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Alert Number 283

Low hemoglobin and platelets: the WHY is important

Date: March 31, 2008

The Rai and Binet staging take cytopenias very seriously. When hemoglobin and platelet counts drop below acceptable levels, that automatically triggers moving up one notch on the Rai and Binet staging.

But that may be more of a knee jerk response than it ought to be. It is important to know the why of the situation, why the platelet and hemoglobin counts are dropping, not just the fact that they are dropping.

The latest issue of British Journal of Hematology has published an interesting paper on the subject, authored by one of my favorite researchers at the Mayo Clinic.  Dr. Clive Zent reports that patients whose platelets and red blood cell counts are lower because of autoimmune disease are not at as high a risk as those whose counts are tanking because of bone marrow disease. Out of 1,750 CLL patients evaluated for this study, 303 had cytopenias (low counts of platelets and /or hemoglobin). It was determined that in a full 75% of these patients the problem was traced to bone marrow failure, while the remaining 25% had autoimmune disease. The interesting finding is that while the folks with cytopenias traceable to bone marrow failure paid for it with decreased survival, there was no similar penalty for low counts because of autoimmune disease.

It makes sense to me.  Autoimmune disease is not fun, but it can be treated.  Bone marrow failure on the other hand is pretty serious business.  Failure of this crucial function means just about all aspects of generation of new blood cells is compromised and this is reflected in poorer survival.  The Rai and BInet staging does not take this crucial “why” into account, both of these staging systems respond only to the fact of the cytopenia, and thereby wrongly downgrade folks whose cytopenias may have nothing to do with bone marrow failure.

We always offer patients help in getting hold of the full text of the article, if they are interested.  However, I have to admit that right now I will most likely be unable to answer hundreds of requests.  I spend most of the day in the hospital with PC, and only rarely get to do CLL Topics business.  That also explains my inability to respond to many emails in the past couple of weeks.  Please bear with us, we will be back in business full time as soon as PC is sprung from his hospital room.  We are told most patients get to spend around 30 days grounded to their room – seems forever as we are only on day +5 as of today.

Be well,




British Journal of Hematology doi:10.1111/j.1365-2141.2008.07086.x

The prognostic significance of cytopenia in chronic lymphocytic leukaemia/small lymphocytic lymphoma

Clive S. Zent11Division of Hematology, et al



The development of cytopenia in chronic lymphocytic leukaemia (CLL) patients can predict poor prognosis. All CLL patients seen in the Division of Hematology at Mayo Clinic Rochester from 1 January 1995 to 31 December 2004 (n = 1750) were evaluated for cytopenia, aetiology of cytopenia and clinical outcome. Cytopenia occurred in 423 (24·2%) patients and was attributable to CLL in 303 (17·3%) cases, with 228 (75%) of these having bone marrow (BM) failure and 75 (25%) having autoimmune disease (AID). Survival from onset of cytopenia was significantly better for patients with AID (median 9·1 years) compared to patients with BM failure (median 4·4 years, P < 0·001). Patients with AID diagnosed within 1 year of the diagnosis of CLL (n = 35) had similar survival from diagnosis compared to patients without CLL-related cytopenia (median 9·3 vs. 9·7 years, P = 0·881). Although cytopenia caused by BM failure predicted a poorer prognosis in CLL, cytopenia caused by AID was not an adverse prognostic factor. These findings suggest that patients with cytopenia due to AID cannot be meaningfully classified by the current clinical staging systems. Revisions of the National Cancer Institute Working Group 96 criteria should consider the aetiology of cytopenia in staging CLL patients.


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