Dear Cancergrace Community,
My relative was accepted into the trail, pending some tests including a blood test. After preliminary tests were done she did a thoracentesis. Unlike the ones she had elsewhere, this one involved many people and a needle re-positioning that resulted in some blood in the subsequent extracted fluid. However, the procedure reduced the pressure she was feeling, but unlike previous times, the relief wasn't 100%. We mentioned this to our trial coordinator, but we also had been prescribed some pain meds, and didn't overly think about it.
When we returned to receive our first infusion, the Hgb had dropped 15% from the earlier blood test and below the trial's threshold. (They retested it too.) Hemolysis was noted. They suggested transfusion, but doing so would require additional waiting, more scans and tests, and the trial window might close too, and they didn't have sufficient units of blood on hand. We decided to come back next week to re-test. Our thinking that whatever this outlier blood result was -- that it was short-term. My thought was malnutrition or possibly iron-deficiency anemia. So we started with protein, vitamins and iron to prep her for her next visit which we've planned for next week. (I didn't realize that it could take a month to recover Hb.)
However, tonight, I just noticed in the blood work, that, compared to the initial blood work, RBC, WBC, and Hgb each decreased about 15% from the pre-thoracentesis to the post-thoracentesis blood work. There was also a 30% increase in platelet count. Because of the uniformity in the RBC, WBC, and Hgb changes, I now suspect that there was some internal bleeding (perhaps over a few days) as a result of the thoracentesis. Perhaps as much as a liter of blood may have gone into the pleural cavity.
1. Didn't they see the numbers too?
2. Can we still get in?
3. Should we worry about blood in pleural cavity if blood parameters are stable?
Thanks for your help,
Reply # - April 26, 2014, 10:57 PM
Reply To: Increase in platelets, decrease in RBC
Also: over the last few days my relative seems to have been experiencing pain that is greater than before thoracentesis. Before we occasionally used a tylenol, but she seems now to be completely reliant on her newly prescribed pain med. We were told, however, that the pain might be caused by the tumor disturbing a nerve, so it is unclear to me what this pain represents.
Reply # - April 26, 2014, 11:18 PM
Reply To: Increase in platelets, decrease in RBC
One last thing: they had mentioned that my relative had gained several pounds. Perhaps she is retaining water resulting in the lowered concentrations? Could that explain it? She is suffering from mild oedema in her ankles.
Reply # - April 27, 2014, 09:53 AM
Reply To: Increase in platelets, decrease in RBC
Both internal bleeding and water retention can affect blood counts, so those are certainly issues to discuss next week; they are the ones best able to try to track down the cause of those counts.
If the RBC has normalized, one would suspect that any internal bleeding has stopped, but again this is something to discuss with your relative's doctors.
JimC
Forum moderator
Reply # - April 27, 2014, 12:47 PM
Reply To: Increase in platelets, decrease in RBC
It's very common to have a little bleeding during a thoracentesis, but it's very uncommon to have that cause a liter of blood to go into the pleural cavity. I would not infer that this is the explanation for a drop in hematocrit and hemoglobin, nor WBC, based on the drop, which can be for many different reasons. I think it's worth review the situation with the oncologist, who is in a far better position to address the specifics of your relative's case.
-Dr. West
Reply # - May 3, 2014, 07:29 AM
Reply To: Increase in platelets, decrease in RBC
An update:
My relative has been booted from the trial. I want to relate our experience here in the event others face something similar. I am not a medical doctor, every individual's situation is different -- the following does not constitute medical advice.
We did a second blood draw after a weekend of eating high-protein bars, vitamins, iron, shakes and food. During that time we gave up on the salt tabs. WBC, RBC, Hgb were back up and in range in the second draw. But the doctors were dissatisfied with the sodium and the rapid change, so we went back home and added salt tabs while restricting water for the next couple of days. My relative experienced edema and her third blood draw showed that WBC, RBC, and Hgb had all fallen to the point where they wanted to transfuse her; sodium had risen to 128. She declined. She returned home and cut the salt and is today feeling great and the edema went away almost immediately.
A review of her records showed hyponatremia about one year prior at the time of diagnosis with NSCLC -- which is apparently more frequent in Asian patients and also a negative prognostic indicator (Bose et. al., 2011).
It looks like water restriction plus oral sodium supplementation (salt tabs) may have caused acute hemodilution or unmasked an underlying anemia.
Sodium depletion and hemoconcentration: overlooked complications in patients with anorexia nervosa? (Caregaro et. al., 2005)
My relative does not weigh a lot (~100lbs), and hasn't lost weight in the last year, but I could imagine she is less nourished than American. (She doesn't have, and has never had, a lot of meat on her bones.)
An open question to me is whether treating chronic hyponatremia in individuals with slowly progressing cancers or those with MPE is a correct course of action.
This contrasts to hemodilution and low NA with SIADH.
Reply # - May 3, 2014, 08:50 AM
Reply To: Increase in platelets, decrease in RBC
To my knowledge, that question has never been addressed systematically.
-Dr. West