What is the appropriate workup for a patient with uterine leiomyosarcoma (stage 3b) on gemcitabine (Gemzar) with docetaxel (Taxotere) who develops severe leukocytosis with neutrophilia?

From the Guidelines

For a patient with stage 3b uterine leiomyosarcoma on gemcitabine/docetaxel who develops severe leukocytosis with neutrophilia, an urgent and comprehensive workup is necessary to identify the underlying cause and guide appropriate management. The initial approach should include:

• A complete blood count with differential to confirm the severity of leukocytosis and assess for any signs of bone marrow suppression or leukemia
• Comprehensive metabolic panel to evaluate for any signs of organ dysfunction or electrolyte imbalances
• Blood cultures and urinalysis to identify potential infection sources, as patients with cancer are at increased risk of infections due to immunosuppression 1
• Chest X-ray and additional imaging (CT scan of chest/abdomen/pelvis) to evaluate for disease progression, abscess, or pneumonia, which can be life-threatening in immunocompromised patients Medication review is essential, particularly focusing on recent administration of granulocyte colony-stimulating factors (G-CSF) like filgrastim, which commonly causes neutrophilia 1. If infection is suspected, broad-spectrum antibiotics should be initiated promptly, typically with agents like piperacillin-tazobactam 4.5g IV every 6 hours or meropenem 1g IV every 8 hours, pending culture results. The chemotherapy regimen may need temporary discontinuation until the cause is identified. Paraneoplastic leukemoid reaction should be considered if infection is ruled out, as this can occur with advanced sarcomas. Bone marrow examination may be necessary if leukemia is suspected. This comprehensive approach is critical as neutropenic cancer patients are at high risk for life-threatening infections, and distinguishing between infection, medication effect, and disease progression has significant treatment implications.

From the Research

Evaluation of Leukocytosis

The patient's sudden development of severe leukocytosis with neutrophilia requires a thorough workup to determine the underlying cause.

• The patient's white blood cell count has increased significantly, with a count of 48 yesterday and 59.7 today, with 85.5% neutrophils, 9.0 leukocytes, and 0.5 myelocytes 2, 3.
• The differential diagnosis of leukocytosis includes physiologic responses to infectious and inflammatory processes, as well as primary hematologic disorders such as leukemias, lymphomas, and myeloproliferative neoplasms 2.
• A careful physical examination, meticulous review of the complete blood count and peripheral blood smear, and judicious application of laboratory and radiologic testing are necessary to evaluate the patient's condition 2, 4.
• The patient's history of uterine leiomyosarcoma and treatment with gemcitabine and docetaxel should be considered in the evaluation, as certain medications can cause leukocytosis 3, 4.
• The workup should include a repeat complete blood count with peripheral smear, as well as other laboratory tests such as bone marrow aspiration and biopsy, imaging studies, and specialized molecular tests if necessary 2, 4.
• The patient's symptoms and clinical presentation should be carefully evaluated to determine if they are suggestive of a hematologic malignancy or another underlying condition 4.
• Consultation with a hematologist/oncologist may be indicated if malignancy cannot be excluded or another more likely cause is not suspected 4.

Laboratory Evaluation

• The laboratory evaluation of leukocytosis should be guided by the patient's clinical history and presentation 5.
• The laboratorian's approach to consult cases should include a review of the patient's complete blood count and peripheral blood smear, as well as other laboratory tests as necessary 5.
• The patient's white blood cell count and differential should be carefully evaluated to determine the underlying cause of the leukocytosis 3, 4.
• The laboratory evaluation should also include a review of the patient's medical history, including their history of uterine leiomyosarcoma and treatment with gemcitabine and docetaxel 3, 4.

Clinical Considerations

• The patient's clinical presentation and symptoms should be carefully evaluated to determine the underlying cause of the leukocytosis 3, 4.
• The patient's history of uterine leiomyosarcoma and treatment with gemcitabine and docetaxel should be considered in the evaluation, as certain medications can cause leukocytosis 3, 4.
• The patient's symptoms and clinical presentation should be carefully evaluated to determine if they are suggestive of a hematologic malignancy or another underlying condition 4.
• The patient's condition should be closely monitored, and the workup should be tailored to the patient's specific needs and clinical presentation 2, 4.