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48 Part I: Clinical Evaluation of the Patient Chapter 4: Consultative Hematology 49

In most cases, if these findings have been chronic and longstanding, not particularly useful and can create patient anxiety. Patients have
they are thought to be unrelated to the paraprotein, and ongoing obser- concerns about their “genetic disease,” and hematologists have a hard
vation is appropriate rather than cytotoxic chemotherapy. In some time explaining the implications of tests they would not typically
cases, particularly those in which historical labs are unavailable, this order. The consulting hematologist should direct the laboratory eval-
distinction is more difficult to make, and marrow exam may be use- uation to avoid unnecessary, duplicate, and/or costly tests.
ful to assess the degree of marrow effacement. In younger patients with • The increasing variety of molecular and genetic diagnostics, in addi-
monoclonal proteins greater than 1.5 g/dL, non-IgG isotypes, or abnor- tion to the evolving complexity of hematopathology, mandates one
mal free light-chain ratios, we often obtain marrow biopsies given the be aware of the resources of their local hematologist. For example,
higher likelihood of progression and potential intervention for patients rare disorders such as systemic mastocytosis, CNL, severe eosino-
with high-risk smoldering myeloma. philia, and atypical CML are often best evaluated in a tertiary center.
Once the diagnosis is made and a treatment plan established, care
ADVICE TO REFERRING PHYSICIANS should then be transitioned to local physicians, with intermittent
input from an academic center if required. Value should always be
A good relationship and open line of communication between hema- placed on avoiding repeat marrow examinations.
tologists and referring physicians are imperative. A few points to keep • With rare exception, diagnoses should not be made off scant mar-
in mind: row specimens. Terms such as “aspiculate aspirate” and “subcortical
biopsy” should trigger concern for an inadequate specimen. In such
• The clinical history is invaluable. If there is lack of clarity, we recom- cases, a repeat biopsy should be obtained by an experienced provider
mend a quick phone call to the referring physician focusing on the rather than making diagnostic assumptions from a poor specimen.
salient features of the patient’s medical history and the reason for • A referral to a hematologist, “cancer center,” or hematologist/oncol-
consultation. Much like pathologists, this information helps us place ogist often generates considerable patient anxiety, even if not ver-
the labs and blood film in appropriate context and aids the diagnostic balized. The waiting period of several days to weeks to see such a
evaluation, particularly in cases with broad differentials such as ane- provider can cause significant distress. Unless the diagnosis is clear,
mia or leukopenia. The importance of the history and physical exam it is useful to counsel patients that such a referral does not imply
also reinforces the need for the attending hematologist to personally the presence of “cancer” or “leukemia” but rather a request for more
review the blood film, rather than relying solely on hematopatholo- information.
gists or laboratory technicians.
• Avoid the laboratory “shotgun” approach. For example, exhaustive
hypercoagulable studies in patients with provoked thromboses are

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