Dr Rajesh Bollam

I am a Medical oncologist ( Cancer specialist) graduated from Tata memorial Hospital. Believes in Evidence based medicine and Precision medicine

[Ahmed Kotb @AhmedKo45911157]

Long aPTT

Mixing corrects → Congenital factor deficiency (hemophilia).

No correction → Inhibitor or heparin.

Incubation worsens → Acquired hemophilia (time-dependent FVIII inhibitor).

Phospholipid corrects → Lupus anticoagulant.

Bethesda positive → FVIII inhibitor.

[Dr Aditya Gudheniya @Gastronaut___]

Adult vaccination in India 🇮🇳 : a short thread 🧵

1/ Adult vaccination in India remains vastly under-utilised: one large study found just ~1.6% of older adults reported any influenza vaccination, ~0.7% pneumococcal.

[Krishan Jethwa @KrishanJethwa]

Key conclusions‼️

🔵 RT may be omitted in patients with MRI defined- favorable risk disease
🔵 TNT preferred for high risk disease
🔵 Organ preservation better preserves QoL and function
🔵CRT➡️chemo sequence preferred for NOM

🚨 LARC Algorithm here!

👆🏽 For discussion!
17/17

[Dr Rishabh Jain @DrRishabhOnco]

Most oncologists can name KEYNOTE, CheckMate, or EMPOWER.

But one PD-1 program has quietly stacked positive phase III trials across lung, esophageal, and gastric cancers.

The ASTRUM program 👇

🫁 ASTRUM-005 | ES-SCLC
Serplulimab + EP vs Placebo + EP
OS: 15.4 vs 10.9 mo
HR 0.63

🫁 ASTRUM-004 | Squamous NSCLC
Serplulimab + nab-paclitaxel/carboplatin vs chemo
PFS HR 0.53
OS HR 0.73

🍽️ ASTRUM-007 | ESCC
Serplulimab + FP vs Placebo + FP
OS: 15.3 vs 11.8 mo
HR 0.68

🍽️ ASTRUM-006 | Resectable PD-L1+ Gastric/GEJ
Peri-op Serplulimab + SOX → Adjuvant Serplulimab
vs
Peri-op SOX → Adjuvant SOX

EFS: HR 0.73
pCR: 21.6% vs 6.4%

4 cancers.
4 phase III wins.

While the oncology world focused on Western PD-1s, serplulimab quietly built one of the most successful immunotherapy development programs in cancer medicine.

Is ASTRUM the most underrated trial program in oncology?

@oncoalert @ASCO @myESMO

#Oncology #Immunotherapy #LungCancer #GastricCancer

[Dr Rishabh Jain @DrRishabhOnco]

Think of a tumor as a block of wood.

RECIST uses a tape measure. It asks only one question: did the tumor get smaller?

But targeted therapy often works like termites. The tumor may look the same size from the outside while dying from the inside.

RECIST says: Stable Disease.

Biology says: Major Response.

That’s why Choi Criteria matter.

Instead of looking only at size, Choi also measures tumor density (Hounsfield Units) on CT. A ≥15% drop in density can indicate treatment response even before meaningful shrinkage occurs.

💡 Clinical pearl:

For GIST, RCC, and HCC, a tumor that isn’t shrinking may still be responding.

Sometimes the most important change isn’t the size of the tumor.

It’s what’s happening inside it.

#Oncology #MedTwitter #GIST #Radiology
@OncoAlert @ASCO @myESMO

[Dr Rajesh Bollam @CancerDochyd]

@TommiPedruzzi Claude

[Rohit Malde @roxboxfix]

INDIGO trial

Gr2 IDH mutant Gliomas woth Residual / Recurrent tumour

Vorasedinib Vs Placebo

NEJM 2023

Updated Analysis from ASCO 2026 added

[Dr Rajesh Bollam @CancerDochyd]

@Larvol @DrRishabhOnco @ASCO Congratulations
You made entire Renova group proud

[Uriel Suárez @UsuarezMD]

How I treat challenging transfusion cases in sickle cell disease | Blood | American Society of Hematology https://t.co/Uifr2RnMBQ

