The Fellow on Call: The Heme/Onc Podcast

Emergencies happen in hematology and oncology. This is a fact. But how do we manage these emergencies? Look no further. In this episode, we talk all about our first hematologic emergency: immune thrombocytopenic purpura (ITP).Immune thrombocytopenic purpura (ITP):Be sure to check out episode 009 on thrombocytopenia for a general approach and differential!Specific instances where there may be close to undetectable platelet count: * Lab artifact (clumping)* Very severe DIC* Thrombotic thrombocytopenic purpura - though usually higher platelets in these cases * Heparin induced thrombocytopenia (in very severe cases) - though usually higher platelets in these cases * ITP ITP: Diagnosis of exclusion How to confirm it is ITP?* Post-transfusion CBC - a repeat CBC 30-60 mins after a platelet transfusion. In ITP, the platelet count will likely not budge. (Not perfect test!)* Immature platelet fraction (if available) - this will be elevated if mature platelets are being destroyed. (Again - not a perfect test) Treatment in acute cases: IVIG 1g/kg daily x2 days + Dexamethasone 40mg daily x4 daysReference:https://ashpublications.org/blood/article/106/7/2244/21649/How-I-treat-idiopathic-thrombocytopenic-purpura - Great How I Treat article from Blood Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Emergencies happen in hematology and oncology. This is a fact. But how do we manage these emergencies? Look no further. In this episode, we talk all about our third oncologic emergency: new brain mets. Cord compression:- If someone has a pathologic fracture, think about the following differential as underlying etiologies: - Females: rule out breast cancer - Males: Prostate cancer- Others: multiple myeloma, lymphoma, lung cancer, renal cell carcinoma, bladder - If cord compression, administer steroids; may require radiation to help with shrinking; also may need involvement of neurosurgery if there is lack of spine stability. Role of radiation in cord compression: -MRI is beneficial to help with radiation planning-Where is the disease in proximity to the spinal cord? In the bone? In the epidural space? Or pushing against the spinal cord +/- blocking CSF?-Is the spine stable? Use SINS scoring (https://radiopaedia.org/articles/spinal-instability-neoplastic-score-sins-2?lang=us) -If good spine stability (low SINS) or is not surgical candidate or radio-sensitive tumor: radiation up front-If poor spine stability (high SINS) then may need surgery up frontRadiosensitive tumors examples:LymphomaGerm cell tumors Small cell lung cancer Radio-resistant tumor examples (resistant does not mean that radiation cannot be used, however):MelanomaColorectal Renal cell Continue steroids as they are undergoing radiation to prevent flare up from inflammation and acute worsening from the mass on the spinal cordRole of neurosurgery: - What is a reasonable time that we can wait before operating for a new cord compression?- As noted above, cord compression has various degrees- Questions to ask: What neurologic symptoms? Over what time period? - Asymptomatic: You have time! Perhaps investigate why mass may be there. - Progressive over a couple of weeks: You have a little bit of time (a few days to get them to surgery)- Acutely having symptoms: You should intervene. - Spinal stability: are the weight-bearing components (ligaments) intact? Assessed via upright X-rays - If the tumor is radio-sensitive, may opt for radiation first (if diagnosis is known)A HUGE thank you to our special guests:Ryan Miller, MD, MS: PGY5 in Radiation Oncology at Thomas Jefferson University Hospital, Philadelphia, PAJoshua Lowenstein, MD, MBA: Neurosurgery Attending, REX Neurosurgery and Spine Specialists, Raleigh, NC Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Emergencies happen in hematology and oncology. This is a fact. But how do we manage these emergencies? Look no further. In this episode, we talk all about our second oncologic emergency: new brain mets. Brain mets:Strongly consider steroids, particularly with the presence of vasogenic edema associated with brain mets Stereotactic radiosurgery (SRS): use of high dose radiation delivered in a single treatment (“fraction”) that is delivered focally to the area of disease seen on imaging (typically MRI); great option for brain mets; can be performed by radiation oncology What to do to expedite Rad Onc planning: Thin-cut MRIStart patient on steroids Interpreting MRI imaging: T1 post-contrast sequence: to look for brain massT2 sequence: looking for vasogenic edema surrounding brain massMidline shift is an issue more so when it is acute; this is very different than slow changes over timeWho to operate on? Functional status prior to surgery; not in an area that can cause other harm; no other good alternative treatment optionsWhat to tell your NSGY colleague during