Who We See

There are seven different areas in hematology that are clinically active. These are CLL/SLL, lymphoma, multiple myeloma, myeloproliferative neoplasms and bone marrow failure issues (also clonal myeloid abnormalities), acute leukemia, stem cell transplantation and cellular therapy and benign hematology. Below highlights how each of these areas is approaching enriching the patient population for diseases that our providers would like to clinically manage.

CLL/SLL or those with monoclonal B cells present in peripheral blood or from a tumor biopsy.

Patients should be referred based on the chart provided below.

Patients with plasma cell diseases should be managed as indicated below.

Likely low-risk monoclonal gammopathy of uncertain significance:

1. Patients being referred within the UNC system: Patients within the UNC system with small M-spikes (non-IgM and <1.5 g/dL), normal or mildly abnormal serum free light chain ratios (<10 and >0.1), and no clinical signs or symptoms to suggest an active plasma cell disorder such as multiple myeloma or amyloidosis, should be referred as an e-consult to malignant hematology.
2. Patients referred from outside the UNC system: Patients meeting above criteria will have their chart reviewed by a physician within the plasma cell dyscrasia group when the referral is received.  Patients with what appears to be low-risk monoclonal gammopathy of uncertain significance (MGUS) will be declined referral, given the extremely low-risk nature of that disorder (<1% annual risk of progression to active multiple myeloma) and the lack of need for specialist evaluation or further workup such as imaging or bone marrow biopsy.  Other patients will be scheduled for a clinic evaluation with the plasma cell dyscrasia group.

Patients with IgM monoclonal gammopathies (M-spikes): should be referred to UNC malignant hematology, attention Dr. Chris Dittus in the lymphoma clinic, since these are more often associated with lymphomas than plasma cell disorders.

Patients with the following will not be evaluated by our program, since these are not actual plasma cell disorders:

1. abnormal serum free light chains without an M-spike, and with ratios that are outside lab-reported normal range but within normal when adjusted for GFR per Rognvaldsson et. al. in Blood Cancer J. This non-pathologic state stems from reduced renal excretion by light chains and not an actual plasma cell disorder.
   1. 46-2.62 when eGFR 45-59 ml/min
   2. 48-3.38 when eGFR 30-44 ml/min
   3. 54-3.30 when eGFR <30 ml/min
2. polyclonal gammopathy, which is a state that represents non-specific activation of the immune system usually due to infection, autoimmune disease, or other inflammatory disorder not stemming from an intrinsic abnormality in plasma cells

Patients with acute leukemia or myelodysplastic syndrome should be referred to the leukemia clinic. Newly diagnosed acute leukemia patients or those with suspected acute leukemia (i.e., circulating blasts, high WBC) should be referred to LEAP (Leukemia Expanded Access Program). LEAP has available visits daily whereby patients can be seen within 24-48 hours of referral so that patients can be evaluated, undergo any diagnostic testing necessary, and can be safely managed and monitored while awaiting for their specific diagnostic tests and genomic profile. A new patient provider appointment can be scheduled 1-2 weeks after newly diagnosed acute leukemia patients are seen in LEAP.

For patients with myeloproliferative neoplasms or non-high grade MDS, referral should be made to the MPN clinic. Patients with the following parameters will not be seen in the MPN clinic:

1. Asymptomatic patients with Hgb > 8, PLT > 50K, ANC > 1K with < 5% circulating blasts. These individuals should undergo a bone marrow evaluation locally and then serial assessment of the peripheral blood count by CBC every 3-6 months until progression.
2. Isolated neutropenia, anemia or thrombocytopenia. These patients should be referred to benign hematology locally for diagnosis and management.

Benign Hematology

Faculty in the Section have varied clinical interests that have led to the development of a number of successful multidisciplinary clinical care programs, such as:

• the Harold Roberts Hemophilia and Thrombosis center
• the HHT Center of Excellence
• the Sickle Cell Disease program (and its growing outreach clinics across the state of NC)
• the Athletes and Thrombosis program
• the Women and Girls with Bleeding Disorders program
• the VTE Transitions clinic (previously called DVT walk-in clinic; APP led program)
• the Iron Deficiency Clinic (APP led program)

In an effort to facilitate Section faculty to focus their clinical care efforts in their chosen areas of interest/expertise, we have developed/implemented a number of approaches and workflows. These are outlined below:

• All referrals to the benign hematology clinic are triaged by the Medical Director for appropriateness
• Referrals that align with the clinical interests of Section faculty are scheduled with the appropriate providers
• Given the increasing demand for eConsults, we have identified the most common eConsult questions to us and developed templates for 7 specific diagnoses that can be safely evaluated as eConsults. The objective is to ensure that requesting physicians provide the necessary information for us to render an opinion in an efficient and timely fashion. The anticipated launch for this is June 2024 and we will expand on this and include additional diagnoses collaboratively with our malignant hematology faculty later in the year. This will allow us to focus on preferred diagnoses in clinic while also providing care of other hematological diagnoses that do not fit with the identified interests of Section faculty.
• Individuals with these seven specific diagnoses (to be provided later) within the UNC system should be referred for an e-consult with benign hematology.
• Created a collaboration with Dr. Bonkovsky at Atrium Health/Wake Forest Baptist hospital, whereby all referral for porphyrias and related diagnoses will be directly referred to Dr. Bonkovsky. This is mutually beneficial as Dr. Bonkovsky is nationally renowned for his expertise in porphyrias and none of the Section faculty have a particular interest in this disorder.

For the bone marrow transplant/cellular therapy program (BMTCTP), patients who are candidates for this therapy and referred to the BMT clinic and those referrals are evaluated by a physician with the BMT/Cellular Therapy Group. The following patients are not evaluated by the BMTCTP.

1. Patients where standard-of-care therapy would not include bone marrow transplantation or cellular therapy. The program will evaluate patients where there is clinical equipoise between conventional and BMT/cell therapy
2. Patients who are not currently insured and are not eligible for North Carolina Medicaid
3. For bone marrow transplantation, patients over the age of 80 are not currently considered for therapy and are not provided a clinic appointment