phase CML with a WBC count >100 prior to the initiation of a TKI?

Would it be reasonable to offer a patient with CLL a treatment break from acalabrutinib or any BTK inihibitor after a period of time, assuming good response?

It is understood that the trials experience was to keep on treatment indefinitely until progression or unacceptable toxicity. We are asking about real...

0 Answers available

Is there any benefit to transplant patients with Ph+ ALL who have achieved MRD-negativity?

For patients receiving outpatient venetoclax/azacitidine who develop profound neutropenia with ANC <200, do you admit for monitoring during the nadir in the absence of fever?

If not, what instructions do you give to patients regarding checking temperature at home/return precautions?

What are your recommendations for a male patient who was recently started on imatinib and wants to conceive?

4 Answers available

How would you approach the treatment of cytopenia related to NK cell LGL leukemia?

When would you opt for a chemotherapy free approach in the first line treatment for hairy cell leukemia?

What would you consider as contra-indications to Cladribine?

Would you ever consider using ibrutinib in CLL patients who have received first line acalabrutinib and then progressed?

How should one manage a patient with leukocytosis and borderline detectable BCR-ABL without other clinical features of CML such as basophilia or splenomegaly?

e.g. IS < 0.002% by qPCR

How do you approach patients with underlying psychiatric disorders who refuse CML treatment due to not believing their diagnosis?

How do you approach conversations regarding discontinuation of transfusions in patients with advanced hematologic malignancies who are otherwise appropriate for hospice?

Are there other supportive care interventions that would otherwise be covered by hospice?

When would you use acalabrutinib in combination with obinutuzumab vs acalabrutinib alone in upfront CLL treatment?

Do you routinely offer fungal prophylaxis for patients on BTK inhibitors?

Can experts comment on fungal pneumonia risk with individual BTK inhibitors as seen in ELEVATE-RR and whether this impacts their management decisions?

What is your approach to CLL in patients with atrial fibrillation and/or on anticoagulation?

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...

For frail patients with cardiac co-morbidities and relapsed CLL with high cytogenetic risk, what are some considerations for using continuous acalabrutinib over fixed duration therapies such as venetoclax/rituximab?

What regimen would you offer a young patient with T-cell ALL who recurred a short time after allo-transplant and was initially treated with CALGB10403?

Especially with the current drug shortage of nelarabine.

Would you start TKI therapy in a patient with new diagnosis of T-ALL without BCR-ABL gene rearrangement on FISH but found to have very low level p190 transcript on RT-PCR?

How would you manage a CLL patient who experienced severe infusion reactions with rituximab and has exhausted all other options?

Is it safe to challenge with other CD20 monoclonal antibodies such as obinutuzumab?

What regimen would you recommend for a younger, fit, transplant eligible patient with relapsed IDH1 positive AML?

Would you consider allogeneic stem cell transplant for a newly diagnosed patient with favorable risk AML who had residual disease after initial therapy that included the need for re-induction?

Would you consider adding midostaurin to azacitadine in elderly patients with newly diagnosed AML with FLT3-ITD mutations in the frontline setting?

How do you approach therapy for a fit adult with relapsed AML with CNS involvement after allogeneic stem cell transplantation?

Is Ommaya placement with CNS-directed therapy preferred to intrathecal or cranial irradiation? How do you interweave this therapy with systemic therap...

Would you recommend stem cell transplant or gene therapy for a patient with CML and sickle cell disease currently on imatinib with worsening anemia?

How do you decide between CPX-351 and HMA + Venetoclax in treating transplant eligible AML-MRC?

Is a patient with secondary myeloid sarcoma a candidate for hematopoietic stem cell transplant?

How would you approach a patient presenting with pancytopenia and splenomegaly whose bone marrow biopsy is morphologically normal but has a positive Philadelphia chromosome in bone marrow as well as peripheral blood?

Would you add chemotherapy to a TKI in treating an elderly patient with de novo CML blast crisis?

How do you decide between blinatumomab or traditional chemotherapy in combination with TKI for upfront treatment of adult patients with Ph + ALL?

