Transcription
Hello everyone. Can you hear me? Yeah. Is the screen visible? Can you see the screen? Let's not first.
This is a 40-year-old mate admitted to the emergency department with high grade fever and productive cough. His hemoglobin is 120. White cell count is 70 and count is 210. This is power 10. And I will do now. Do we have any lab scientist in the audience?
Okay, if there is no lab scientist, for example, I am the lab scientist. I have seen this blood pin and reported as luccoytosis with NRBC likely CMN. refer this blood to clinical hematologist. You are the clinical and you have to report this. The first on the list is how many godwin. How many, if you have any comments on this, but we have a short hello. So, do you have any comment on this blood?
Okay, sorry. Please brief history again. Sorry, my this is a 40 year old man admitted to the emergency department with fever and cough. The full blood count shows hemoglobin of 120, white cell count of 76 and plated count of 220. Lab scientists have seen the blood thin and he has reported as luccoytosis with NRBC likely CML. The blood film referred to hematology clinical hematology. If you can report this blood film as a clinical hematology.
Um, so the red the red blood cells um, so the red cells I would say an iso an isoccytosis. Um, they are neglected red blood cells, neglected LBC for the red cell and then for the white cells I will say nuctois um with complete myoid spectrum and for the platelets. So for the platelets I say feel I'm looking at now uh reduce on film but not yeah and that's what I can appreciate here. Yeah.
What is your impression? So my impression with this would be would be CML and what opinion you will what suggestion you will give to the team because they will contact you shortly from the ED that the patient has high white cell count. Is this a leukemia or what is this? So this is this looks like this this CML. So I'll go with CML.
So for this [Music] um the immediate care for this patient would be uh I could get some cycle reduction for the patient while waiting to get um a more definite diagnosis. Uh so I could give some hydroxy ura give hydroxy ura and then ensure patient is hydrated. Then give um [Music] alopurino to prevent um in case of TLS and then for patient having fever. So we could also do the sepsy work, get a chest x-ray, uh do the blood culture, get the full blood, uh do blood culture, do urine and then start question antibiotics. Um yeah, so that will be the immediate care care for this patient and then eventually um we try to get a more definitive diagnosis. Although for CML we could still send blood sample for fish to get the BCR ABL but uh we will still need to do a bone marrow so as to help us do the staging properly and also for cytogenetics and then for this patient we also need to look at uh other co-mobilities. Is the patient diabetic? Does the patient have any uh cardiac concerns because that would eventually determine the treatments that we would offer this patient.
Okay. Is there anyone in the audience who disagree with God? Ravia, what do you think is Ominy correct in reporting the blood? Raj. Hi Aish. Um, do you agree with Omi Goodwin or do you disagree with Omin? Yeah, I think um I saw a couple of blast um but just I would like to see more um like tight of the film just to decide like if like in blast crisis or not. I agree that it's CML is the probability but obviously we just we need to make sure that there is no significant uh number of blast like it's not in blast crisis. Um so far in this field I can see like it's uh I agree that there is variation in the in the granular site at different maturation stages with um mainly milocy peak uh many negated red cells in this field. Um is there anything missing in this blood fields? If you are saying the visual field is missing then why are you saying that this is lost crisis or Yeah. Yeah. I couldn't appreciate any Yeah. There was no battlefield as far as I can see. Yeah. Did you see any you see nothing? No. No. No. No, I couldn't appreciate um any basil or edenophil. Yeah. So then what what could it be if there is no basopil? No, and there is myoid peak and this is the picture. Yeah. Um action. Yes. Patient has success. Yeah. And there is yeah definitely left shift neutrophilia. So this is the common case that appeared in the partat exam and people write it as CML both reaction and CML has high count but the difference is bopilia and we didn't see any bopil here. We didn't see any here. Also all other components of myoid series are present here with NRBC as well and the patient is fibbral having uh pneumonia symptoms. This is a septic blood not for CML you should see eucinophils you should see basopils as well. Yeah that's true. Yeah. So reactive blood film is a must thing in the exam and people write it as EMF. So you need to see uh blood picture blood films of septic patient in your hospital and also the CML patient blood as well so that you could know what is the difference between the two.
