Non-neoplastic heme

[Enkidu]

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So I've been reading a book on non-neoplastic hemepath and I think it's pretty cool. There's all kinds of stuff on patterns in reactive lymph nodes and things like that, but how important is that stuff in reality? If you get a reactive lymph node are you supposed to investigate further and provide a differential for specific causes of that *type* of reactivity? Also, what is the role of hemepath in working up all those hemostasis disorders (like glanzmann's thrombasthenia or bernard-soulier syndrome, or whatever).

Here's a link to the book, if any of you have read it and what to share a thought.

(http://www.amazon.com/Non-Neoplasti...-ebook/dp/B0078XBYYS/ref=cm_cr_pr_product_top)

 

[TMZ2007]

So I've been reading a book on non-neoplastic hemepath and I think it's pretty cool. There's all kinds of stuff on patterns in reactive lymph nodes and things like that, but how important is that stuff in reality? If you get a reactive lymph node are you supposed to investigate further and provide a differential for specific causes of that *type* of reactivity? Also, what is the role of hemepath in working up all those hemostasis disorders (like glanzmann's thrombasthenia or bernard-soulier syndrome, or whatever).

Here's a link to the book, if any of you have read it and what to share a thought.

(http://www.amazon.com/Non-Neoplasti...-ebook/dp/B0078XBYYS/ref=cm_cr_pr_product_top)

Yes, the histologic pattern of injury usually suggests one particular etiology (or a small differential). If the node (or a biopsy thereof) has been submitted specifically, you need to try to figure it out. If it's a benign node from a cancerous colon, a quick "negative for mets" is OK in my experience.

Those classic hemostasis disorders are rare (the platelet things are vanishingly rare). The vast majority of coagulation problems have acquired, secondary causes (too much/little coumadin, inactivity, etc.) Heterozygotes for Factor V Leiden/Prothrombin g20210a are supposed to be reasonably common, although I can't say I've worked one up. At our heme lab, director approval is needed for platelet aggregation studies, which requires them to defend their order. We do like 25 of these a year and to my knowledge we haven't had one come back positive for a congenital platelet disorder in my four years of residency. Coag problems are usually worked up according to an algorithm like this: http://www.uthsc.edu/Internal/syllabus-consult/coag_tests.pdf or this: http://njms.umdnj.edu/departments/pathology/services/Coagulation_Flow_Charts.pdf. You will need to know how to work these things up.

All of this is highly relevant for board prep, naturally.

 

[Enkidu]

Yes, the histologic pattern of injury usually suggests one particular etiology (or a small differential). If the node (or a biopsy thereof) has been submitted specifically, you need to try to figure it out. If it's a benign node from a cancerous colon, a quick "negative for mets" is OK in my experience.

Those classic hemostasis disorders are rare (the platelet things are vanishingly rare). The vast majority of coagulation problems have acquired, secondary causes (too much/little coumadin, inactivity, etc.) Heterozygotes for Factor V Leiden/Prothrombin g20210a are supposed to be reasonably common, although I can't say I've worked one up. At our heme lab, director approval is needed for platelet aggregation studies, which requires them to defend their order. We do like 25 of these a year and to my knowledge we haven't had one come back positive for a congenital platelet disorder in my four years of residency. Coag problems are usually worked up according to an algorithm like this: http://www.uthsc.edu/Internal/syllabus-consult/coag_tests.pdf or this: http://njms.umdnj.edu/departments/pathology/services/Coagulation_Flow_Charts.pdf. You will need to know how to work these things up.

All of this is highly relevant for board prep, naturally.

That's interesting about the reactivity pattern in lymph nodes. How often are nodes submitted for lymphadenopathy that result in a diagnosis like "cat scratch fever", or some other specific non-neoplastic etiology?

That's funny about the platelet diseases. They were a big deal in medical school too. Oh well - I guess that medical hematology doesn't have much interesting going on after all. Does hemepath play a role in diagnosing TTP and diseases like that?

 

[2121115]

That's interesting about the reactivity pattern in lymph nodes. How often are nodes submitted for lymphadenopathy that result in a diagnosis like "cat scratch fever", or some other specific non-neoplastic etiology?

That's funny about the platelet diseases. They were a big deal in medical school too. Oh well - I guess that medical hematology doesn't have much interesting going on after all. Does hemepath play a role in diagnosing TTP and diseases like that?

At my practice, I'm the heme path guy, and I frequently look at smears with clinicians to rule out TTP. It is probably the most common benign heme issue I see, but I look at lots of smears to rule out iron deficiency too. Had a rule out grey platelet syndrome earlier this year too. I occasionally get calls about pre-op platelet function studies. And a few coag factor issues here and there (mixing studies, inhibitors, Lupus anticoagulant, etc). So yes, you need to know it, particularly for CP boards even if you won't use it in practice. For a non-heme person in general practice, you'll need to be able to recognize the benign lymph node stuff too.

But by far I see more malignant heme than benign. Throw that in with the general surg path and cytologies and it keeps you on your toes! Totally love my job and wouldn't trade it.

 

[Enkidu]

At my practice, I'm the heme path guy, and I frequently look at smears with clinicians to rule out TTP. It is probably the most common benign heme issue I see, but I look at lots of smears to rule out iron deficiency too. Had a rule out grey platelet syndrome earlier this year too. I occasionally get calls about pre-op platelet function studies. And a few coag factor issues here and there (mixing studies, inhibitors, Lupus anticoagulant, etc). So yes, you need to know it, particularly for CP boards even if you won't use it in practice. For a non-heme person in general practice, you'll need to be able to recognize the benign lymph node stuff too.

But by far I see more malignant heme than benign. Throw that in with the general surg path and cytologies and it keeps you on your toes! Totally love my job and wouldn't trade it.

Hemepath seems so vast. Is it normal for someone to do fellowship in hemepath as well as some surgpath subspecialty or cytopath? That seems like too much information to have at one time.

 

[member0007]

Hemepath seems so vast. Is it normal for someone to do fellowship in hemepath as well as some surgpath subspecialty or cytopath? That seems like too much information to have at one time.

For you maybe, the rest of us in pathology are doing fine.

 

[2121115]

Hemepath seems so vast. Is it normal for someone to do fellowship in hemepath as well as some surgpath subspecialty or cytopath? That seems like too much information to have at one time.

You will never be an expert at everything. This is one reason that multiple fellowships are not necessarily looked favorably upon. What exactly is your niche? Heme, cyto, and GU? LOL.

Most general private groups work similarly to mine - if they have a hard heme case they run it by me; likewise, if I have a hard surgpath case (or cyto or whatever) I run it past the appropriate person in my group. But that means that we are all signing out the more routine stuff in every discipline, so you have to know it well enough to sign out the routine stuff and (more importantly) to recognize when you are dealing with a hard/controversial issue and not blow it off.