Human Pathology (2014) xx, xxx
www.elsevier.com/locate/humpath
Correspondence
New-onset pancytopenia: a diagnostic approach—reply To the Editor, We appreciate the interest in our recent article [1] regarding bone marrow evaluation in new-onset pancytopenia. The goal of our article was to serve as a general outline for pancytopenia-driven diagnoses in an academic medical center. In response to the comments by Dr Kar, we note that our criteria for pancytopenia were not arbitrary but were derived from our well-established laboratory-based reference ranges. We know of no worldwide criteria for pancytopenia; indeed, as individual laboratories define their own reference ranges based on their individual populations and their individual instrumentation, there is no possible way to arrive at a truly universal definition of pancytopenia. In addition, although absolute neutropenia was a key part of our definition of pancytopenia, most patients in our study were also leukopenic by our laboratory-based criteria. Dr Kar also points out that we included several patients who were unicytopenic or bicytopenic in our study and claims that these patients biased the study in favor of neoplastic diagnoses. As to our including them, we did so because they were initially referred to the clinician for pancytopenia, based on the requisition sheet, and thus were, presumably, at one point, pancytopenic. Dr Kar claims that these patients biased the diagnoses in favor of neoplastic diagnoses. In fact, the opposite was true, as is stated in the article. In these cases, the diagnoses were split evenly between neoplastic and nonneoplastic diagnoses, as demonstrated in the Table (please refer back to Weinzierl and Arber [1] for more details). Although we appreciate the logical algorithm put forth by Dr Kar, we note that this algorithm is, in general, arbitrary and not evidence based. Despite that, we agree that most treating
0046-8177/© 2014 Elsevier Inc. All rights reserved.
Table Division of patients who did not meet laboratory criteria for pancytopenia Patients who did not meet Neoplastic Nonneoplastic laboratory criteria for pancytopenia diagnoses diagnoses Adults Children Total
8 5 13
11 1 12
physicians probably currently use a similar algorithm. Indeed, physicians currently perform bone marrow biopsies in virtually all malignant cases, cases of aplastic anemia, and cases of reactive pancytopenia with clinical doubt. Our survey was not meant to direct clinicians to perform a bone marrow biopsy; instead, it was meant to serve as a general overview of potential results if they chose to perform this procedure. Elizabeth Weinzierl MD, PhD Children's Healthcare of Atlanta Atlanta, GA 30322, USA E-mail address: [email protected] Daniel A. Arber MD Stanford University, Stanford CA 94305, USA
http://dx.doi.org/10.1016/j.humpath.2013.10.041
Reference [1] Weinzierl EP, Arber DA. Bone marrow evaluation in new-onset pancytopenia. HUM PATHOL 2013;44:1154-64.
www.elsevier.com/locate/humpath
Correspondence
New-onset pancytopenia: a diagnostic approach—reply To the Editor, We appreciate the interest in our recent article [1] regarding bone marrow evaluation in new-onset pancytopenia. The goal of our article was to serve as a general outline for pancytopenia-driven diagnoses in an academic medical center. In response to the comments by Dr Kar, we note that our criteria for pancytopenia were not arbitrary but were derived from our well-established laboratory-based reference ranges. We know of no worldwide criteria for pancytopenia; indeed, as individual laboratories define their own reference ranges based on their individual populations and their individual instrumentation, there is no possible way to arrive at a truly universal definition of pancytopenia. In addition, although absolute neutropenia was a key part of our definition of pancytopenia, most patients in our study were also leukopenic by our laboratory-based criteria. Dr Kar also points out that we included several patients who were unicytopenic or bicytopenic in our study and claims that these patients biased the study in favor of neoplastic diagnoses. As to our including them, we did so because they were initially referred to the clinician for pancytopenia, based on the requisition sheet, and thus were, presumably, at one point, pancytopenic. Dr Kar claims that these patients biased the diagnoses in favor of neoplastic diagnoses. In fact, the opposite was true, as is stated in the article. In these cases, the diagnoses were split evenly between neoplastic and nonneoplastic diagnoses, as demonstrated in the Table (please refer back to Weinzierl and Arber [1] for more details). Although we appreciate the logical algorithm put forth by Dr Kar, we note that this algorithm is, in general, arbitrary and not evidence based. Despite that, we agree that most treating
0046-8177/© 2014 Elsevier Inc. All rights reserved.
Table Division of patients who did not meet laboratory criteria for pancytopenia Patients who did not meet Neoplastic Nonneoplastic laboratory criteria for pancytopenia diagnoses diagnoses Adults Children Total
8 5 13
11 1 12
physicians probably currently use a similar algorithm. Indeed, physicians currently perform bone marrow biopsies in virtually all malignant cases, cases of aplastic anemia, and cases of reactive pancytopenia with clinical doubt. Our survey was not meant to direct clinicians to perform a bone marrow biopsy; instead, it was meant to serve as a general overview of potential results if they chose to perform this procedure. Elizabeth Weinzierl MD, PhD Children's Healthcare of Atlanta Atlanta, GA 30322, USA E-mail address: [email protected] Daniel A. Arber MD Stanford University, Stanford CA 94305, USA
http://dx.doi.org/10.1016/j.humpath.2013.10.041
Reference [1] Weinzierl EP, Arber DA. Bone marrow evaluation in new-onset pancytopenia. HUM PATHOL 2013;44:1154-64.