Okay. This black film contains a lot of NRBC. There is nasocytosis. We could see many uh teardrop cells here in this picture. You can see target cells as well. There were few homology bodies in the red cell. There's myoid peak in the white cell. Okay. You can see also of uh my series there. ated count is low which is low because patient has renome uh as evident by the target cells and by the whole jib body. So this was the septic blood.
Now the same patient presented to hematology department after 5 years. Okay. The GP referred the patient to hematology department because of persistent luccoytosis. This is instruction. This is power. His full blood count shows hemoglobin of 105, white cell count of 400 and fed count of 100. Okay. Now I will go to power 50. Okay. So, what do you think about this blood? The same scientist has seen the blood film again and he says that this patient has litery and likely leukemia. The blood film has come back to you again. Now you have to report it. Roia, are you there? So Raa is hiding today. Uh next one is Rashag Guda. Okay. Samir Abas. Hi. Hi. So I um I can still see like very large number of left checked um uh granular sides with with all stage of maturation and and I think it is still with some like ro formation in the background of well which might be like suggesting possibility like of a severe infection again. So um I I couldn't appreciate any basils or xenophils still in this film. So I would still go with um reaction.
Can you see my Oh yes, this one. No, this is um there were many things like this and this look that we have seen. Is that a basil? This is a vasopen. [Music] Vasopen is a very very adrenaline and there are many lucod reaction will not give you wide cell count of 400. This is another reason. This is the business. This one see this. Yeah. This pin is full of these. So now this is a CML. This is a PML but we don't know whether this is plus prices or how would you differentiate? So between the two. So the blast percentage um is the most important here. Mhm. We don't have now in the classification anymore the accelerated phase but um which will be like a 15 to 29% of blast and if more than 30% it will be blast face otherwise it will be chronic more than 20% blast if you have now in CML you will treat it as AML. Okay. So for CML and for the SEA mutation BCR ABL and for SEPA mutation you need more than 20% blast treat them as AML. For others if you have just mutation or transfocation present irrespective of the blast percentage you will treat them as AML. This is according to WHO 2022. Okay. All right. The chronic pain, the blood, how um I think then it will be anything less than than the 19 10 to 19%. Yeah. Because now the accelerated page has been removed. Yeah. So anything less than 20 we considered as in a chronic case. Previously 10 to 20 was accelerated and less than 10 was chronic. But now most of the hospitals in they use WH 2022.
What are the major root abnormalities in KML? Was it the K? Um, there's no KOS in CML. Anyone who knows which of the major root abnormalities in the CML try eight and others there's also additional chromosome X8 19 and chromosome 17 or consider as major root abnormality. Okay. What is the progress score that you use in your hospital for CMI? The ELA score. ALTS score. If the care score is high in this young patient, which medication you would like to offer to this patient? Yeah. Uh second generation KKI um like the satinate. The certain highs young patient you can offer them second generation the certain what are the contra indications of the certain um I think plural diffusion edema or picard fusion yeah anything which desaturates is the contra indication Sorry. Contra indication for the detert. Um got already pulmonary or pericardia disease. Yeah. So deep for the certain D for desaturation. Anything which desaturates the person means cause hypoxia can lead to uh or the contra indications of um inter 20 female.
Okay. Uh so presented to ED with fatigue. Okay. The full blood count shows hemoglobin of 90, white cell count of four and plated count of 150. The lab scientists have reported the blood film as thrombocytosis likely essential thrombocymia. The blood film has been referred to you for your comments. So this is the power 10. Now I will go to power. Okay. Any comments from your site? How to report this blood thin for the exam purpose? I think I will say um RPC is showing a need for ktoytosis um with some um with Mhm. Okay. Um I think in the previous film I appreciated um some pencil cells but I can't see them here. Um um there are um occasional fragments. Mhm. Okay. There are there is some mild plateless clumping. um pllets. Um an isocytosis. Yeah. So here there are some um I think uh there are some pencil cells here in this field. There are few cells lacking the central pala looks I don't want to commit myself to spherees here but um yeah and my trombocytosis um lymphocytes. So there is lymphocy in the middle here and if we compare the size the red cells is slightly microitic. Yeah. But I think I will say feature suggestive of um iron deficiency anemia.