What would be your choice of therapy in a fit patient with relapsed CLL previously treated with bendamustine and rituximab who does not want BTK inhibitor therapy?

Relapsed disease occurred 3.5 years after initial treatment

How would you manage CML first-line second generation TKI with a best response of MMR 4, but now with a loss of MMR with more than one log response loss but still in complete cytogenetic remission and mutation panel negative?

What is your preferred frontline treatment for CLL in young patients < 50 years old?

What would be your choice for re-induction in a young patient with FLT3+ refractory AML after 7+3 induction therapy with no FLT3 mutation on the day 14 marrow?

How would you treat a de novo CLL with WBC of 1,000,000 and no overt signs of leukostasis?

Would you consider holding treatment with hypomethylating agents and venetoclax in elderly with AML who achieve CR and are MRD negative?

What maintenance treatment would you recommend for Ph positive ALL following Hyper-CVAD, transplant eligible or ineligible?

Do you offer enasidenib with azacitadine in AML with an IDH2 mutation for patients ineligible for intensive induction chemotherapy?

Does the absence of an OS benefit in the AG221-AML-005 presented at ASCO 2020 deter you from this strategy?

Are there any special considerations for treating CML in the very elderly, greater than 85 years old?

What frontline therapy would you offer for a patient who is elderly or unfit for standard induction therapy with both IDH-2 and FLT-3 ITD mutations?

How would you approach treatment in an otherwise young, fit patient with transformed AML currently in remission with a plan for transplant and was found to have an invasive fungal infection not amenable to resection upon recovery from induction?

Would you consider “bridging” therapy with something like an HMA?

How do you adjust the dose of Ibrutinib in hepatic dysfunction, particularly if disease related?

Would you consider adding Enasidinib to frontline combination therapy with HMA and Venetoclax in a patient with newly diagnosed AML with IDH2 mutation that is >75 or unfit for standard induction therapy?

During induction therapy for acute leukemia, when do you decide to discontinue the antimicrobial prophylaxis?

Is it at neutrophil recovery, at documentation of CR on bone marrow biopsy, or is there a different point in time?

What are the options of induction treatment of young AML patients who are on CRRT, continuous renal replacement therapy ?

How do you approach the treatment of patients with an e14a3 (b3a3) BCR-ABL fusion in chronic phase CML?

For pre-menopausal female patients who present with acute leukemia in need of urgent anti-neoplastic therapy, what is your preferred approach in effort to preserve fertility?

Does acute leukemia sub-type affect your decision?

When during ALL induction therapy are you checking for MRD?

What's your preferred management for a newly diagnosed chronic phase CML with concurrent thrombocytopenia?

How long after discontinuation of TKI (for complete remission) would you feel it is safe for a patient with CML to consider pregnancy?

Do you ever discontinue ibrutinib in patients with CLL who have a good response?

For instance, would you discontinue when there is resolution of adenopathy and normalization of counts? If so, do you overlap ibrutinib with other the...

What factors do you consider when choosing between a 1st and 2nd generation TKI in a newly diagnosed CML patient?

Do you prefer hyper-CVAD or the CALGB 9111 protocol for high intensity remission induction treatment in Ph-negative ALL patients?

The NCCN recommends both regimens.

Do you include gemtuzumab ozogamicin for any of your newly diagnosed AML patients who are candidates for 7+3 induction chemotherapy?

Or do you consider addition of this agent in the re-induction setting for refractory disease?

What is your recommendations for vaccines to prevent shingles in CLL patients?

Why do we immediately perform CNS staging with a LP at diagnosis of ALL when the risk of seeding is highest with a high lymphoblast count?

How would you manage a patient with minimal residual disease (<1% of CD25 positive cells) six months after completing therapy with 2-CDA for Hairy Cell Leukemia?

Would you offer next-line systemic therapy to a patient with LGL leukemia with chronic severe neutropenia, who has had treatment failure with methotrexate, cyclophosphamide, cyclosporine, and danazol?

If the patient has not experienced significant infectious complications? If so, what agent?