[Ahmed Kotb @AhmedKo45911157]

🔬How to Approach Acute Leukemia of Ambiguous Lineage?🧬
🩸Stepwise classification of acute leukemia:
✅AUL: No lineage markers
✅ PAL: Multiple lineage markers
🧑‍⚕️Use cytogenetics, FISH & molecular tests for confirmation!
📊 Decision flowchart below! 👇
#ASH #Hematology #Leukemia

[Dr. Chokri Ben Lamine @abouabdrahman0]

🩸 APL (Acute Promyelocytic Leukemia) – Hema Board Summary
🎯 Ultra-focused, guideline-based, exam-oriented
🧪 ELN + NCCN aligned

⸻

🧬 Diagnosis

• 🧲 Suspect APL with: DIC, low fibrinogen, �� PT/PTT, ↑ D-dimer, severe cytopenias + classical promyelocytes
• 🔬 Flow cytometry:
•CD33+++, CD13+, CD117+, MPO+
•HLA-DR−, CD34−, CD15−, CD11b−
•“Cup-shaped nuclei” blasts
• 🧬 Confirmatory test: PML-RARA by RT-PCR or FISH
• 🚨 Start ATRA immediately → do NOT wait for confirmation

⸻

💉 Transfusion Targets (Life-saving in APL)

• 🩸 Platelets > 50,000/µL at all times
• 🧵 Fibrinogen ≥ 150 mg/dL (4.4 μmol/L) → cryo preferred
• 🧪 INR < 1.5 → FFP
• 🟥 Hb 8–10 g/dL
• ⚠️ Maintain aggressively for first 10–14 days

⸻

🛑 Precautions

• 🚨 Do NOT delay ATRA
• 🩸 Treat DIC aggressively
• 🔥 Differentation syndrome (DS): monitor weight, edema, O₂ need
• 💉 Avoid IM injections
• 🧪 Keep TLS monitoring
• 🚫 Avoid anticoagulation unless mandatory (VTE with platelets >50K)

⸻

💊 Management (Detailed)

⭐ 1. ATRA – Start immediately

• Dose: 45 mg/m²/day divided BID
• If intracranial hemorrhage → still give ATRA

⭐ 2. ATO (Arsenic Trioxide)

• Standard low-risk protocol (WBC ≤10k): ATRA + ATO
• High-risk (WBC >10k): add Idarubicin or GO
• Monitor QTc, electrolytes (K >4, Mg >2), LFTs

⭐ 3. Differentiation Syndrome (DS)

• Clinical: fever, ↑ WBC, edema, hypoxia, pulmonary infiltrates
• Treatment:
•Dexamethasone 10 mg IV q12h immediately
•Hold ATRA/ATO only if life-threatening
•Diuretics if overload

⭐ 4. Supportive Care

• TLS prophylaxis
• DIC management as above
• Infection prophylaxis standard for AML

⭐ 5. Monitoring

• PCR PML-RARA every 3 months for 2 years
• Stop after 2 years if persistently negative

⸻

🧩 Hema Board Pearls

• 💥 APL = medical emergency
• 🧬 Flow: CD34– / HLA-DR– → think APL
• 🚑 Start ATRA even before labs return
• 🩸 Fibrinogen target ≥150 mg/dL saves lives
• 💊 ATRA+ATO cures >90%
• ⚠️ DS is the leading cause of early death → treat early
• 🔍 Monitor QTc every 48–72h with ATO
• 🩺 CNS prophylaxis NOT routinely needed

⸻

🎓 10 MCQs (With Perfect Answers)

1️⃣ Most important first step in suspected APL?
A. Bone marrow biopsy
B. Start ATRA
C. Cryoprecipitate
D. Confirm diagnosis by PCR
➡️ Answer: B

2️⃣ Flow cytometry hallmark?
A. CD34+ HLA-DR+
B. CD34– HLA-DR–
C. CD7+ CD3+
D. CD19+ CD10+
➡️ Answer: B