Do you think this is iron deficiency anemia or combined deficiency or this is ET? So um the cell sizes um some of them are smaller than the size of the side nucleus but there are few a little bit bigger cells like this one on top here. Yeah. And another one here at the middle. So it could be mixed. Yeah. You're right. It is not eaten. I don't think so. Well, I can't say for sure, but because we need to do further testing, check the iron stores, check the inflammatory markers. Um, and if all negative, then I can check the dark mutation and um yeah, but initially we need to exclude reactive causes. Your approach is correct. First they have to exclude the metine deficiency and the uh infection marker in if they are normal then we have to send blood to smds or or yes this has a lot of uh nosytosis both microitic macroic cell uh one of the cell has joy bodies as and I bring out this nucleite for you so that you can compare the size of the RBC with the lymph and he is a female and can have been as well leading to R& defic. So yes, we cannot jump straight to ET. We have to exclude R deficiency and uh infection first according to the BSF algorithm to exclude exclude the rejected.
For example, this patient was diagnosed as ET. what treatment you would like to give to this patient? So, she is a young lady. Um, I need to check her um uh if check if she had any previous history of thrombosis. Or um yeah, VTE before um if no. So, if not, she's uh then that means she's low risk. Uh so, I will start now on aspirin. and keep monitoring how cows no need to start cy reductive therapy at the like currently better to check your hospital guidelines whether they would like to give aspirine or not because her plated count is about thousand I've seen some of the trust do not give aspirine if the count is above thousand some of the trust do not give aspirine if the count are about 1,500. So check your hospital guideline or discuss with your myoid consultant. If they say yes, you will give then okay. If they say no, then in the exam you can mention to them. According to my first guideline, they usually avoid aspiring about when the plate count is about,000 because of the risk of acquired one gram. So practice according uh practice studies in terms of aspiring but below thousand yes everyone will get aspiring and no indication of reductive therapy.
This is 70 year old man presented to ED with a large neck mask on the left side of the neck. CT scan neck, abdomen, pelvis shows lympadinopathy above and below diaphragm. The full blood count shows hemoglobin of 110, white cell count of 12 and count is normal. He has weight loss, night sweats and lack of appetite. The night the neck mass is quite big and it is causing discomfort to him. This is power 10. Let's go to power 50. Now there are some dropets in the slide. No. Okay.
So I have seen this blood pin as a biomedical scientist and I have labeled this case as a lymphoma because of these abnormal cells in the patient um lymphocy in the blood. I don't know about the history of the patient because we do not have access to the patient record. I was trying to preserve the blood by keeping a slip on it. And this has created all the so when I saw this stud I thought this is some kind of neoma I should refer it to clinical hematology. Do you know the story of the patient and this is the blood. Next on the list is Imbraim. Im said Ahmed Ibraim is silent. Then we have top on the list is doc d o c doc dr. Yes. Yes.
