You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question
submitted through the Consult-a-Colleague program and post the expert’s
response. But, what would YOU do? We’ll also pose a submitted question
and ask you to send your responses. See how your answer matches up to the
experts’ in the next print issue.
This month, Geoffrey L. Uy, MD, answers a question about white blood cell
counts in a patient being treated for acute promyelocytic leukemia.
Clinical Dilemma:
A 52-year-old man with low-risk acute promyelocytic leukemia (APL) presenting with a white blood cell (WBC) count of
3,200 and a platelet count of 70,000 was started on all-transretinoic acid (ATRA) + arsenic trioxide. The patient experienced a rise in WBC count from 16,000 on day 12 to 25,000
on day 20 – despite starting dexamethasone on day 15. The
patient experienced bilateral swelling in the lower extremities with no effusion. I am concerned about differentiation
syndrome and the continued rise in WBC count, despite treatment with 10 mg dexamethasone delivered every 12 hours.
Should ATRA be held until WBC count improves, or
should the patient be started on idarubicin or another agent?
Consult a Colleague
Through ASH
Consult a Colleague is a service for ASH
members that helps facilitate the exchange of information between hematologists and their peers. ASH members
can seek consultation on clinical cases
from qualified experts in 11 categories:
• Anemias
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström
macroglobulinemia
• Myeloproliferative Disorders
Experts Make the Call
• Myelodysplastic Syndromes
• Thrombocytopenias
Geoffrey L. Uy, MD
Associate Professor of Medicine
Section of BMT & Leukemia, Division of Oncology
Washington University School of Medicine
St. Louis, Missouri
Assigned volunteers (“colleagues”) will
respond to inquiries within two business
days (either by email or phone).
Have a puzzling clinical dilemma?
Submit a question, and read more
about Consult-a-Colleague volunteers at
hematology.org/Clinicians/Consult.aspx
or scan the QR code.
In this setting, steroids like dexamethasone are
thought to reduce the risk of complications from
differentiation syndrome; however, they really do not
have any effect on the leukocytosis associated with
ATRA + arsenic trioxide.
If the patient is clinically stable, our practice is to continue treatment. We would only hold treatment in cases
of severe differentiation syndrome, i.e. the patient was
significantly hypoxic, experiencing pericardial/pleural
effusions, or was hypotensive.
For the leukocytosis, we generally treat the patient
with hydroxyurea, in a regimen outlined in The New
England Journal of Medicine.1 Their treatment guidelines are as follows: In patients developing leukocytosis
after treatment initiation, hydroxyurea is administered
at the dosage of 500 mg once-daily for WBC between
10 and 50 x109/L, and 1.0 g once-daily for WBC >50
x109/L. Hydroxyurea was discontinued when WBC
count was again <10 x109/L.
*If you have a request related to a
hematologic disorder not listed here, please
email your recommendation to ashconsult@
hematology.org so it can be considered for
addition in the future.
REFERENCE
Lo-Coco F, Avvisati G, Vignetti M, et al. Retinoic acid and arsenic trioxide for acute promyelocytic
leukemia. N Engl J Med. 2013;369:111-21.
DISCLAIMER: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and
disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is
solely at your own risk.
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