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Improving Efficiency in the Haematology Laboratory

molecular Haematology
From educational sessions in the rapid advancements in molecular haematology to the different aspects of haematopathology, coagulation and haemostasis amongst others, the Haematology track at the MEDLAB Americas Exhibition and Congress will also address everyday quality challenges in the haematology lab.

As the Chair of the Haematology track, it is my great pleasure and a privilege to welcome you to the MEDLAB Americas Exhibition and Congress, that will take place in a few short months in sunny Orlando, Florida, USA. The overarching theme of this session is “Improving Efficiency in the Haematology Laboratory” and we were fortunate in securing a roster of content experts who will describe their experience in achieving more streamlined diagnostic processes, that ultimately lead to improved patient care. 

The topics that will be covered in the Haematology track are varied, and touch upon several broad diagnostic categories, as well as different areas of the Haematology laboratory. I will summarise some of the highlights in the remainder of this article. 

Our first featured speaker is Dr Stephanie Mathews, an assistant professor of Haematopathology from the University of North Carolina School of Medicine in Chapel Hill, North Carolina, USA. Dr Mathews specialises in the diagnosis of chronic myeloid neoplasms and is a consummate educator in her work with several professional societies, including the American Society for Clinical Pathology and the Society for Haematopathology. Dr Mathews will provide an overview of the updated classification and nomenclature of myelodysplastic syndromes, that will be listed in the upcoming 2016 version of the WHO Classification of Tumors of Haematopoietic and Lymphoid Tissue, and she will discuss the best practices in working up myelodysplastic syndromes, based on state-of-the-art best diagnostic approaches. 

This is a timely topic of practical utility, since haematologic malignancies comprise a unique spectrum of disorders as they are associated with significant morbidity and mortality, and the diagnostic algorithm is complex and involves a multidisciplinary approach, including clinical, morphologic, immunophenotypic, and cytogenetic findings, as outlined in the current WHO classification of haematolymphoid neoplasms. There is a constant process of improving and refining diagnostic, prognostic, and therapeutic modalities, in order to maximise favourable outcomes in this group of patients. Because of the amount of rapidly changing information in the specialties of Haematopathology and Haematology/Oncology, it is necessary for practitioners to be knowledgeable of the most recent developments in these fields, in order to provide the most optimal patient care.

Recent literature data have shown that only 33% of general pathologists are confident in diagnosis myelodysplastic syndromes (MDS), and professional organisations such as the American Society for Clinical Pathology and American Society of Haematology have identified myelodysplastic syndromes as a heterogeneous group of haematopoietic malignancies that represent a diagnostic challenge for pathologists.

In addition, surveys showed that neither general pathologists nor haematopathologists are comfortable using the International Prognostic Scoring System to characterise risk. This poses a problem, as accurate classification and prognostic scoring are essential to treating myelodysplastic syndromes. We hope that you will find Dr Matthew’s discussion helpful in becoming acquainted with the most recent national and professional consensus guidelines for the diagnosis of myelodysplastic syndromes. 

Our second distinguished speaker is Dr Chung-Che (Jeff) Chang, who is the medical director for Haematology and Molecular Diagnosis at Florida Hospital, and also serves as a professor of Pathology at the University of Central Florida, in Orlando, Florida, USA. Dr Chang has published extensively on diagnostic and molecular Haematopathology, and is intimately involved in educational and laboratory quality improvement activities as a member of the Haematology and Clinical Microscopy Resource Committee of the College of American Pathologists.

His talk will cover multiple myeloma, which is another topic of wide clinical interest. Multiple myeloma (MM) is a common haematologic malignancy (10-15% of haematopoietic neoplasms) and is defined by a triad of clinicopathologic criteria, including the presence of a serum or urine monoclonal protein; the presence of a clonal plasma cell population in the bone marrow (or plasmacytoma); and disease-related end-organ or tissue impairment, usually summarised under the CRAB acronym, and also including hyperviscosity, amyloidosis, or recurrent infections. 

