Hematology Pills

In this episode, Prof. Robin Foà and Prof. Filippo Milano are joined by Dr. Joshua A. Hill, infectious disease specialist at Fred Hutchinson Cancer Center in Seattle, to take on one of the most clinically relevant challenges of contemporary hematology: the immune deficiency and infectious risk that accompany increasingly effective cancer therapies. From allogeneic stem cell transplantation to CAR-T cells and bispecific antibodies, the conversation examines how progress in disease control has brought new questions about how to protect patients over the long term.
The discussion opens with the evolution of infection prevention in transplantation. Historically, infections, particularly cytomegalovirus (CMV), were a leading cause of early mortality after hematopoietic stem cell transplant, and antiviral prophylaxis with agents such as letermovir has dramatically reduced severe CMV reactivations. The speakers then turn to post-transplant cyclophosphamide (PTCy), which has substantially lowered the incidence of graft-versus-host disease (GVHD) but also affects T-cell function. Registry data from the CIBMTR point to higher rates of viral, bacterial, respiratory,and fungal infections, prompting clinical research into reduced-dose cyclophosphamide, for example from 50 mg/kg to 25 mg/kg, to preserve GVHD protection while limiting immune toxicity.
A second axis of the conversation compares prophylaxis strategies across the Atlantic. In the United States, antibacterial prophylaxis with levofloxacin and antifungal prophylaxis with fluconazole are used more systematically, and in centers withlow local resistance, such as Seattle, they can reduce febrile episodes and bacteremia in neutropenic patients. European practice, reflected in the ECIL guidelines, is more conservative: given high rates of bacterial resistance, including to fluoroquinolones, routine antibiotic prophylaxis is consideredineffective and potentially harmful, with a risk of further resistance and disruption of the microbiota.
The episode then moves to CAR-T cells and bispecific antibodies, which cause secondary immune deficiency and prolonged cytopenias. Infections account for roughly half of non-relapse deaths and remain relevant up to five years after treatment.With CAR-T, infectious risk is highest early after infusion and then tends to stabilize, whereas with bispecific antibodies repeated dosing may lead to T-cell exhaustion and a viral risk that grows over time. The speakers also discuss a randomized trial of monthly intravenous immunoglobulin (IVIG), started before CAR-T and continued for four months versus placebo, which looks at infection rates and at any effect on CAR-T persistence and efficacy. They further address the “antibiotic dilemma”: broad-spectrum antibiotics before infusion are associated with reduced gut microbiota diversity, more relapses, and poorer survival in lymphoma and myeloma, yet about 75% of CAR-T patients develop fever after infusion, mostly from low-grade cytokine release syndrome, while true bacteremia occurs in only 1–2% of cases. Developing precisionmarkers to separate inflammatory from infectious fever is an important goal. The conversation closes with a historical reflection: diseases such as chronic lymphocytic leukemia, hairy cell leukemia, and multiple myeloma carry intrinsic immune alterations, and these persist even as modern therapies extend survival and spare patients conventional chemotherapy. A thoughtful conversation on why infectious risk must be continually reassessed as hematologic treatment evolves.

In this episode, Prof. Robin Foà and Prof. Filippo Milano are joined by Dr. Jordan Gauthier, Associate Professor at the Fred Hutchinson Cancer Center and an internationally recognized expert in the management of CAR-T cell toxicities. The conversation explores how the field has evolved from acautious, reactive approach to immune-related complications toward proactive, biomarker-guided prevention—an evolution essential to extending the safe use ofCAR-T therapy beyond major academic centers. The discussion retraces the paradigm shift in corticosteroid management, from the early Seattle trials of 2012–2017, when high-dose steroids were withheld out of fear of compromising CAR-T efficacy, to current evidenceshowing that early intervention mitigates toxicity without blunting antitumor activity. The speakers also examine the growing role of risk biomarkers—including CRP, ferritin, LDH, and pre-treatment thrombocytopenia—alongside emerging evidence on host genetic variants in T-cell function genes that may predispose patients to more severe complications. A significant part of the conversation addresses the pharmacological management of severe or steroid-refractory neurotoxicity, focusing on high-dose intravenous Anakinra and its role in facilitating corticosteroid weaning, as well as the ongoing investigation of JAK-STAT inhibitors such as itacitinib as alternative strategies. The speakers also discuss a distinct and less understood clinical entity: late-onset neurological toxicities (NINTS) associated with anti-BCMA CAR-T products such as ciltacabtagene autoleucel, includingcranial nerve palsies and Guillain-Barré-like syndromes, and the hypotheses behind their unique pathogenesis. Looking at the broader clinical landscape, the conversation turns to thegrowing demand for cellular therapies and the structuralchallenges—particularly hospital bed availability and long-term care logistics—that limit expanded access, alongside the value of multidisciplinary immunotoxicity meetings in managing complex cases. A rigorous and timely conversation on how deepening our understanding of CAR-T toxicities is paving the way for safer, more accessible immunotherapy.

In this episode, Prof. Robin Foà and Dr. Filippo Milano arejoined by Prof. Stefano Pileri, one of the world's leading hematopathologistsand a key contributor to the WHO Classification of Hematolymphoid Tumors. Inspired by his recent book, Where do we come from? What are we? Where are we going? A journey through theevolution of Pathological Anatomy over the last half century, the conversation retraces the remarkable evolution of hematopathology—from the era of purely morphological diagnosis to the integration of molecular technologies and artificial intelligence.
The discussion explores the milestones that transformed the field, including the introduction of immunohistochemistry, the discovery ofdisease-defining biomarkers such as CD30, and the transition toward molecular diagnostics and next-generation sequencing. These advances have progressively reduced diagnostic subjectivity while enabling increasingly precise disease classification and the development of targeted therapies.
A central theme of the episode is the growing need for highly specialized reference centers. As diagnostic techniques become more sophisticated, accurate pathological assessment has become essential not only for selecting the most appropriate therapy but also for avoiding unnecessary treatments and optimizing healthcare resources. The speakers also emphasize the importance of multidisciplinary collaboration, where pathologists and clinicians combine increasingly complex biological data to guide patient care.
Looking to the future, the discussion turns to digital pathology, tele pathology, and artificial intelligence. While AI promises to improve standardization and diagnostic consistency, it is seen as a tool that will support—rather than replace—the expertise and clinical judgment of experienced pathologists. A thoughtful conversation on how technological innovation has transformed hematopathology and how it will continue to shape precision medicine in the years ahead.

In this episode, Prof. Robin Foà, Dr. Filippo Milano, and Dr. Jerald Radich revisit the extraordinary journey of chronic myeloid leukemia (CML), one of the greatest success stories in modern hematology and the disease that transformed precision medicine from concept to clinical reality.
The discussion retraces the evolution of CML treatment, from an era when bone marrow transplantation represented the only curative option to the revolutionary introduction of tyrosine kinase inhibitors (TKIs), which have dramatically changed the natural history of the disease. Today, most patients receiving TKI therapy can expect a life expectancy comparable to that of the general population, making CML the prototype of targeted cancer therapy.
The conversation also highlights the global impact of scientific innovation through the partnership with The Max Foundation, an initiative that has expanded access to molecular diagnostics and lifelong TKI treatment for tens of thousands of patients in low- and middle-income countries. By combining innovative diagnostic strategies with worldwide collaboration, the program has demonstrated that precision medicine can become a global reality rather than a privilege limited to high-income healthcare systems.
Looking toward the future, the episode explores MyeloMatch, the largest precision medicine trial ever conducted in acute myeloid leukemia (AML). By integrating rapid molecular profiling, next-generation sequencing, and targeted therapies, the initiative aims to redefine frontline AML treatment while advancing increasingly sensitive measurable residual disease (MRD) assessment. The discussion examines both the promise and the challenges of applying precision medicine to a biologically complex disease such as AML, where molecular diversity continues to shape prognosis and therapeutic decision-making.
A compelling conversation on how decades of scientific discovery have reshaped leukemia care—demonstrating how precision medicine, global collaboration, and molecular innovation continue to redefine the future of hematology.

In this episode, Prof. Robin Foà and Prof. Filippo Milano reflect on a groundbreaking phase two study out of Seattle that introduces a novel and highly effective approach to cord blood transplantation. Unlike traditional double cord blood transplants, which have historically been hindered by severe complications when T-cells from both units interact, this new methodology overcomes these major disadvantages to reshape patient outcomes.
The conversation delves into the biological mechanics of this pioneering technique. Prof. Milano details how his research team successfully combined a single matched cord blood unit with an off-the-shelf product made from a pool of six to eight different units. By meticulously CD34-selecting and expanding these pooled cells for 14 days on a Notch platform, they created a therapeutic product rich in CD34 and monocytic cells, yet completely lacking T-cells.
A major theme of the discussion is the striking clinical success of this trial. Among approximately 30 patients, the approach yielded a 96% overall survival rate and a remarkable 0% incidence of acute grade 3 and 4 Graft-Versus-Host Disease (GVHD). Beyond survival metrics, the episode explores a fascinating biological phenomenon observed between day 7 and 10 post-transplant: a massive spike in active CD8 lymphocytes. Single-cell RNA sequencing revealed that these monoclonal cells originated from the matched unit, reacting to the mixed HLA of the pooled product. Prof. Milano highlights ongoing research using mouse models to see if this immune response can be predictably directed to enhance the Graft-Versus-Leukemia (GVL) effect, which would be especially beneficial for patients with active disease.
The debate then turns to the broader structural challenges facing the field today. With the overall number of cord blood transplants declining and public banks shrinking—even halting collections in major cities like New York—Prof. Milano strongly advocates for the preservation of this critical resource. Cord blood remains a vital, immediately available, pre-typed stem cell source, a readiness that proves essential during unexpected global emergencies like pandemics.
As the episode closes, the speakers look ahead to the future, discussing plans to test this pooled cell product in mismatched related haploidentical transplants. This dialogue is a candid examination of both scientific ingenuity and systemic challenges—a reminder that persistent innovation and dedicated research continue to push the boundaries of what is possible in the field of hematopoietic stem cell transplantation.