a consult: A quick neuro exam (consciousness, strength, sensation, focal neurologic issues)Brief cancer historyUnderlying organ dysfunction Antiplatelet/anticoagulants A HUGE thank you to our special guests:Ryan Miller, MD, MS: PGY5 in Radiation Oncology at Thomas Jefferson University Hospital, Philadelphia, PAJoshua Lowenstein, MD, MBA: Neurosurgery Attending, REX Neurosurgery and Spine Specialists, Raleigh, NC Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Emergencies happen in hematology and oncology. This is a fact. But how do we manage these emergencies? Look no further. In this episode, we talk all about first oncologic emergencies: superior vena cava (SVC) syndrome.Superior vena cava syndrome: Important: although we focus on a possible malignant mass in this discussion about SVC, other things can also cause SVC syndrome. How do you know about the chronicity of someone’s possible SVC syndrome? Compare to a recent picture!Image of patient with collateralization with SVC syndrome: DOI: 10.1056/NEJMicm1311911Workup: Need to determine the etiology; imaging is important: CT of chest (CT venogram)Consider ultrasound to rule out thrombosis Get biopsy (eventually) if this is malignancy DDx of mediastinal masses: 5Ts:ThymomaTerrible lymphoma (B or T-cell)Testicular cancerTeratoma Thyroid malignancies Central line (causing occlusion) +/- clotSo now what? Yes, an answer to what is causing the issue is important, but we need to ensure that patient has a stable airway and temporize the situationOften requires input of specialists, such as Interventional Radiology or Radiation Oncology How to treat patients with SVC syndrome?- Chemotherapy: Important in chemo-responsive tumors (ex. germ cell tumors, lymphomas, small cell lung cancer); This can take a while to work -Placement of stents: Provides more immediate relief, but more invasive -Radiation treatment: Not always possible - Laryngeal edema/cerebral edema: steroids for life-threatening complications; Can affect diagnostic yield of sample and affect diagnosis, but may be required in emergent situations When is more emergent treatment indicated and consultants definitely need to be called (TELL YOUR CONSULTANT IF ANY OF THESE ARE SEEN!):Hemodynamic instabilityWorsening respiratory statusWorsening neurological status Final decision for what to do is often a multi-disciplinary discussion Stents: Provides quick reliefDoes not prohibit a diagnosis and curative treatment for the underlying malignancy Radiation: Takes several days or weeks; depending on underling histologyIf they have received prior radiation, they may not be eligible for more radiation A HUGE thank you to our special guests:Ryan Miller, MD, MS: PGY5 in Radiation Oncology at Thomas Jefferson University Hospital, Philadelphia, PA (https://www.jefferson.edu/university/jmc/departments/radiation_oncology/education/residency/residents/miller.html)Rupal Parikh, MD: PGY6 in Diagnostic/Interventional Radiology at the Hospital of the University of Pennsylvania, Philadelphia, PA (https://www.pennmedicine.org/departments-and-centers/department-of-radiology/education-and-training/residency-programs/current-residents/ir-integrated-residents/ir-dr-fifth-year/rupal-parikh-md)Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

In our final stop in our Cytopenias series, we discuss the ins and outs of neutropenia. This is another very commonly seen issue in the clinic and in the hospital so most definitely high yield!Why is neutropenia dangerous?Prone to infections, especially gut translocation of bacteriaDefinition of neutropenia:NORMAL: WBC 4400-11000 cells/microL; neutrophils make up 40-70% of thatNeutropenia defined by ANC: WBC (cells/microL) x percent (PMNs  +  bands) ÷ 100 Breakdown:Neutropenia: ANC <1500 cells/microLMild: ANC ≥1000 and <1500 cells/microLModerate: ANC ≥500 and <1000 cells/microLSevere: ANC <500 cells/microLAgranulocytosis: ANC <200 cells/microLApproach to workup: HISTORY IS KEY!Medications; examples of common culprits-  Chemotherapy Methimazole Clozapine InfectionsAny infections due to bone marrow suppression Toxins Less common causes: CongenitalSevere congenital neutropenia:Diagnosed in childhood; used to be fatal, but now patients living longer because of G-CSF support10-30% risk of AML in lifetimeMutations in neutrophil elastase (ELANE) gene or mitochondrial HAX1 gene Cyclic neutropenia:Self-limiting neutropenia that occurs every 2-5 weeksSpectrum of symptoms: none or oral ulcers/mild infectionsConstitutional/ethnic neutropenia:Mild neutropenia (ANC >1000)No history of infectionsMore common in people of Mediterranean and African descentDuffy Antigen Receptor Complex (DARC) gene mutations in patients of African originBenign Familial:Mild neutropeniaNot linked to particular ethnic groupUnclear underlying etiologyAutoimmunePrimary autoimmune neutropenia rare in