Hematological malignancies: in a physician's perspective.pptx

Hematological malignancies: in a physician's perspective.pptx

• 1.
  Hematological Malignancies: A Physician’sPerspective Pritish Chandra Patra Consultant Clinical Hematology & Hemato-oncology Apollo Hospitals, Bhubaneswar
• 2.
  Physician’s Perspective
• 3.
  Physician’s Perspective • Whendoes a physician comes across a case of hematological malignancy? • Routine OPD • weakness, anorexia, weight loss, bleeding, swelling, jaundice etc. • abnormal values of Hb, WBC, platelets • Emergency/Critical Care setup • Sepsis • Respiratory failure • GI bleed • Tumour lysis syndrome • Superior mediastinal syndrome • CNS SOL • Palliative care
• 4.
  Real Life CaseScenarios
• 5.
  Case 1. • 2021 •65 yr old female, no comorbidities • Presented with anemia requiring transfusions- 1 yr • No fever, jaundice, anorexia, weight loss • O/E- • Pallor++, no icterus, no LN pathy, no HSM • Initial tests • CBC- Hb- 5, TLC- 8500, DLC- normal, Plt- 5L • Retic- 2.5% • MCV- 102, MCH- 25, MCHC- 28, RDW- 14.5 • PS- RBC normo-macrocytic, DLC normal, no atypical cells. • LFT, RFT normal • Iron and B12- borderline low values • Treatment- • Iron and B12 injections • In between blood transfusions • Continued for- 1yr  no improvement • Patient visited us
• 6.
  Case 1.. • Tests- •CBC- Hb- 8, TLC- 7000, DC- normal, Plt- 5L • MCV- 103 • PS  • Iron and B12- rechecked- normal Macrocytosis with thrombocytosis Peripheral smear
• 7.
  Case 1… Bone marrowaspiration Bone marrow biopsy Cytogenetics deletion of the long arm of chromosome 5 atypical, hypolobated • BMA, BMBx- below • Conventional cytogenetics & FISH  • 5q del • Started Lenalidomide • Today it’s more than 4 yrs & no BT MDS with isolated 5q deletion
• 8.
  Clues in thecase • Checking the PS, red cell indices • After a trial of hematinics  if no response  re-assess the disease • Timely referral
• 9.
  Case 2. • 2022 •52 yr female • No co-morbidities • Gum bleeding, reddish to dark skin spots • No fever, anorexia, weight loss, dyspnea • O/E- • Few cervical and axillary LNs • Multiple purpuric and petechial spots in oral cavity and all over body • Tests • CBC- Hb- 13, TLC- 15000, N25 L70 M3 E2, Plt- 12000 • LFT, RFT, urine- normal • Treatment • Antibiotics • ITP  steroids  initial response  relapsed after 2 months • Hematology referral
• 10.
  Case 2.. • O/E- •Cervical and axillary small nodes+ • Tests • CBC- Hb- 13, TLC- 20000, Plt- 15000 • PS- lymphocytosis, small mature lymphocytes, few prolymphocytes, smudge cells, low platelets • LFT, RFT, LDH, uric acid- normal • Flowcytometry from PB: • +ve for CD5, CD23, CD19, CD20, CD200, kappa restriction  CLL • Treatment- BR  remission till now Peripheral smear Small mature lymphocytes and smudge cells Chronic lymphocytic leukemia
• 11.
  Clues in thecase • Clinical examination  LNs • Checking the PS  morphology • Before starting steroids- exclude all possible DDs • Timely referral
• 12.
  Case 3. • 2024 •55-yr female • Low grade fever, weakness, cough- 2 months • Evaluated by physician- • O/E- • pallor+++, Ict-, LN-, edema+, no HSM • Tests • CBC- Hb- 4, TLC, DLC, Plt- normal, • iron and B12 normal • Oral antibiotics- multiple course • Anemia progressed- • Received- 8 BT in 2 months  No improvement • Referred to Hematology
• 13.
  Case 3.. • Tests •CBC- Hb- 5, TLC, DLC, Platelet- normal • PS- NCNC RBC • Reticulocyte count- 0.1% • LFT, RFT, LDH, Uric acid- normal • Coombs test (direct & indirect)- neg • X ray chest- normal, USG abd- normal • BMA, BMBx- erythroid precursors <1% • PCR for parvo virus B19- negative • CECT thorax and abdomen- solid-cystic mass in lower mediastinum in cardiophrenic angle • CT guided biopsy- Thymoma • Excision of the mass • Remission- Hb-12 • Today it’s 5 months post surgery Thymoma with PRCA Bone marrow biopsy marked reduction in erythroid precursors
• 14.
  Clues in thecase • Severe anemia requiring frequent BT- check PS and reticulocyte count • Clinical examination  LNs, mass • BM • CECT thorax and abdomen • Suspected PRCA • R/o secondary  thymoma, thymic Ca, parvo B19 • Primary PRCA
• 15.
  Case 4. • 2020 •65 yr male • h/o HTN >10 yrs, CVA- 5 yrs back • C/o- Chronic diarrhea- 1yr- watery stool, 2-3/day • Weight loss- 8 kgs in 6 months • No- hematochezia, melena, fever, abdominal pain, nausea, vomiting, or any recent use of antibiotics • Evaluated by physician • O/E • Pallor+, B/L pedal edema+, no LN, liver- 2cm • PN- grade 1 • Tests- • CBC- Hb- 9, TLC- 7500, Plt- 2L • PS- NCNC RBC • RFT, LFT- normal (raised ALP- 320), • Stool- no ova, cyst, parasite, -ve for c. diff toxin, • Neg for Celiac panel
• 16.
  Case 4.. • UGIE-mild antral gastritis, Colonoscopy- normal • Biopsy from duodenum & stomach  • BMA+BMBx- • Plasma cells 12% with amorphous material in BMBx • Congo red stain +ve apple-green birefringent in polarized light • SPEP- M band- 3.2 gm/dl • PET CT- lytic skeletal lesions+ • C-R-A+B+ Amyloidosis • Diffuse lymphoplasmacytic infiltrate within the lamina propria, and focal loss of Brunner glands. • Diffuse deposition of eosinophilic, amorphous material, which is positive for Congo red stain. Duodenal mucosa
• 17.
  Clues in thecase • Anemia, chronic diarrhea, hepatomegaly, PN • High ALP • Biopsy • High index of suspicion
• 18.
  Case 5 • 2024 •65 yr female • h/o HTN >10 yrs • Admitted under cardiology for pacemaker implantation • CBC- Hb- 9, TLC- 11000, Plt- 1.3L • Lab informed regarding the PS  leucoerythroblastic picture • Bedside  spleen 5cm • BMA, BMBx- PMF • MPN panel- Jak2 V617F mutation +ve Primary Myelofibrosis Peripheral smear Bone marrow biopsy Reticulin stain
• 19.
  Clues in thecase • Clinical examination  LN, liver, spleen, mass etc. • CBC  see the full reports • PS  don’t ignore the comments of the pathologist • Timely referral
• 20.
  Summary • Managing hematologicalmalignancies requires a multifaceted approach • Non-specific vague complaints, emergency or critical care management • CBC, reticulocyte count, peripheral smear • LFT- albumin:globulin ratio, RFT/creatinine clearance • Lymph node/mass- excision biopsy > core biopsy > FNAC • ITP/AIHA > rule out D/Ds before steroids • Timely referral • By integrating these considerations  early diagnosis  avoid complications  improved outcomes
• 21.
  Thank You