Oncology (General Cancer)/Persistent leukocytosis

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QUESTION: My WBC has persistently been elevated for the past several months, ranging from 11.2 to 13.3.  My HCT has steadily dropped on each consecutive CBC from 42 down to 34 with a Hgb of 13.2 down to 12.  The percentage of granulocytes has increased from 66% up to 73.3 % (making my ANC at the highest 9.7).  My PCP didn't bother do a diff and, much to my dismay, has now turfed me to a hematologist whose next available appt is a month from now. I realize that the abnormal values are not extreme, just a little on the high or low side but the trending of the numbers seems to be of some concern.  I've had no recent infections, steroids, or symptoms of autoimmune disease. I am a non smoker.  How concerned should I be ??  Is CML in the list of possible differential diagnoses ??

ANSWER: Although CML may emerge down the line, I don't think that's likely at gthe moment.  I would be concerned about chronic blood loss of some sort, which could account for the drop in HGB and the rise in granulocyte percentage. (When the bone marrow is more active than normal, it can pump out more granulocytes than normal as well).  There is a set of disorders called "myelodysplasia" which can vary from very benign to life-threatening.  If you have that, it sounds like it is on the benign side.  You might have something else going on in the bone marrow, and chronic inflammation from an low grade infection or autoimmune process could be the cause of your findings.  I don't think waiting for your hematologist is a problem, but I think if you were my patient I would probably do a bone marrow examination if the answer was not apparent from other tests, like serum iron, B12, folic acid, and stool positivity for blood.  I don't think you are at any risk by just waiting till you see the hematologist.  Hope this helps.

---------- FOLLOW-UP ----------

QUESTION: Thanks for your prompt reply.  I did have a CBC w/diff done after I posed the question.  The WBC is still slightly elevated, but the hgb/hct is within normal this time as are the other values.  Differential was unremarkable.  I failed to mention in my first inquiry that on one of the three previous CBC's, one platelet count was a little high at 499.  On this last CBC, it was up more at 511.  Does this add anything to the picture ? Also of note, I do have a brother who has myelodysplastic syndrome.

Answer
Although your blood tests tend to be slightly abnormal, the rising platelet count is a little concerning.  However, most of the time such elevations are due to external disturbances to the bone marrow, rather than leukemia or myelodysplasia.  There is a disorder called "essential thrombocytosis" but with your numbers where they are, I would probably just continue to watch until some progression appears.  All of the primary diseases of the bone marrow are such that it doesn't matter how long they've been present in order to offer the best available therapy, provided that the individual is reasonably healthy.  This is of course not true for cancers of other organs, where the outcome is very dependent on how much tumor there is and whether it has metastasized or not.  So see the hematologist by all means, but with a normal differential and a hemoglobin level that fluctuates and is not trending, I suspect that you don't have anything too serious.  

Oncology (General Cancer)

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Donald Higby, M.D.

Expertise

I can answer almost all questions related to the treatment and natural course of most kinds of cancer, especially cancers of prostate, colon, lung and breast.

Experience

I have been a practicing medical oncologist for 36 years, and have been chief of service at a major medical center for 25 years. I've also done research in cancer treatments.

Organizations
American Society of Clinical Oncology

Publications
New England Journal of Medicine American Journal of Medicine Journal of the American Society of Clinical Oncology Hematology Transfusion Medicine

Education/Credentials
MD, Stanford University Internal Medicine residency, St. Louis University School of Medicine, St. Louis, MO Medical Oncology Fellowship, Roswell Park Cancer Institute, Buffalo, NY

Awards and Honors
America's Best Physicians, last 14 years

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