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A 65-year-old male with a h istory of pros tate cancer on hormonal therapy presen ts for evaluation of worsening fatigue and increasing bone pai n. Physical· examination reveals pallor and diffuse vertebral tenderness . Laboratory evaluation shows hemoglobin of 8.6 g/d l, leukocyte count of 22.600/,LLL. and platelet count of 58 .000/.uL. PSA is i ncreased 597 ng/ml. Peripheral blood smear is shown below.
What is the most appropriate next step in management?
- Discontinue hormonal therapy and initiate chemotherapy
- Check testosterone levels
- Check iron, folate, and vitamin B12 levels
- Flow cytometry of the peripheral blood
- Bone marrow aspiration and biopsy
Medicine
E. Peripheral slide reveals evidence of nucleated red blood cells (RBC) in addition to leuko-cytosis, with evidence of promyelocytes and metamyelocytes in peripheral blood and thrombocytope-nia. This picture is concerning for an underlying bone marrow dysfunction and constitutes an indication for bone marrow evaluation. Leukoerythroblastosis is characterized by the presence in peripheral blood ofRBCs exhibiting abnormal morphology: dacrocytes (tear drops), nucleated RBCs, and immature leukocytes, including occasional blasts and giant platelets. It is usually indicative of bone marrow replacement by an exogenous process.
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