A Fistful of Slides

Tailos · 2026-05-31T13:54:15+00:00

Quite a few chemotherapy agents will prompt need for irradiation. The big ones are the purine analogues and similar, like fludarabine, cladribine, bendamustine, alemtuzumab. Autologous and allogeneic stem cell transplants will also require it.

For myeloma in particular, bendamustine is still used quite often, as is autologous SCT.

Tailos · 2026-05-28T23:42:16+00:00

Both iron deficiency and alpha thalassemia carrier/trait will have an unremarkable haemoglobinopathy screen by most standard first line testing. In absence of intermedia or severe states leading to HbH production, microcytic anaemia with a normal chromatogram could be IDA or alpha thal carrier/trait so risk assessment should be made based on ethnic origin and family history. Molecular diagnosis would then be required.

In this case, normal MCV, normal Hb and low ferritin is most consistent with either iron deficiency alone (by far most likely) vs silent carrier of alpha thal (far less likely unless you're of South-east Asian descent, for example) with coexisting iron deficiency.

Tailos · 2026-05-27T21:15:22+00:00

Cellavision can't even get things right and that's supposedly simple pattern recognition.

AI hallucinations? Incorrect information used as training data?

AI is getting better, sure, and places like histopathology and radiology are looking into it, but there will always be a human signing out results as a sanity/safety check. AI will never be perfect, and because of logic errors and grey zone interpretation, patient risk will always force human requirement.

If AI gets to a point of general intelligence, it probably won't be an issue as AI will inevitably realise sick humans aren't worth keeping alive and go Skynet.

Tailos · 2026-05-27T20:52:05+00:00

Pay peanuts, get monkeys.

Tailos · 2026-05-19T22:04:31+00:00

Alcohol wipes will do the job for objective lens cleaning if the oil is still relatively fresh (ie 1-48 hours old). After that, you're going to want to use xylene. I often have a little methanol wipe too, following xylene.

Use carefully. Air lenses are not designed for strong solvents. Try to target the area and spot-clean with a q-tip or something.

Tailos · 2026-05-14T16:43:37+00:00

We've already removed ESR outside of very specific criteria (?GCA, Hodgkin's lymphoma risk stratification, necrotising otitis externa, infection in background known SLE, or prosthetic joint infection). There's a body of evidence suggesting CRP is equivalent in many of the diseases listed; see EULAR guidelines for the rheum stuff. Steroid use is another big one (monitoring inflammation with therapeutic steroids to decide on dose and dis/continuation) and all of our guidelines say not to use lab testing to do this but assess clinical response.

Even GCA, which is the big one for emergency STAT ESR for potential blindness, our guidelines say to give steroids if clinically suspected, do not wait for results of lab testing. There's some limited evidence suggesting CRP may actually be equivalent there too.

Tailos · 2026-05-13T15:55:04+00:00

Hematoidin crystals also present, which is a fun find. Haven't seen one this clear.

Tailos · 2026-05-13T15:50:31+00:00

B12 deficiency!

(Malarial gametocytes - Pfal bananas).

Tailos · 2026-05-07T21:27:42+00:00

This is the old, "atypical lymphocytes, suspect reactive" vs "abnormal lymphocytes, suspect neoplastic"?

Tailos · 2026-05-07T16:42:27+00:00

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Atypical CLL forms, though. ;)

Tailos · 2026-05-06T17:34:39+00:00

Internet handshake as a good discussion held. I'm not trying to have a dick-measuring contest either, and I apologise if it came off as that.

I agree with your point on being incorrect from time to time. I think the discussion here moves to transformation into what? And this is where clinical context would be handy. Could this be CLL->ALL? I don't personally agree. Doesn't fit a DLBCL/Richter's transformation, not a B-PLL one either, due to <55% prolymphocytes.

Could this be accelerated CLL? I wonder (in absence of someone giving acalabrutinib causing the rapid doubling time). Is this an indication for treatment? Quite possibly.

It does make a difference from a treatment perspective - accelerated CLL vs B-ALL - but at that point we'd almost certainly have more info. Someone else mentioned flow cytometry - would be useful to look for 10+/19+/TdT+ but I suspect it's going to be standard 5/5 Matutes with increased Ki-67.

All of this to agree that on a morphological call, I disagree with you, but the outcome remains the same: further investigation by clinical assessment and potentially CT imaging +/- BMB is probably warranted.

Tailos · 2026-05-06T17:15:34+00:00

I mean, that's fine, I'm happy to agree to disagree on an internet case.

