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Hematology eConsult - From a Specialist in London, ON
January 30, 2018
As waiting lists for specialist referrals continue to rise, we need to look at alternative ways of managing our increasing complex patient problems. OTN`s eConsult is a good option. Referrals can be sent to any specialist in the OTN directory.

Experience from the Champlain LHIN (Ottawa) has shown that the location of a specialist is not a barrier to getting the information required and avoids the need for a direct face to face consult. It's a small world when you are referring via eConsult!

Some specialties have set up province-wide specialty groups, where an administrative person receives requests and assigns them to one of the specialists in the group. The following example is a hematology referral, sent to the hematology specialty group and answered by Dr. Ian Chin-Yee, who is a hematologist at London Health Sciences.
REFERRAL:
  • CBC done as patient's two brothers have hemochromatosis found to be abnormal
  • Flow cytometry suggested and done (attached)
  • Patient is 57 years old, feels well, no constitutional Sx. Otherwise healthy.

Question for specialist: Could you offer some guidance on possible follow-up testing and interval?

RESPONSE:
Your patient is 57 year old man and has a mild ( <5 x 10 (9) lymphocytosis with no associated cytopenias. An incidentally identified lymphocytosis in patients over age 50 is not uncommon and usually not cause for worry in the absence of other cytopenias – ( anemia, thrombocytopenia). The flow cytometry confirms this in monoclonal B cell population with the typical pattern of CLL like cells but because the absolute monoclonal B lymphocytes is less than 5 x 10(9) we call this a monoclonal B cell lymphocytosis. See below. This is by far the most common cause of lymphocytosis in older patients - a B cell lymphoproliferative neoplasm, most commonly CLL but other lymphoproliferative neoplasm such as Non-Hodgkins lymphoma can cause a peripheral lymphocytosis as well. Assuming the patient is well and has no cytopenias , there is no urgency to diagnose or treat. Treatment of CLL is not curative and is reserved for patients with symptomatic CLL. From this perspective, you could argue that making an early diagnosis is probably not necessary as the management is going to be “watch and wait” for most low grade lymphoid neoplasms in the absence of symptoms. Having said that, I usually do the flow cytometry to confirm and to exclude other lymphoid neoplasms but often wonder whether the “psychological trauma” of labelling someone with CLL was necessary. More than 30% of patients diagnosed over age 70 with a lymphocytosis only from CLL never need treatment and survival is similar to an age matched controls without the disease. I suspect your patient has a precursor syndrome to CLL called monoclonal B cell lymphocytosis ( MBL is arbitrarily defined as clonal lymphocytosis like CLL but with absolute # of clonal cells < 5 x 10(9)) and is otherwise well, I would simply follow on q 6 monthly basis checking for symptoms or cytopenias. If these were to develop then referral to hematology for consideration of treatment would be warranted.
OF NOTE TO ACADEMY CLINICAL DAY ATTENDEES:

The Hamilton Academy Clinical Day (happening next Wednesday, January 31) features a talk at 8:40 a.m. by Dr. Jennifer Everson and Dr. Joan Bellaire on eConsult: The Untapped Gold Mine. Check it out!

HITS (Hamilton Health Sciences and Clinical Connect) and OntarioMD will also have booths at the conference where you can sign up for eConsult and ONEID.
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