adultsTypically secondary autoimmune neutropeniaDue to underlying autoimmune disorderSeen with SLE and can worsen with flare of diseaseTypically mild, seldom needs treatment unless ANC <500Felty syndrome:  Rheumatoid arthritis, splenomegaly, and neutropeniaNeutropenia improves with treatment of RA MalignancyLarge granular lymphocyte (LGL) leukemia:Often associated with RA and shares features of Felty syndrome (RA, splenomegaly)Caused by monoclonal population of large granular lymphocytesIn contrast, in Felty’s: polyclonal or oligoclonalT-cell LGL is more commonly associated with neutropeniaRequires treatment with methotrexate or cyclophosphamideDietaryB12 and folate rarely cause isolated neutropeniaCopper deficiency (gastric bypass): Zinc excess can cause copper deficiencies – ask about denture creams in your history!  Workup:History:Prior CBCsHistory of recurrent infections (pneumonia, sinusitis, skin/soft tissue, dental caries)Ethnic backgroundFamily historySocial historyDietary historySurgical history (gastric bypass)Physical exam:AdenopathySplenomegalySkin findings suggesting recent ulcersAphthous ulcersexample: https://en.wikipedia.org/wiki/Aphthous_stomatitisTesting:CBC with differentialCMP – assess liver and renal function Peripheral smearHIV, Hepatitis serologiesSpecial scenariosANA – if autoimmune disease expectedRF – if autoimmune disease expectedESR – if autoimmune disease expected; probably not great for inpatient workupCRP – if autoimmune disease expected; probably not great for inpatient workupFlow cytometry for LGLBone marrow biopsy – mainly for unexplained neutropenia to rule out neoplastic process, such as leukemia, lymphoma, myeloma; if longstanding, likely negativeManagement:Treat the underlying causeAutoimmune neutropenia –When to suspect? Workup is negative, but their counts still continue to worsenTreatment if they have serious complicationsTreat with rituximabLGL-Responds to low dose methotrexate or cyclophosphamideDo you give G-CSF?For patients with recurrent/severe infections or mucosal erosionsDo not treat based on the number aloneTakes time for the growth factors to workReferences: https://doi.org/10.1182/blood-2014-02-482612 - Great “How I Treat” article from Blood! https://www.uptodate.com/contents/approach-to-the-adult-with-unexplained-neutropenia - UpToDate article written by same author as Blood article Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

We continue on our cytopenias journey, this time talking all about anemia. This is a high yield topic for anyone who sees patients, as this is something we will all see. Determining the acuity of the anemia is the most important first step. Acute drop in hemoglobin? Consider active bleeding or hemolysis. Dilutional anemia (a drop in hemoglobin following fluid resuscitation) is also on the differential but should be a diagnosis of exclusion.Remember that we normally transfuse at a hemoglobin level of 7g/dL. If the patient has active cardiac issues, we transfuse at 8g/dL. Anemia Severity> 10g/dL = mild 7g/dL to 10g/dL = moderate 4.5g/dL to 7g/dL = severe, especially if acute 1g/dL to 4.5g/dL = these are almost always chronic if patients are conscious. Think about chronic blood loss or nutritional deficiency.History: Ask about nutrition, melena, hematochezia. Note that a small amount of blood can change the color of the urine, so beware of contributing rapidly developing anemia to hematuria.Physical Exam: Check the flanks and thighs for bruising. Feel for an enlarged spleen.Work Up: Smear—to evaluate for spherocytes, schistocytes, bite cells, etc.LDH—will be markedly elevated if blood is actively hemolyzingDAT/Coombs testing—to screen for AIHA, note that there is a high false positive rateType & screen Haptoglobin—sensitive but non-specific marker for blood breakdownReticulocyte count Macrocytic Anemia: Consider copper, B12, folate deficiency, reticulocytosis. Note that chronic zinc excess can cause copper deficiency. Microcytic Anemia: Consider iron sequestration or deficiency, lead poisoning, thalassemia. Normocytic Anemia: Usually multifactorial. Consider low erythropoietin level from chronic kidney disease or early iron deficiency anemia.Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