So what do you think is going on with this patient? The biome the biomedical scientist think that this is some lymphoma in this patient. He has not mentioned which lymphoma but after seeing these cells he think that maybe there is lymphoma in the patient. Okay. Um um these uh these cells are uh large and um maybe it could be a leukemia too. I don't know the exact count of the cells. I don't uh recall the DLC. What cell count is 13? 13. is hemoglobin is 105 count is normal and the age of the patient is 70. Is there any history of fever? Patient has no fever but he has a history of weight loss, history of uh night sweats and he has a big uh neck mass. Okay. Um what is the ESR of the patient and um we don't do ESR here. Okay. Um I would like to rule out uh plasma cell or plasma blastic. This is your blood cell. You have to report it. Okay. So uh the the WBC's show large uh large cells with abundant cytoplasm and few vacules and nuclei also prominent in the large nuclei. Mhm. Um I could not decipher how how many these cells are because it really counts. I would like to know the exact DLC. uh because if these cells are like around greater than 10% or greater than 5% then I would uh because these are very big and um they are definitely not reactive lymphocytes. They are a little more bizarre looking than those. They have here yes. Mhm. And also I wanted to see whether there is ruler formation but I don't think there is any ruler formation on the on the smear and uh the RBC's uh are showing some kind of uh maybe some kind of fixation defect uh some the and the platelets look normal. So um I'd like to advise uh flowcytometry on this since the patient has a mass in the neck. So and also there should be uh FNAS or um biopsy of that mass uh to rule out any lymphoma or uh what do you think call it neoplasm? What is your impression? Yes, you have commented on the blood film. You have g your plan as well. But what what is your impression? I don't know. But I had seen one case of plasma plastic leukemia somewhere and uh I don't know why these cells are reminding me of those cells. I have no idea. But somehow it is giving me that sort of look. Leukemia come with a mouse. Come. No, I'm the the just the cells. Just the cells. If I'm just looking at the cells then I'm it's giving me that sort of thing. It's very big and they're very aggressive looking. Could be DLBC but the DLBC does not have so much cytoplasm. Mhm. Or um anoplastic large cell would be one of the di differentials. You would see any plastic love cells in the aspirate or in the fine. They rarely appear in the blood. Yes. Fine. True. Okay.
So the flow settric result have come back. It is CD5 negative, TD7 negative, TD 10 negative, CD19 positive, 20 positive, 23 negative, 43 negative, BCL2 positive, BCL 6 positive, TP 53 positive, mid 88 is positive, Do you have the cold immunoistochemistry result? Yes. DLBCL. So you think this is DBCL? Yes. These are not uh blast. You can see the size of the blast with the surrounding RBC. And some of them have a single formula nuclei or some of them have two permanent nuclei or more than that. Okay. And if a patient has a big mass in the neck as well, that is telling you that it can be a highrade lymphoma because bucket lymphoma or DDCL with always present with huge masses either in the groin or in the tummy or in the axilla or in the neck compressing other structures and putting the patient in agony and and the mass appear very quickly. in a matter of days because they are aggressively improved. If the mass appear over months and the cells in the blood frame are small as well, small to medium size, then I may think that maybe this low break, but these lymphocytes are quite big with a very permanent nuclei in the center as you can see in this picture. You always worry for a high grade. If it was a bucket, burket has different morphology. Um the cytoplasm is very deeply dissipated if they involve the blood with some meulation as well. Um so this patient age is 70 LDH is um 5,000. He has a lymphopathy above and below the diaphragm and his performance status is true. Do you think which regimen of therapy he would be fit for? Okay. I um are you asking me? Yes. Um I'm sorry. I do not remember the drugs right now. Okay. So anyone can if this patient is aging 70 LDH is 5,000 he has a disease below and above the length of the diaphragm his performance status is two what regimens do you have in UK to offer to this patient? I would ask Ravia or AA. Okay, Samir, you can talk if you have an answer. I was thinking that maybe his IBI score could be three plus. Mhm. Because of the age and the high LDH um and the performance status and then um and he's double hit um so um we can give him our chop like um or um or our uh or polar chip. Mhm. Plus we can consider like um the radiotherapy to the net mass to reduce like the symptoms of of the pressure. Radiotherapy is an option here but because of many vital structures [Music] um people may avoid it. They would like to see the response to chemotherapy first. Because if you offer him any chemotherapy um the mask reduces very quickly. But if it