Do you ever start with lower than standard doses of TKIs when initiating treatment for chronic phase CML?

For instance, do you ever start with dasatinib 50 mg daily? Are there any titration schedules that you follow?

Can we ever observe newly diagnosed chronic phase CML patients and not immediately start them on therapy?

if so, are there specific cytogenetic, molecular, clinical, or hematologic factors that you take into consideration?

How would you manage a CML patient with a T315I mutation that developed severe abdominal pain requiring hospitalization after starting ponatinib 45 mg?

Thrombosis was ruled out and no etiology was found. Would you start ponatinib back at a lower dose, transition to omacetaxine or begin transplan...

For patients who have exceptionally long responses to HMA with high risk MDS or AML and not candidate for more aggressive therapy/transplant, do you consider treatment holidays or spacing out doses into longer intervals?

For a patient with relapsed FLT3 positive AML on HMA and venetoclax, is there ever a role for the addition of midostaurin to the treatment regimen to improve response rate?

With the recent FDA approvals of Venetoclax and Glasdegib in AML, is one generally preferred over the other for elderly and/or unfit patients in combination with a hypomethylating agent/low-dose cytarabine?

In a newly diagnosed elderly patient with AML who harbors an IDH1 mutation, would you treat with upfront with ivosidenib or would you proceed with venetoclax and HMA as your first line treatment?

Do you use absolute WBC count or doubling time to determine whether to start treatment for early stage CLL?

Would this affect your decision regardless of the stage and symptoms?

What is your approach to the decision to use CPX-351 or standard 7+3 for de novo AML?

Do you await molecular and cytogenetic results prior to initiating therapy, or does age and function status primarily drive your choice?

What is your preferred TKI and dosing for AYAs or adult patients with Ph+ ALL?

NCCN does not list any preferences for the TKIs in their guidelines.

What is the role (if any) for Rituximab in a patient with CD20+, Philadelphia chromosome positive ALL?

Would using Obinutuzumab and Venetoclax second line after Bendamutine and Rituximab be a reasonable option for a patient with IGHV-unmutated CLL?

How do you dose midostaurin in patients with AML who need azole antifungal prophylaxis?

FDA package insert lists posaconazole as strong cyp3A4 inhibitor and states to consider other therapies.

How much later after starting a hypomethylating agent in an elderly patient with AML being treated in the upfront setting can venetoclax be started?

Can it be added after 2 or 3 cycles of HMA?

Do you make diagnostic lumbar puncture part of routine work up for newly diagnosed AML if patient is asymptomatic?

Does presenting total white blood cell count affect your decision? Does myeloid subtype affect your decision?

Why are hypomethylating agents as single agents not approved yet by FDA for treatment of AML (technically off-label)?

How would you approach treatment in an older (>65), but fit patient with intermediate-risk AML, but with MRD persistence after induction with 7+3?

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?

In a patient with high risk acute promyelocytic leukemia, when do you consider ATRA+ATO with GO vs ATRA+ATO with idarubicin?

Will you offer Ibrutinib and Rituximab for untreated patients with CLL without a 17p deletion?

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...

What is your approach to choosing a conditioning regimen for allogeneic transplant in AML?

What factors influence your decision (patient/disease characteristics, additional agents added to induction chemotherapy, CR1 or later, etc)?

How do you approach the treatment of hairy cell leukemia with inadequate response to front line therapy?

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...

What is your general approach to post-allogeneic HSCT maintenance therapy for AML?

When is it warranted to utilize targeted therapies for known mutations (eg. midostaurin or an alternative TKI for FLT3 mutations, ivosidenib for ...

Would you use alternative management in a chronic phase CML with a 3 way translocation between chromosome 9, 22 and 7?

Does anything need to be done if hyperlymphocytosis (i.e. ALC > 300K) develops in a CLL patient just starting ibrutinib?

If you decide to discontinue TKI after prolonged molecular remission in CML, how often would you follow the BCR/ABL after discontinuation?