One of our most common consults in hematology is teams seeking guidance for workup and management of thrombocytopenia. In this episode, we cover our approach to this hematologic conundrum. Major Points Covered:Thrombocytopenia is defined as a platelet count <150K- Mild: 100-150K- Moderate: 50-100K- Severe: <50K- We get really worried when <20K (risk of spontaneous bleeding) What to ask in history and in chart review: - How quickly did the platelets drop - this is just as important as the absolute number; platelets may still be “normal” but have dropped significantly!- Mucosal bleeding? Menstrual bleeding?- Rashes?- Infections/Meds/Toxins?- Constitutional symptoms- Weight loss Our approach to a differential diagnosis - analogous to everyone’s favorite approach to renal AKI: “pre”, “intra,” and “post”:Pre: Infections/Meds/Toxins- 1st: HIV, Hepatits - 2nd: EBV, CMV, Histoplasmosis Intra: Primary bone marrow failurePost: Destructions/consumption/splenomegaly (Cirrhosis, too)- DIC- ITP- TTP - Platelet clumpingWorkup: - Smear - helps to quickly rule in or rule out a lot of the post-BM issues that are emergencies!- Citrated platelet count (to rule out platelet clumping)- Repeat CBC- Coags (PT/PTT/INR)- Fibrinogen- HIV serologies - Hepatitis B/C serologies- +/- Haptoglobin (note: in liver disease, you can have low haptoglobin) - Don't send SPEP/IFE!- If there is no abdominal imaging, consider abdominal ultrasound to evaluate for cirrhosis and/or splenomegaly References: https://www.sciencedirect.com/topics/medicine-and-dentistry/hypersplenism (Textbook of Gastrointestinal Radiology, 3rd edition 2008)- 90% of platelets in spleen at one timehttps://pubmed.ncbi.nlm.nih.gov/29978544/ (J Thromb Hemostasis 2018)- Platelet threshold for bleeding riskhttps://www.bjanaesthesia.org/article/S0007-0912(18)30753-0/fulltext#fig1 (British Journal of Anesthesia 2019)- Perioperative thrombocytopenia (Look at Figure 1)https://ashpublications.org/blood/article/131/8/845/104418/How-I-treat-disseminated-intravascular-coagulation (Blood 2018) - DIC with normal fibrinogen (Look at case 1, Table 2 shows good diagnostic criteria)Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Not to be confused with “carcinoma of unknown primary,” in this episode of metastatic disease of “origin TBD”, we discuss the workup of a mass noted incidentally on imaging. This is a very high yield topic often faced on solid oncology consults! Major Points Covered:Mass found incidentally on imaging → we need to stage alwaysInitial Workup:Reasonable to get CBC, CMP, UA, PSA (if male)Low blood counts, maybe marrow involvementCr elevated concern for obstruction possiblyLFTs elevated concern for mass in the biliary/pancreas regionUA w/ hematuria → maybe bladderBut bottom line you’re gonna get a scan, which scan to get though?Recommend referencing NCCN guidelines to determine additional staging scansCreate an account on nccn.org and look at guidelines by tumor typeNot all cancers require a PET/CT scanThere are newer modalities for imaging other than FDG PET including PSMA PET (prostate), Auxumin PET (prostate), and DOTATE PET (neuroendocrine)Certain cancers can be diagnosed on imaging alone (RCC and HCC)Some cancers require Brain MRI for stagingWhat to biopsy?FNA often adequate for solid tumors but may need core if non diagnostic Need core or ideally excisional if highly concerned for lymphomaAlways try to biopsy the site that will upstageDistant lymph nodes or other metastatic sitesWhat about tumor markers?We use this for treatment monitoring, not for diagnostic purposesImportant to establish a baseline to follow, special circumstances for diagnostic purposes to consider below:PSA in male if concerned about prostate cancerAFP helpful if concerned for HCC → liver masses in a cirrhoticAFP and b-HCG if concerned for testicular → young or middle aged male with mediastinal massMolecular testing not necessarily needed at the time of biopsy Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Heme Path Capstone Pt. 2 PearlsIn this episode, we continue our conversation with guest, Dr. Emily Mason, hematopathologist at Vanderbilt University Medical Center (Nashville, TN), as we apply all that we have learned in our Heme Path series. This time, we talk about a patient with a new leukocytosis, fevers, and easy bruising; and our approach to workup and management. Reminder: While these episodes may seem a little more in-depth than the prior Heme Path episodes, simply break down the conversation into the components we have discussed already and you will be amazed at how much you actually know - we promise!ELN Risk Stratification: https://www.researchgate.net/figure/ELN-2017-risk-stratification-of-AML-by-genetic-abnormalities-Adapted-from-Dohner-et_fig1_334634713original paper: https://dx.doi.org/10.1182%2Fblood-2016-08-733196Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast

Heme Path Capstone Pt. 1 PearlsIt’s time to put all you have learned in our Heme Path series to the test! Listen in as our guest, Dr. Emily Mason, hematopathologist at Vanderbilt University Medical Center (Nashville, TN) sits down with us to discuss the approach to diagnosis and workup of a new enlarged lymph node. While these episodes may seem a little more in-depth than the prior Heme Path episodes, simply break down the conversation into the components we have discussed already and you will be amazed at how much you actually know - we promise! Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast