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Hemepath

I am officially well into my PGY-2 year and my current rotation is Hemepath for 3 months.  It’s been a bit of a shift from the mentality of Surgical Pathology, but the workflow is similar to that other, “foreign” world.  I enjoy the types of cases we get to work up and actually have found that doing diffs and working on flow studies is particularly rewarding (once I’ve understood what I’m actually doing!)

Here’s a Hemepath case I had on-call a few weeks ago:

I was called on Friday night at 6:30pm by our Hematology lab to evaluate a peripheral blood smear with “unclassified cells” on a 45 year-old man who had a complete blood count showing 165,000 WBCs/microliter.  Surprisingly he felt ok overall, except for slight malaise.  His labs were as follows:

WBC 165k/ul

Manual differential: 5% unclassified cells, 39% neutrophils, 10% bands, 9% metamyelocytes, 13% myelocytes, 1% promyelocytes, 10% lymphocytes, 8% monocytes, 3% eosinophils, 2% basophils

Hgb 10.2 (normocytic, normochromic);

Plt 137

Creatinine 0.79

LDH 737 (ref range 100-190)

The peripheral smear that I reviewed looked like this:

For any beginning residents in the audience, how would you handle the case at this point?

After I triaged the case that night with my attending, we looked at the bone marrow on Saturday and signed out the flow cytometry on Monday.

Examination of the bone marrow showed 95% cellularity, decreased and small, hypolobated megas, decreased erythroids, and an immature shift of granulocytes.

Flow cytometric analysis showed 91% granulocytes, 4.5% monocytes, 1.1% T cells, 1.0% erythroids, 0.71% immunophenotypically unremarkable myeloid blasts, 0.21% NK cells, a subset of granulocytes and monocytes CD56+, and maturation disruption of granulocytes based on the CD11b/CD16.

How should this case be signed out?

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Leukemoid reaction as there is neutrophilia, left shift with mainly increased early precursors. Also highly increased LDH which again favors leukemoid reaction

Did this get FISHed?

What a wonderful case. Although this could be a leukemoid reaction, one would certainly include CML in the differential diagnosis. The peripheral smear and bone marrow findings are classic. The small hypolobated megas have been commonly described in CML (dwarf megas). I am not sure exactly what is being referred to as a maturation disruption based on CD11b and CD16 – more detail would be helpful. All of the findings that have been described are consistent with CML. I would want confirmation of the presence of the BCR-ABL1 fusion protein to make this diagnosis (required). As for how it gets signed out – you didn’t’ comment on the percentage of blasts in the marrow… 10% blasts in the PB puts us at accelerated phase and is concerning that the blast phase is on the way. OR, this may be already in the blast phase. A qPCR for BCR-ABL1 would be a critical piece of information in this case, both to make the correct diagnosis and for monitoring response to treatment. A bit more information (blast count) is needed to give you a bottom line.

Some more CML images can be found here: http://pathologypics.com/PictView.aspx?ID=72

Classic CML core biopsy findings:
http://www.pathologypics.com/image.aspx?ID=72&Size=Mid

[...] Hemepath (2) [...]

see followup to this case in a future post here: http://pathtalk.org/archives/1567

Oops – I saw 10% blasts in the peripheral blood and it says 10% bands… Bottom line (including the results from the other post) – CML chronic phase.

Love the hemepath unkowns. Thanks for the post.