The term macrocytosis refers to a blood condition in which red blood cells (RBC) are larger than normal. Macrocytosis is reported in terms of mean corpuscular volume (MCV). Normal MCV values range from 80 to 100 femtoliters (fl) and vary by age and reference laboratory. 1 MCV is calculated according to the following formula:Macrocytosis can be identified by reviewing peripheral blood smears and/or by automated RBC indices. The peripheral blood smear is more sensitive than RBC indices for identifying early macrocytic changes because the MCV represents the mean of the distribution curve and is insensitive to the presence of small numbers of macrocytes. 2 However, compared to the peripheral blood smear, MCV may underestimate macrocytosis in over 30% of cases. 3 Although determination of the MCV by automated blood cell counter is rarely inaccurate, hyperglycemia, marked leukocytosis and cold agglutinins may result in false elevations of the MCV. [4][5][6] Moreover, partial occlusion of the instrument aperture and/or leaving the blood sample at room temperature for several hours may also result in false elevations of the MCV value. Clinical SignificanceMacrocytosis is a relatively common finding in the era of automated blood cell counters, with prevalence estimates ranging from 1.7% to 3.6%. 3,7,8 Its significance tends to be underestimated by physicians, since about 60% of patients present without associated anemia, 8 unless there are other accompanying abnormalities noted.No complications arise from macrocytosis itself as an isolated finding. However, its identification can provide important information regarding the presence of an underlying disease state. Thus, in the appropriate clinical setting, MCV values above the upper limit of normal or those that differ significantly from the patient's baseline values may require further clinical and laboratory assessment to determine the underlying cause of the macrocytosis. 9

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The value of maintenance therapy after the achievement of complete remission in adult acute nonlymphocytic leukemia (ANLL) has never been clearly established. A randomized Eastern Cooperative Oncology Group (ECOG) study of postremission therapy compared outcomes in patients who received no further therapy to those administered long-term maintenance chemotherapy. Adverse results in the group administered no further therapy led to early termination of this trial after only 51 patients were randomized. Patients receiving no postremission therapy experienced significantly inferior remission durations (P = .002) compared with patients receiving maintenance therapy. All 26 patients in the group administered no postremission therapy have relapsed, with a median duration of remission of 4.1 months. In contrast, four of 25 patients (16%) who received maintenance therapy remain disease free, with a median duration of remission of 8.1 months.

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Case reports and case series or case study research are descriptive studies that are prepared for illustrating novel, unusual, or atypical features identified in patients in medical practice, and they potentially generate new research questions. They are empirical inquiries or investigations of a patient or a group of patients in a natural, real-world clinical setting. Case study research is a method that focuses on the contextual analysis of a number of events or conditions and their relationships. There is disagreement among physicians on the value of case studies in the medical literature, particularly for educators focused on teaching evidence-based medicine (EBM) for student learners in graduate medical education. Despite their limitations, case study research is a beneficial tool and learning experience in graduate medical education and among novice researchers. The preparation and presentation of case studies can help students and graduate medical education programs evaluate and apply the six American College of Graduate Medical Education (ACGME) competencies in the areas of medical knowledge, patient care, practice-based learning, professionalism, systems-based practice, and communication. A goal in graduate medical education should be to assist residents to expand their critical thinking, problem-solving, and decision-making skills. These attributes are required in the teaching and practice of EBM. In this aspect, case studies provide a platform for developing clinical skills and problem-based learning methods. Hence, graduate medical education programs should encourage, assist, and support residents in the publication of clinical case studies; and clinical teachers should encourage graduate students to publish case reports during their graduate medical education.

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Between July 1, 1981 and November 1, 1982, 45 patients with acute nonlymphocytic leukemia (age, greater than or equal to 70 years) were randomly assigned to receive induction chemotherapy using either daunorubicin, cytosine arabinoside, and 6-thioguanine in full dosage (F DAT) or an attenuated schedule of the same drugs (At DAT) as part of an Eastern Cooperative Oncology Group controlled trial. Forty patients were deemed evaluable, 20 on each arm. The overall complete remission (CR) rate for all patients in both arms was 28% (11/40). There was no significant difference in CR rates between the two arms. There were 12 early deaths (less than 60 days) in the F DAT arm compared with only five early deaths on the At DAT arm (P = .05). Due primarily to this early death rate, the median survival for the F DAT group was 29 days v 159 days for the At DAT groups (P = .02). The range of survival of the patients in CR for the At DAT group given either one or two cycles of induction therapy was 121 to 414 days, while the survival range for the F DAT CR patients was 121-186 + days. The median survival for those not achieving CR was 14 days for the F DAT group v 80 days for the At DAT (P less than .02). Fifty-nine percent of the At DAT patients spent greater than 100 days out of the hospital v 12% for the F DAT group. Attenuated chemotherapy with lower doses of DAT is the preferred induction regimen for elderly patients with acute nonlymphocytic leukemia since it causes fewer early deaths, allows a better quality of life, and yields survival times as durable as intensive therapy.