HemeOnc

Question 1

What are some RBC morphologies we may see on the boards?

Answer 1

Spherocytes- autoimmune/drug-induced
Schistocytes- DIC, TTP
Bite cells- G6PD deficiency

Question 2

What are the endpoints of an MTP?

Answer 2

Hemodynamic stability and adequate tissue oxygenation
Hgb 7-9
INR <1.5x normal
Plts 50-100k
fibrinogen >150

Question 3

What are the platelet targets for various procedures?

Answer 3

Question 4

What are some of the buzzwords for leukemias?

Answer 4

AML: gingival hyperplasia, rash, LAD
APL: bleeding, thrombosis (DIC, hyperfibrinolysis)
ALL: LAD, organomegaly, CNS, bone pain, tumor lysis
TCell leukemia: hypercalcemia, bone lesions

Question 5

What are the features of APL differentiation syndrome?

Answer 5

15-25% of patients treated with ATRA, 2-47days post treatment
Due to cytokine release, increased APL adhesion (beta2 integrins)
Fever, leukocytosis, pulm infiltrates, effusions, rapidly improves with dexamethasone

Question 6

How is hyperleukocytosis treated?

Answer 6

Leukopheresis, dexamethasone, cranial irradiation

Question 7

How is TLS prevented and treated?

Answer 7

Low risk: fluid status and look at labs for allopurinol?
Intermediate risk: 7 days allopurinol and crystalloids
High risk: rasburicase (unless G6PD deficiency), crystalloid
Febuxistat in allopurinol hypersensitivity

Rasburicase in established TLS
HD for refractory cases

Question 8

When to consider NSGY versus radiation for brain mets?

Answer 8

Question 9

How is spontaneous splenic rupture managed?

Answer 9

Embolization. US has 90% specificity for splenic rupture

Question 10

What are some side effects of dasatinib?

Answer 10

Second generation TK inhibitor
Cytopenias, pleural effusions, bleeding (decreases platelet function)

Question 11

Recall shapes of TEG results and what they mean

Answer 11

Question 12

What complications can be triggered by chimeric antigen receptor Tcell treatment?

Answer 12

Cytokine release syndrome
will see fever, multiorgan dysfunction, shock and hypoxemia
Tx with anti IL-6 (tocilizumab)

Question 13

How is refractory TTP treated?

Answer 13

PLX, steroids, rituxumab, and caplacizumab (vWF monoclonal antibody fragment)

Question 14

What are the features of vaccine-induced immune thrombocytopenia?

Answer 14

IgG antibodies that recognize platelet factor 4 but with different epitpoe than HIT. 5-10 days post adenovirus vector vaccine
Will have thrombocytopenia around 50, has disproportionate cerebral/splanchinic involvement compared to HIT
Can still use heparin despite the similarities with HIT

Question 15

What is the Pelger-Huet anomaly signify on peripheral smear?

Answer 15

Neutrophils with fewer lobes than normal.
Seen in COVID, leukemia, myelodysplasia, myxedema, malaria, or drugs. May also be inherited

Iron deficiency can cause hypersegmentation FYI

Question 16

In hyperleukocytosis, is SpO2 or PaO2 more accurate?

Answer 16

SpO2, as leukocytes in blood gas sample use up oxygen

Question 17

In hemorrhagic shock, is whole blood or parts preferred?

Answer 17

Parts, 1:1:1 ration is equal to 2:1:1

Question 18

How do steroids help in treating hypercalcemia

Answer 18

Decreases extrarenal calcitriol production (lymphoma/myelomas)
Increase renal excretion, inhibit osteoclastic absorption

Question 19

What are the features of engraftment syndrome?

Answer 19

Systemic inflammation with fever, rash, diffuse capillary leak

Question 20

How is transplant-associated microangiopathy treated?

Answer 20

Risk factors: calcineurin inhibitors, tacrolimus, GVHD, multiple previous transplants, HLA mismatch, opportunistic infection, total body irradiation

Doesn’t stop with drug discontinuation or plasmaphoresis.

Rituxumab, defibrotide, eculizumab may be beneficial

Question 21

When are exchange transfusions indicated in acute chest syndrome?

Answer 21

If patient continues to decline after transfusions to baseline, multiorgan failure, sickling 30% or more, SpO2 <85% on RA or 90% with oxygen, PaO2 <60 or PCO2 >50

Question 22

What are the risk factors for cytokine release syndrome?

Answer 22

CAR-T therapy, see in hours to days of starting therapy but can be as long as several weeks.

Severe CRS is treated with tocilizumab

Question 23

What are the features and treatment for differentiation syndrome?

Answer 23

Leukemic cells differentiate to more mature forms after receiving ATRA/ATO.

Dyspnea, fever, weight gain more than 5kg, shock, AKI, pulmonary opacities/effusions

Tx with dexamethasone 10mg Q12

Question 24

What is ICANS (immune effector cell-associated neurotoxicity syndrome)

Answer 24

CAR-T therapy induced with risk factors: youth, pre-existing neuro disease, high intensity chemo, early severe CRS. Develops 3-10days after CAR-T and 2-4 days after CRS

Tx with dexamethasone 10mg q6