TRAINING and EDUCATION

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 Ruben A . Mesa , MD , discusses treatment options for a 73-year-old male patient with severe macrocytic anemia .

I have a 73-year-old male patient with the following characteristics : severe macrocytic anemia ; hemoglobin 7.4 gm / dL ; atypical monocytes 1.6k / μL in peripheral smear and confirmed by flow cytometry ; bone marrow hypercellular ( 80 %); severe erythroid hypoplasia ; 1-3 percent blasts ; JAK2-negative ; myelodysplastic syndromes FISH panel that was negative ; erythropoietin > 797 mIU / mL ; immunoglobulin M parvovirus negative ; and with a clinical diagnosis of chronic myelomonocytic leukemia-1 . I doubt that he will respond to an erythropoiesis stimulating agent . How should he be managed ?

Ruben A . Mesa , MD Consultant Hematologist – Mayo Clinic in Arizona Chair , Division of Hematology & Medical Oncology Deputy Director , Mayo Clinic Cancer Center Chair , Arizona Cancer Coalition Professor of Medicine

I agree that an erythropoiesisstimulating agent is not likely to be helpful . If leukocytes and platelets are adequate ( i . e ., absolute neutrophil count > 1 x 10 9 / L and platelets > 50 x 10 9 / L ), I would start with lenalidomide 5 mg / day and if tolerated after a month titrate up to 10 mg / day . I would have a goal of a 3- to 4-month period to see if anemia improves . If leukocytes and platelets are still low and / or problematic at baseline , I would try 5 days of azacitidine 75mg / m 2 .

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

• Myelodysplastic syndromes

• Thrombocytopenias

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 .

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 .

* 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 .

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