What is your experience with liposomal-encapsulated daunorubicin and cytarabine (CPX-351) for first line treatment of therapy-related AML or AML with myelodysplasia-related changes in elderly patients?

Do you have experience administering these agents in the outpatient setting?

Is there a situation where you would use a purine analogue in combination with rituximab for the frontline line treatment of normal variant Hairy Cell Leukemia?

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 ?

What is the best strategy after initial treatment with hypomethylating agents for high grade myelodysplatic syndromes, mainly for responders who became transfusion independent?

Do we continue the hypomethylating agent indefinitely?

Do you routinely do imaging on patients to look for intrathoracic or abdominal lymphadenopathy in newly diagnosed patients with CLL?

How are you making the diagnosis of chronic lymphocytic leukemia transforming to prolymphocytic leukemia?

Technically, you can have up to 55% of larger cells circulating and still be called CLL.

Do you give 3 or 4 cycles of HiDAC during consolidation for good/intermediate-risk AML without an available allotransplant donor?

How do you choose between 3 and 4?

How do you approach small lymphocytic lymphoma that does not have a leukemic phase. Do you follow treatment guidelines for indolent lymphoma or CLL?

How do you get 17p testing on someone with only lymphadenopathy

Do you think there will be a role for duvelisib in the treatment of relapsed/refractory chronic lymphocytic leukemia?

Specifically, in patients that had progression or developed toxicity on ibrutinib? Idelalisib is very toxic and venetoclax a labor-intensive drug to g...

When do you combine hypomethylating agents with venetoclax or gemtuzumab ozogamicin in elderly patients with AML who are ineligible for intensive chemotherapy?

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 aggressive presentation of multiple squamous cell carcinomas of the skin an indication for treatment of CLL?

In the absence of any other classic CLL indications for treatment.

What would you choose as a first line therapy for a patient with CLL who is asymptomatic with Rai Stage 4 with bulky adenopathy and organomegaly?

Would it change your management if patient if IgVH mutated?

Is a CLL FISH panel sufficient to aid in treatment decisions in CLL or is p53 sequence analysis also needed?

What is your preferred dosing and schedule for interferon in pregnant CML patients?

Is venetoclax expected to be useful in patients with refractory CLL/SLL who do not have Del(17p)?

For male patients in chronic phase CML on a TKI and not yet in a MMR, is there a preferred amount of time spent in a MMR before discontinuing TKI therapy to conceive or bank sperm ?

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...

How would you approach a chronic phase CML patient who is responding to second generation TKI but not yet in molecular remission and is now pregnant?

How do you manage a patient who has developed a symptomatic pleural effusion while on dasatinib?

Specifically, can you rechallenge after the effusion has resolved (e.g. therapeutic thoracentesis)? If so, how long do you wait to rechallenge (especi...

When starting a patient on a tyrosine kinase inhibitor for chronic phase CML, which drug do you choose upfront?

Imatinib, or a second-generation TKI? Are there specific factors that make you choose one over the other?

After induction therapy for acute promyelocytic leukemia with arsenic trioxide and ATRA, at what point do you start consolidation?

Specifically, do you just wait for count recovery? Do you check for morphologic or molecular remission at all during this time?

How do you manage severe cytarabine syndrome in AML patients (manifesting as severe hypotension, fevers, rash, myalgias)?

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?

For CLL patients with high-risk cytogenetics on ibrutinib who develop a cardiac event such as an MI, would you continue ibrutinib?

Would you continue ibrutinib even if they are placed on anti-platelet therapy such as clopidogrel or ticagrelor?

4 Answers available

How would you treat a young man with refractory AML after HIDAC induction who developed cerebellar toxicity to HIDAC and previously received doxorubicin (300 mg/m2) for lymphoma?

What re-induction regimen without cytarabine or an anthracycline is likely to be most effective?

Should FISH studies be repeated when CLL patients under active surveillance have progressive disease warranting treatment?

What is the utility of repeating FISH studies to evaluate for clonal evolution if FISH studies were done at diagnosis?

When would you consider testicular RT prior to TBI for BMT?

What dose do you recommend?