Diagnostik Laboratorium Keganasan Hematologi

MICM Interactive Clinical Reasoning Session

🎯 Learning Goals

• Mengidentifikasi leukemia dari pola klinis
• Menggunakan MICM sebagai framework diagnosis
• Mengambil keputusan awal pada kegawatan hematologi
• Melatih clinical reasoning berbasis data

🔍 SESSION 1

CLINICAL RECOGNITION

🧑‍⚕️ Kasus: Robert Pale (17 tahun)

• Lemas progresif
• Pucat
• Sesak saat aktivitas ringan
• Gusi berdarah
• Petechiae

❓ THINK

Apa sistem utama yang terganggu?

A. Sistem respirasi
B. Sistem koagulasi
C. Sistem hematopoietik
D. Sistem endokrin

👉 Jawaban: C

⚠️ RED FLAG CHECK

Manakah yang paling mengkhawatirkan?

A. Fatigue
B. Pallor
C. Gingival bleeding
D. Night sweating

👉 C → indikasi infiltrasi + trombositopenia

🧪 SESSION 2

INITIAL LAB INTERPRETATION

CBC Results

• Hb 5.8 g/dL
• Plt 11.000/µL
• WBC 92.000/µL

❓ THINK

Pola ini paling sesuai dengan:

A. Iron deficiency anemia
B. Acute leukemia
C. Viral infection
D. Hemolytic anemia

👉 Jawaban: B

🔥 KEY INSIGHT

“High WBC + cytopenia → marrow failure with clonal expansion”

🧠 MINI CHECKPOINT

Apa langkah berikutnya?

A. Observasi
B. Antibiotik
C. Flowcytometry + apusan darah
D. Suplemen besi

👉 Jawaban: C

🧬 SESSION 3

COAGULATION EMERGENCY

Lab Koagulasi

• PT ↑
• aPTT ↑
• Fibrinogen ↓

❓ THINK

Diagnosis paling mungkin?

A. Hemofilia
B. DIC
C. ITP
D. Liver cirrhosis

👉 Jawaban: B

🚨 CRITICAL MESSAGE

Jika leukemia + DIC → pikirkan:

⚠️ APL until proven otherwise

🧠 SESSION 4

MICM FRAMEWORK INTRO

MICM

• M = Morphology
• I = Immunophenotype
• C = Cytogenetics
• M = Molecular

❓ THINK

Kenapa kita tidak cukup hanya CBC?

A. CBC terlalu mahal
B. CBC tidak spesifik
C. CBC tidak bisa melihat klonalitas
D. B dan C benar

👉 Jawaban: D

🔬 MORPHOLOGY

Apusan Darah Tepi

Ciri AML:

• Blast besar
• Nukleolus jelas
• Auer rods

❓ THINK

Auer rods menunjukkan:

A. Lymphoid lineage
B. Myeloid lineage
C. Plasma cell disorder
D. Viral infection

👉 Jawaban: B

🧫 IMMUNOPHENOTYPE

Flow Cytometry Concept

• CD45 dim gate
• Low SSC = blast region

❓ THINK

Marker paling khas AML?

A. CD3
B. CD19
C. MPO
D. CD20

👉 Jawaban: C

⚡ APL SIGNATURE

• CD34 negative
• HLA-DR negative
• MPO positive

❓ THINK

Ini paling sesuai dengan:

A. ALL
B. AML NOS
C. APL
D. CML blast crisis

👉 Jawaban: C

🧬 CYTOGENETICS

❓ THINK

Translokasi paling emergensi:

A. t(8;21)
B. inv(16)
C. t(15;17)
D. t(9;22)

👉 Jawaban: C

🚨 CLINICAL PEARL

t(15;17) =

Emergency hematologic condition
Treatment before confirmation allowed

🧬 MOLECULAR

FLT3 Mutation

• constitutive signaling
• rapid proliferation

❓ THINK

FLT3-ITD implies:

A. Good prognosis
B. Chronic disease
C. High relapse risk
D. Benign condition

👉 Jawaban: C

🧩 INTEGRATION CASE

Semua Data Robert

• CBC abnormal
• DIC
• Blast + Auer rods
• CD34-/HLA-DR-
• t(15;17)
• PML-RARA+

❓ FINAL DIAGNOSIS

A. ALL
B. AML NOS
C. APL
D. MDS

👉 Jawaban: C

💥 TREATMENT DECISION

❓ WHAT TO DO NOW?

A. Tunggu hasil sitogenetika
B. Mulai ATRA segera
C. Kemoterapi standar dulu
D. Observasi

👉 Jawaban: B

⚠️ GOLDEN RULE

“Suspect APL → treat immediately”

🧠 SUMMARY

MICM Logic

• Morphology → suspicion
• Immunophenotype → lineage
• Cytogenetics → entity
• Molecular → precision & MRD

🧬 FINAL MESSAGE

Hematologic malignancy = system failure of differentiation

🎓 END OF SESSION

“Think in patterns, not in memorization”