Malignant heme

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

Duke1K

Full Member
7+ Year Member
Joined
Mar 2, 2015
Messages
76
Reaction score
28
I'll be doing my internal medicine subI soon, and I've been placed on the malignant hematology service. I have no idea what to expect. There are no rotations in the cancer wards during clinical year, and very few fourth-year students actually get placed on the heme service. All I've heard (from friends who've heard from their interns/residents) is that it's very, very busy.

What is the malignant heme service like? What kind of admits do we usually have (patients admitted for the initial workup of cancer/relapse, or patients coming in for maintenance chemo, or patients having cancer or treatment-related complications, or patients with cancer admitted for other reasons)? What is the bread and butter? Why is it so busy? What should I be reading? How do I impress my attendings?

Seeking some advice from people who know the field. Thank you!

Members don't see this ad.
 
I'll be doing my internal medicine subI soon, and I've been placed on the malignant hematology service. I have no idea what to expect. There are no rotations in the cancer wards during clinical year, and very few fourth-year students actually get placed on the heme service. All I've heard (from friends who've heard from their interns/residents) is that it's very, very busy.

What is the malignant heme service like? What kind of admits do we usually have (patients admitted for the initial workup of cancer/relapse, or patients coming in for maintenance chemo, or patients having cancer or treatment-related complications, or patients with cancer admitted for other reasons)? What is the bread and butter? Why is it so busy? What should I be reading? How do I impress my attendings?

Seeking some advice from people who know the field. Thank you!

Depending on the setup, leukemia and lymphoma will reign and perhaps myeloma but at my institution myeloma goes to onc.

As a 4th year, you are far from a knowledge base to impress based on hematology specific knowledge from a management standpoint.

You should know diagnostic criteria for leukemia (acute) and the basics of blood smears in case you look at them. Know what tumor lysis syndrome is and how to recognize it and treat it. Know abx guidelines for febrile neutropenia. Know your patients echo results because you will give lots of anthracyclines. Know about fungal coverage and gaps with abx and antifungal regimens (myca doesn't get aspergillus, fluc doesn't either but myca gets candida glabrata and fluconazole doesnt, voriconazole gets aspergillosis but can cause hallucinations and lft abnormalities, posaconazole and ampho exist too).

Know basic chemo alphabet soups and side effects associated with each drug:

Leukemia:
7+3
FLAG
FLAG-IDA
MEC
HIDAC
Hyper-CVAD

Lymphoma
R-CHOP
ICE
R-EPOCH
R-Bendamustine
ABVD
Brentuximab vedotin

Myeloma
RVD
VTD-PACE
Kyprolis
Elotuzumab
Daratumumab
Pomalidomide

That's an aggressive start. Focus on being good from a medicine perspective. There are lots of nuances when it comes to leukemia and lymphoma molecular studies and cytogenetics.

Know FLT3 in leukemia is bad. MLL gene rearrangement is bad. Chromosome 17 deletions are almost always bad in any cancer (p53 tumor suppressor gene lives here). BCL2 and MYC in lymphoma is bad.

Know basic transolocations

9;22 Philadelphia
14;18 follicular
11;14 mantle
8;14 Burkitts

If you know this stuff when you start, you will look very good. It's a lot in itself but hopefully it helps. Can post more later if you want.
 
  • Like
Reactions: 3 users
Extremely helpful. The more, the better. Thank you!
 
Extremely helpful. The more, the better. Thank you!

APL 15;17 look for dic treated with atra and arsenic if low risk (WBC <10k) and add idarubicin if high risk

This is the leukemia you don't want to screw up. Know about differentiation syndrome because when you stop the maturation arrest in apl it will often occur.

Better AML cytogenetics are inv (16), t(8;21) and t(15;17) the so called core binding factors

Complex monosomal Karyotypes are the worst of the worst

Last tidbit for the night: you can induce Philadelphia + ALL with Dasatanib and steroids

I would know about some TKIs for CML and know the difference between chronic phase, accelerated phase, and blast crisis.

You will also see hypomethlyating agents in AML and MDS (know how to differentiate the two)--Decitabine and vidaza
 
  • Like
Reactions: 1 user
Top