The current diagnostic criteria, as listed in the 2008 WHO classification of haematolymphoid neoplasms and initially defined by the International Myeloma Working Group (IMWG) in 2003, apply to symptomatic MM (i.e. requiring therapy) and have been used for the past decade in clinical practice and research trials. However, the spectrum of plasma neoplasms encompasses other entities, such as monoclonal gammopathy of undetermined clinical significance (MGUS), asymptomatic or smoldering multiple myeloma (SMM), plasma cell leukaemia (PCL), solitary plasmacytoma, Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome, and systemic AL light chain amyloidosis. 

From a clinical standpoint, it is postulated that Multiple myeloma is almost always preceded by MGUS, which is present in 3-4% of the general population age >50 years and has a rate of progression to MM of approximately 1% per year. The diagnostic criteria for MM, SMM, and MGUS have been recently updated by the IMWG and will be adopted by the 2016 WHO classification of haematolymphoid neoplasms.

The rationale for updating these definitions is based on observations from several studies that have identified a subset of patients with SMM who showed a much higher progression risk to MM, even in the absence of traditional CRAB features. The introduction of these new myeloma-defining biomarkers (such as BMPC≥60%, involved: uninvolved sFLC ratio≥100, and MRI findings with more than one focal lesion) removes the need for documenting end-organ damage as an obligatory requirement for the definition of a neoplastic condition (MM) and allows the identification of a cohort of SMM patients that may benefit from treatment initiation prior to the occurrence of irreversible end-organ damage. 

It is the recommendation of the IMWG that these criteria should be implemented in routine clinical practice and future trials. Furthermore, it proposes the consideration of flow cytometry-based potential future biomarkers for the diagnosis of a Multiple myeloma, such as high levels of circulating plasma cells and the presence of abnormal plasma cell immunophenotype≥ 95% (in combination with immunoparesis). With this background in mind, Dr Chang’s review will provide an overview of the best practices in the diagnosis of Multiple myeloma. 

I will then have the pleasure of discussing clinical and pathology features of aggressive B-cell lymphomas. This is an area of clinical interest not only for our group of oncologists at the Medical College of Wisconsin, where I practice Haematopathology as an associate professor, but also at national and international levels. In part, this is due to the updated classification of these entities in the 2016 WHO revision, and also spurred by the opportunity of developing local consensus guidelines for diagnosis and treatment, in the absence of national or professional benchmarks.

Our expertise is supported by literature data, that have shown how a second review of haematologic malignancy cases at academic institutions result in major diagnostic changes in as many as 15% of cases, of which 13% may have resulted in a therapeutic change, thus supporting the need of expert haematopathology review. My talk will cover the current classification of aggressive B-cell lymphomas, in the context of the 2016 WHO updates; prognostic algorithms in diffuse large B-cell lymphoma; biologic variables that impact prognosis in diffuse large B-cell lymphoma; and will conclude with some practical recommendations derived from our own clinical practice regarding locally-developed guidelines on the judicious work-up of “double hit” lymphomas. 

Finally, the Haematology track will be concluded by an expert speaker, Dr Juliana Gaitan from Florida Hospital in Orlando, Florida, USA, who will discuss quality, value and risk in transfusion medicine, thus providing a balanced counterpoint to the prior haematopathology-based talks.

I hope that this summary has provided you with a taste of the full-length discussions and raised your interest in coming to Orlando to listen to our speakers in person. Together, we can learn how to be more efficient in the Haematology laboratory, how to improve our own practice, and thus, how to better serve our patients. We look forward to seeing you at the Conference!

Dr Horatiu Olteanu will chair the MEDLAB Americas conference session on Haematology held under the theme, ‘Improving Efficiency in the Haematology Laboratory’, at the Florida International Medical Expo (FIME) on August 9, 2017.

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