Suspected blasts on peripheral blood smear: Difference between revisions

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===Suspect or exclude acute promyelocytic leukemia (APL)===
===Suspect or exclude acute promyelocytic leukemia (APL)===
[[File:Faggot_cell_in_AML-M3.jpg|thumb|left|Aute promyelocytic leukemia, showing characteristic abnormal promyelocyte with multiple Auer rods.]]
[[File:Cytology of acute promyelocytic leukemia, annotated.png|thumb|300px|Main features of '''acute promyelocytic leukemia''' (APL).]]
[[File:Peripheral blood smear of acute promyelocytic leukemia, hypogranular variant.png|thumb|400px]]
[[File:Peripheral blood smear of acute promyelocytic leukemia, hypogranular variant.png|thumb|400px]]
APL typically shows blast cells (high nuclear/cytoplasmic ratio, finely dispersed chromatin and prominent nucleoli) and Auer rods. However, it may also have a hypogranular variant with very scant Auer rods.
APL typically shows blast cells with ample amount of cytoplasmic granules and Auer rods. However, it may also have a hypogranular variant with very scant Auer rods.


Even a suspicion of APL on microscopy should be reported relatively quickly to the ordering clinician, without waiting for additional workup or for the regular work hours of people with more expertise.<ref group=note>The reason for the quick reporting of suspected APL is that even a suspected APL mandates immediate initiation of ATRA treatment before confirming or disproving the diagnosis by further workup, so initially, it is much better to report that you suspect it even if further workup will disprove that diagnosis, rather than delaying reporting and thereby the initiation of treatment for a patient that actually has APL. After all, the initial treatment only costs about $40 as a first dose.<br>- '''Indication for treatment''': {{cite journal| author=Sanz MA, Fenaux P, Tallman MS, Estey EH, Löwenberg B, Naoe T | display-authors=etal| title=Management of acute promyelocytic leukemia: updated recommendations from an expert panel of the European LeukemiaNet. | journal=Blood | year= 2019 | volume= 133 | issue= 15 | pages= 1630-1643 | pmid=30803991 | doi=10.1182/blood-2019-01-894980 | pmc=6509567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30803991  }}<br>- '''Cost of treatment''': Dosage of ATRA in APL is 45 mg/m<sup>2</sup>/day administered as two evenly divided doses, which for a typical adult is about 40 mg as a first dose. The cost per 10mg capsule is about $10.<br>- '''Dosage reference''': {{cite journal| author=Osman AEG, Anderson J, Churpek JE, Christ TN, Curran E, Godley LA | display-authors=etal| title=Treatment of Acute Promyelocytic Leukemia in Adults. | journal=J Oncol Pract | year= 2018 | volume= 14 | issue= 11 | pages= 649-657 | pmid=30423270 | doi=10.1200/JOP.18.00328 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30423270  }}
If there is even a suspicion of APL, ensure that the following will be done, without waiting for any additional workup, and without waiting for the regular work hours of any people with more expertise:
<br>- '''Cost''' per 10mg capsule: {{cite web|url=https://www.pharmacychecker.com/vesanoid/#!|title=Vesanoid Prices|website=pharmacychecker.com|accessdate=2022-11-09}}<br>The treatment must be started immediately to counteract severe coagulopathy of untreated APL.</ref> Also report any suspicion of APL to the oncologist/hematologist on call if applicable.
*That any outpatient seeks the emergency clinic to be admitted (such as by having the ordering physician or another clinician call the patient, or call yourself).
*That the patient will be treated by a clinician who knows your suspicion of APL, as well as the urgency and drug of choice for initial treatment (such as an oncologist or hematologist on call, but it may not be the emergency room staff).<ref group=note>The reason for the urgent reporting and treatment of suspected APL is that even a suspected APL mandates immediate initiation of ATRA treatment before confirming or disproving the diagnosis by further workup. It is much better to make a false positive call and have a patient treated with a vitamin A-like drug, rather than delaying or missing a report of APL, and thereby delay the initiation of treatment which can quickly be fatal. After all, the initial treatment only costs about $40 as a first dose.<br>- '''Indication for treatment''': {{cite journal| author=Sanz MA, Fenaux P, Tallman MS, Estey EH, Löwenberg B, Naoe T | display-authors=etal| title=Management of acute promyelocytic leukemia: updated recommendations from an expert panel of the European LeukemiaNet. | journal=Blood | year= 2019 | volume= 133 | issue= 15 | pages= 1630-1643 | pmid=30803991 | doi=10.1182/blood-2019-01-894980 | pmc=6509567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30803991  }}<br>- '''Cost of treatment''': Dosage of ATRA in APL is 45 mg/m<sup>2</sup>/day administered as two evenly divided doses, which for a typical adult is about 40 mg as a first dose. The cost per 10mg capsule is about $10.<br>- '''Dosage reference''': {{cite journal| author=Osman AEG, Anderson J, Churpek JE, Christ TN, Curran E, Godley LA | display-authors=etal| title=Treatment of Acute Promyelocytic Leukemia in Adults. | journal=J Oncol Pract | year= 2018 | volume= 14 | issue= 11 | pages= 649-657 | pmid=30423270 | doi=10.1200/JOP.18.00328 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30423270  }}
<br>- '''Cost''' per 10mg capsule: {{cite web|url=https://www.pharmacychecker.com/vesanoid/#!|title=Vesanoid Prices|website=pharmacychecker.com|accessdate=2022-11-09}}<br>The treatment must be started immediately to counteract severe coagulopathy of untreated APL.</ref>


===Non-APL===
===Non-APL===
[[Consultation|Consult]] with a senior or hematopathologist as needed, before conveying a preliminary report to the lab technician and/or clinician. At least during on call hours, it is not necessary to speculate about further sub-classification of blast cells.
[[Consultation|Consult]] with a senior or hematopathologist as needed, before conveying a preliminary report to the lab technician and/or clinician. At least during on call hours, it is not necessary to speculate about further sub-classification of blast cells.
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