3️⃣ Fibrinogen target?
A. 100
B. 150
C. 200
D. 250
➡️ Answer: B

4️⃣ DS treatment first-line?
A. Lasix
B. Dexamethasone
C. Hold ATRA
D. IVIG
➡️ Answer: B

5️⃣ QTc risk associated with?
A. ATRA
B. ATO
C. Idarubicin
D. GO
➡️ Answer: B

6️⃣ Low-risk APL regimen?
A. 7+3
B. ATRA + ATO
C. ATRA + Idarubicin
D. ATRA alone
➡️ Answer: B

7️⃣ Platelet target?
A. >10k
B. >20k
C. >50k
D. >100k
➡️ Answer: C

8️⃣ CNS prophylaxis?
A. Routine
B. Not needed
➡️ Answer: B

9️⃣ Leading cause of early death?
A. Infection
B. DS
C. DIC/bleeding
D. TLS
➡️ Answer: C

🔟 PCR monitoring schedule?
A. Monthly
B. Every 3 months
C. Yearly
➡️ Answer: B

⸻

🧪 5 OSCE Scenarios

🩺 OSCE 1 – Emergency APL
• Patient: WBC 2k, platelets 12k, fibrinogen 80 mg/dL, bleeding gums
✔️ Start ATRA immediately
✔️ Give cryo to target ≥150
✔️ Platelets to >50k
✔️ FFP for INR

⸻

🩺 OSCE 2 – DS on Day 7 of therapy
• Fever, weight gain 5 kg, O₂ sat 90%
✔️ Start Dexamethasone IV
✔️ Chest X-ray
✔️ Continue ATRA unless severe

⸻

🩺 OSCE 3 – QTc 510 on ATO
✔️ Hold ATO
✔️ Correct K/Mg
✔️ Restart once QTc <460

⸻

🩺 OSCE 4 – APL pregnancy
✔️ Give ATRA + anthracycline
✔️ Avoid ATO
✔️ Control DIC aggressively

⸻

🩺 OSCE 5 – Post-remission monitoring
✔️ PCR every 3 months
✔️ Rising PCR → preemptive ATO-based therapy

#️⃣ #ASH #SOHO #SOHO_KSA #ESH #Emirates_Hematology_Society

[Dr. Med @DrNikhilMD]

Pancytopenia is one of the most dangerous “abnormal CBC” findings in medicine.

Because it may represent:
• Simple vitamin deficiency
• Severe sepsis
• Bone marrow failure
• Acute leukemia
• HLH
• Advanced liver disease

3 cell lines low together is NEVER something to ignore.

A practical clinical approach 🧵

[Dr. Chokri Ben Lamine @abouabdrahman0]

🩸 Polycythemia Vera (PV) – Diagnostic Criteria (WHO/ICC 2022–2025)
By Dr Omar Albanyan
⸻

🔥 Major Criteria

1️⃣ Elevated Hemoglobin / Hematocrit
• Men: Hb >16.5 g/dL or Hct >49%
• Women: Hb >16.0 g/dL or Hct >48%
• OR >25% increase in red cell mass

2️⃣ Bone Marrow Morphology
• Hypercellular for age
• Trilineage proliferation (panmyelosis):
– Erythroid
– Granulocytic
– Megakaryocytic (large, pleomorphic, hyperlobated)

3️⃣ JAK2 Mutation
• JAK2 V617F or JAK2 exon 12 mutation
• Present in ~85–98% of cases

⸻

🟡 Minor Criterion

• Low serum EPO level
– Below reference range

⸻

📌 Diagnosis

• Requires all 3 major criteria, OR
• Major #1 + Major #2 + minor (low EPO)

ICC also allows diagnosis if:
• Meets Hgb/Hct criteria
• JAK2 mutation present
• Subnormal EPO, even without biopsy (under specific contexts)

⸻

🧠 Bone Marrow Image Hallmarks

• Hypercellular
• Dense trilineage proliferation
• Large, pleomorphic megakaryocytes with hyperlobated nuclei

⸻

#PV #Myeloproliferative #JAK2 #WHO5 #HemeFellows #SOHO #ASH #KFSHRC

[Dr. Chokri Ben Lamine @abouabdrahman0]

🩸 Secondary Polycythemia (Adult) – Causes & Practical Workup (Hematology-Focused)

⸻

1️⃣ What defines secondary polycythemia?

➡️ ↑ Hb/Hct due to ↑ EPO drive, not a primary marrow disorder
➡️ EPO normal or high
➡️ JAK2 negative

⸻

2️⃣ Causes of Secondary Polycythemia – by Mechanism

🔵 A. Hypoxia-driven (MOST COMMON)

Chronic or intermittent tissue hypoxia → ↑ EPO

Pulmonary / hypoventilation
•COPD
•Interstitial lung disease
•Obstructive sleep apnea (OSA)
•Obesity hypoventilation syndrome

Cardiac
•Cyanotic congenital heart disease
•Right-to-left shunts

Environmental
•High altitude 🏔️
•Chronic smoking → CO exposure 🚬

📌 Clue: SpO₂ low or borderline, ± secondary erythrocytosis symptoms
📌 EPO: High or inappropriately normal

⸻

🟣 B. Renal / Local Renal Hypoxia

Kidney senses hypoxia → ↑ EPO
•Renal artery stenosis
•Polycystic kidney disease
•Hydronephrosis
•Chronic kidney disease (selected cases)

📌 Clue: Renal bruit, HTN, abnormal imaging
📌 EPO: High

⸻

🔴 C. EPO-Secreting Tumors (Paraneoplastic)

Autonomous EPO production
•Renal cell carcinoma (classic)
•Hepatocellular carcinoma
•Cerebellar hemangioblastoma
•Uterine leiomyoma
•Pheochromocytoma

📌 Clue: Markedly ↑ EPO, systemic or mass-related symptoms
📌 EPO: Often very high

⸻

🟠 D. Drug- or Hormone-Induced
•Testosterone / anabolic steroids 💉
•Exogenous EPO (athletes, CKD misuse)
•Androgens for hypogonadism

📌 Clue: Medication history
��� EPO: High or normal (if exogenous EPO)

⸻

⚪ E. Congenital / Rare (consider in young pts)
•High-affinity hemoglobin variants
•2,3-BPG deficiency
•VHL / EPAS1 / EGLN1 mutations

📌 Clue: Lifelong erythrocytosis, family history
📌 SpO₂: Normal
📌 EPO: Normal or high

⸻

3️⃣ Practical Differentiation: Step-by-Step Workup

✅ Step 1: Confirm real erythrocytosis
•Repeat Hb/Hct
•Exclude dehydration, diuretics

⸻

✅ Step 2: Serum EPO (key test)
•Low (<4 mIU/mL) → Think PV
•Normal / High (≥4 mIU/mL) → Secondary polycythemia

⸻

✅ Step 3: Rule out PV
•JAK2 V617F ± exon 12
•If JAK2 negative + EPO normal/high → NOT PV

⸻

✅ Step 4: Look for hypoxia
•Resting SpO₂
•ABG if needed
•Sleep study if OSA suspected
•Smoking history ± carboxyhemoglobin

⸻

✅ Step 5: Renal evaluation
•Creatinine, UA
•Renal ultrasound / CT if suspicion

⸻

✅ Step 6: If EPO markedly high & no hypoxia

➡️ Search for EPO-secreting tumors
•CT abdomen (kidneys, liver)
•Brain imaging if neurologic symptoms

⸻

✅ Step 7: Drugs & hormones
•Testosterone / anabolic use
•EPO injections

⸻

4️⃣ Key Differences: PV vs Secondary (Clinical Pearls)

FeaturePVSecondary
EPO⬇️ LowNormal / High
JAK2PositiveNegative
WBC / PlateletsOften ↑Normal
SplenomegalyCommonRare
B12↑Normal
IronOften ↓Normal

⸻

5️⃣ Management Principle

🎯 Treat the cause, not the number
•OSA → CPAP
•Smoking → cessation
•Tumor → resection
•Testosterone → dose adjust

⚠️ Routine phlebotomy NOT indicated unless:
•Symptomatic hyperviscosity
•Very high Hct with risk factors

