Hematology / Oncology

PCP submission

51 year old male with ahistory of diabetes (recently well controlled), smoking who has persistent leukocytosis (14k – 16k) over last 5 months. Elevated driven by neutrophilia (~11k). Smear was unremarkable. No evidence of etiology for a reactive leukocytosis. Recent CMP normal. Other cell lines are normal (Hg, 15, Plts 160 – 300s). Had sent smear to look for abnormalities and repeated CBC which again showed neutrophilia and nothing abnormal on smear.

Can I send some additional labs to begin a workup of this? Or other tests? Or does he need to be seen by heme in person for BM biopsy, etc.

Specialist response

Dear Provider,

Thank you for the consultation. In the evaluation of neutrophilia the first determination to make is whether this is reactive or clonal. Reactive causes include inflammation, infection, smoking, etc. and clonal causes are malignancies such as leukemias and other myeloproliferative neoplasms. If there are no clear signs or symptoms of inflammation I would suggest the following:

• serum ESR, CRP
• age-appropriate cancer screening, also taking into account the family history of malignancies if any
• peripheral smear review
• serum ACTH and AM cortisol level

If she is a non-smoker and without signs or symptoms of active inflammation, and the above workup was negative and with persistent neutrophilia, I would suggest the following: – peripheral blood FISH (or PCR) for BCR-ABL – peripheral blood flow cytometry (Quest code 35080) I’m happy to follow along on the results with you. Hope this was helpful.

PCP follow up

Thanks – this was helpful. The smear was normal already and we are in the process of completing colon cancer screening which is all that he is due for. I will send the inflammatory markers and the ACTH and AM cortisol. Out of interest, what are the ACTH and cortisol for? He is a smoker – would this change the workup you do? Would you attribute it to the smoking alone or would you still do FISH/flow if inflammatory markers are normal?

Specialist follow up

Yes, this is very likely secondary to his smoking, especially prior to the last 5 months his WBC count and absolute neutrophil count was overall reassuring. I would suggest we continue to monitor alone without further testing; if we see ongoing progression of his neutrophilia or circulating immature forms we will then proceed with the testing for clonal disorders. Hypercortisolism is a known cause neutrophil demargination and relative neutrophilia hence the ACTH and a.m. cortisol levels.

PCP follow up

Ok thanks. I don’t actually have any value prior to 5 months ago – I just know that it has been stably elevated for 5 months. To confirm – given that he is a smoker and values are stable, it is reasonable to monitor for now and not do further workup? Or would you still do ESR/CRP and then if normal monitor? Also, with what frequency would you check labs if monitoring

Specialist follow up

It would be safe to proceed with monitoring alone without further workup. I would suggest a CBC diff every 3 months for the next 12 months then every 6 months indefinitely. If we identify concerning trends we can then consider advancing the workup. Happy to continue to follow along.