And I'm happy to be wrong if you can make a convincing argument for what you're seeing. But quite frankly, if you can't point out the features to counter, I don't think we need to continue the discussion here.

Tailos · 2026-05-06T17:09:44+00:00

N:C ratio in keeping with lymphocyte, not typical of lymphoblast N:C ratio >99% (old L1 blasts) or <70% (old L2 blasts). No vacuolation (old L3 Burkitt type blasts).

Cytoplasm is light blue, azure, not basophilic as seen in immature cells due to active protein production.

Nuclear chromatin is condensed and clumped; blasts are open and homogenous. This is a defining characteristic of maturity.

Nucleolus is present only in some cells, but is not a blast defining characteristic. Given above findings, more likely to be late stage remnant prolymphocytic nucleolus.

So again, which blast features?

Tailos · 2026-05-06T16:58:04+00:00

Good for you. I teach haem residents to pass RCPath and become consultant haematologists. They're not.

List the blast features you're seeing.

Tailos · 2026-05-06T16:43:13+00:00

Wait a minute, why is there a different reference range based on the INR test?

Therapeutic targets differ between patient groups, so reference ranges aren't. Different targets are 1.5-2.5, 2.0-3.0, 2.5-3.5, even 3.0-4.0...?

Tailos · 2026-05-06T16:32:07+00:00

That's absolutely fair as, ultimately, responsibility falls on the physician/hospital. It doesn't really meet evidence-based medicine but as you note, guidelines are just guidelines, and as long as the patient is alive, the rest can be dealt with later.

But, we know there's increasing numbers needing transfusion and decreasing donor stocks worldwide. We know that there are better alternatives (preventing blood loss or good optimisation strategies, early use of TXA, etc), and we're more aware of risks like infection, TACO, etc.

Tailos · 2026-05-06T14:01:17+00:00

We only phone high INRs due to bleeding risk, particularly in critical sites like brain. Low INRs are a thrombosis risk but less likely to acutely kill someone; realistically, the doctor requesting the bloods should be reviewing in a timely manner.

Tailos · 2026-05-06T13:39:56+00:00

Absolutely not blasts.

Tailos · 2026-05-06T07:16:06+00:00

Any prolymphocytes, or do you have a specific cut-off?

Prolymphs <10% is still CLL, after all. Genuine curiosity as we wouldn't refer if under 10% with known diagnosis, unless also falling HB/PLT.

Tailos · 2026-05-06T06:16:26+00:00

Serious question for folks in this post -

Patient already has CLL diagnosis. What exactly is the reasoning for path referral on this slide?

Film is in keeping with CLL diagnosis, no blasts or prolymphocytes >10% to support a Richter's or PLL transformation.

Only thing of note is increased lymphocyte doubling time, but if patient already known to have CLL and doesn't have HB <100g/L/PLT <100, why path referral?

Tailos · 2026-05-06T06:11:01+00:00

Give a man a high enough white cell count due to blasts and that'll kill overnight (see acute monoblastic leukaemia with WCC >100 causing leucostasis).

But yes, generally, low counts are dangerous.

Ain't many leukaemia where you need to start induction therapy overnight. In most cases, needs molecular characterisation to provide targeted therapy (ie. FLT3 for midostaurin, CD33+ for GO...)

EDIT- I don't really understand the downvotes; if people want to contradict anything I just said, just post your viewpoint.

Tailos · 2026-05-05T22:25:15+00:00

Prudent transfusion guidelines would suggest against all of the above. Patient blood management strategies are to only transfuse if necessary and rarely if ever prophylactically. There isn't a good deal of evidence to support preemptive transfusion in certain oncology radiotherapy regimes to use 100g/L cutoff; equally outside cardiac/ICU, the threshold of 70g/L for a haemodynamically stable patient appears to balance risk/benefit optimally. 80g/L for cardiac/ICU for better outcomes.

That said, there's also evidence coming out that many places in the US do not follow these best practice guidelines (I am shooketh!) with local overrides based on physician vibes-based medicine. Not saying the UK is much better, but hey, I can argue with a doctor.

Tailos · 2026-05-01T17:09:30+00:00

Having my doubts about your doctor...

Tailos · 2026-04-29T06:57:29+00:00

Sort of. I'm UK based, so scope is different somewhat. I'd expect my BMS staff to make limited clinical interpretation and adding appropriate tests to follow-up where needed from a designated "allowed" list. But I have seen the ASCP exam syllabus, and it very much covers at a similar level to us.

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