⸻

6️⃣ Take-home algorithm (one line)

⬆️ Hb/Hct → EPO →
•Low = PV
•Normal/High = Hypoxia, kidney, tumor, drugs

[Dr Rajesh Bollam @CancerDochyd]

Does biopsy spread cancer?
❌ MYTH
✅ Biopsy does NOT spread cancer
✅ It helps diagnose &amp; plan treatment early
⚠ Delay = Risk
Don’t fear the test. Trust science.
📞 9505878232
#CancerMyths #Oncology #EarlyDiagnosis #RenovaHospitalsre

[William Aird @WilliamAird4]

HYPERGAMMAGLOBULINEMIA IN LIVER DISEASE

Not all polyclonal gammopathies are the same.

IgM → PBC
IgG → autoimmune hepatitis
IgA → alcohol-related liver disease

A small detail.
But a useful one.

[Dr. Chokri Ben Lamine @abouabdrahman0]

🩸 Melena in Hemophilia A = treat as MAJOR BLEED until proven otherwise ⚠️

🚑 ABC first → IV access x2 → fluids ± PRBC → labs (CBC, aPTT, FVIII level, inhibitor)

💉 DO NOT DELAY FACTOR
➡️ FVIII 50 IU/kg IV bolus
➡️ Target 80–100% 🎯
➡️ Maintain >50% for 7–14 days (GI bleed = major)

🔁 Repeat dosing / continuous infusion based on levels 📊

🚫 Suspected inhibitor? Think failure to respond
➡️ Use bypassing agents:
⚡ rFVIIa 90 µg/kg q2–3h
⚡ aPCC 50–100 U/kg q8–12h (max 200 U/kg/day)
❗ Avoid alternating → thrombosis risk

💊 Start IV PPI immediately (pantoprazole bolus → infusion)

🧪 Add tranexamic acid cautiously (avoid if hematuria)

🔍 Endoscopy ONLY after correction
➡️ Ensure FVIII ≥50% before EGD

📉 Monitor closely
➡️ Hb q6–8h
➡️ Hemodynamics
➡️ FVIII levels
➡️ Watch rebleed 🔁

⚠️ On emicizumab?
➡️ Prefer rFVIIa
❌ Avoid high-dose aPCC → TMA/thrombosis

🧠 Causes same as general population
➡️ PUD 🥼
➡️ Gastritis
➡️ Angiodysplasia
➡️ Varices (don’t miss)

🔥 Key rule:
Factor first → scope later

#Hemophilia #GIbleed #Hematology #BMT #KFSHRC

[Karamvir Yadav @K_Yadavir]

Continue TKI during RT — or hold?

The ESMO-ESTRO consensus provides practical guidance:

✅ Most high-dose RT → Major adaptation
⚠️ Skin toxicity signal strong with BRAF/MEK
🛑 Clear “Do NOT combine” scenarios defined

Data limited. Decisions must be multidisciplinary.

#RadOnc #ThoracicOncology #MedTwitter @OncoSKY @OncoAlert @oncodaily @OscarTahuahua @myESMO @ESMO_Open @sciqst @MedicalwatchHQ

[Karamvir Yadav @K_Yadavir]

MIBC 2026: What’s practice-changing?

• GC + durvalumab → EFS & OS benefit
• EV + pembrolizumab → HR 0.40 (EFS) in cisplatin-ineligible
• Adjuvant IO for high-risk disease
• ctDNA-guided strategies emerging

Perioperative therapy is no longer optional — it’s foundational.

#GUOnc #BladderCancer #MedTwitter @OncoAlert @oncodaily @EvidenceOpen @EUplatinum @UroDocAsh
@shilpaonc

[Ahmed Kotb @AhmedKo45911157]

Ph+ ALL in CMR: Is allo-SCT needed? 🩸

🔹 Early CMR (≤3 months) analyzed by propensity score
🔹 Allo-SCT ↓ relapse risk but ↑ non-relapse mortality
🔹 No improvement in OS or RFS

👉 In deep responders, transplant may not add survival benefit.
#POSS26