is it does not reduce he fail the chemotherapy then we go for ready therapy of the neck. So what regimen do you suggest stop or stop? You mentioned his IP is more than three. So in high IPI you give them polar. If the IPI was 01 or two then you would have offer art. This patient has no other coorbidity. So he can take cola art with high RPL. There are two other things about which we need to be careful in DLBCL or in in this patient. What are they? Can we consider them in every TBC CNS involvement or if they were like high for that? Yeah. CNS IPI you have to calculate and second TLS profile because these patients they have high um tumor burden and they can go into TLS very quickly. All right. Do you have any question? Oh, thanks. No question. Then we can Sorry. Um, just a quick one, please. I I have thought question on the last one. So sorry to take us back for the patient with ET lowrisk ET and a young patient. Um if you're thinking of acquired bonibra so what would we now offer the patient since we won't be giving aspirin? So if the patient has ET and can you please repeat? So ET um young patient less than 60 high plate light count and we are we are bothered about acquired one disease. So what would be the treatment option? So the risk of acquired one librar is high most if the pllet count is above 1500. In that case you can give this patient cyto reductive therapy because u you will not always follow what is written in the guideline. The case scenario sometime get different according to the clinical situation. If this patient plated count is for example 2,000 I know that he can bleed any she can bleed any time I will cly reduce the patient because without cyto reduction you cannot reduce the plated count of the patient in that cases in such cases you offer them cyto reductive therapy. Okay, thank you. And then you and you avoid the aspirine as well. In our trust, we usually avoid aspirin if the plated count is above thousand and because we are at high risk of um bleeding related to acquired one. Okay. So still in a young patient. So once we've been able to cycle reduce um this patient would we continue it long term or would there be option of stopping it after some point? Can you please my question? So I'm saying so I'm saying yes we know that for younger patient we would usually want to opt for aspirin. Yes in this patient patient because of the high platelet count we opted for cytored reductive to reduce the platelet count. So we've had a platelet count going far less than a thousand maybe in 600 thereabouts. Would we still carry on the cyto reductive long-term or at some point we get to stop and only give aspirin? If the rated count is 600 and patient has no VTE, no hemorrhage related to to the ET, you only give them you only give them aspirine if the patient is young. If the patient has any uh if the patient has any VTE event or if the patient has any hemorrhage related to ET you will start uh profile you will start cyto reductive therapy even at low plated count as well. So what I'm asking I'm not talking of a new patient I'm saying the patient that initially had cytored reductive then the platelet has now gone down to 600. So are we to carry on with the cyto reductive or we get to stop at that point? Yes. So once the plated count is in normal range 150 to 400 at this stage we can pause the hydroxyarbomide and see whether whether the patient can maintain the plated or not. If the plated count start to rise again, we reintroduce the hydroxyarbomide because if you continue hydroxy carbomide, it is cytored reductive. it will continue to destroy your red cells and platelet and it may go down dangerously low because if you open the hydroxyarbomide algorithm in the BSH they have mentioned if your platelet count goes down below 100 or hemoglobin goes down below 45 or neutrfil count goes down below 1 1.0 zero you have to stop the hydroxyarbomide and you have to repeat the full blood count after a week and if they are above these values you can reintroduce hydroxy carbomide with a lower dose. So once they reach the normal values you can give a pause but we know that we follow these patient regularly and uh we check their full blood count uh every month or in the control patient every 3 month. Uh if they if the count increase again above 400 we will start a small dose of hydroxyamite again. So if you open the hydroxyabomide algorithm in the in the BSH we always manage our patient um patient hydroxyomide according to the guidelines for hydroxyamide and this is the algorithm in any case if it if it is a polyythemia if it is ET if it is any other MPN we follow this algorithm where is that this one it is on the screen count less than 1.0 Zero plated less than 80 having to be less than 45. Stop hydroxy moment and repeat full blood count weekly until neutral is above this level plated above this level to be about once a stable dose is established. So this is the hydroxyomide algorithm that we follow in our MPN patient all MPN. Okay. Okay. Right. Thank you. Okay. If nothing else then we will see you next week. Thank you. Thank you very much. Thank you. Take care.