What is complex malignant hematology (CMH)?

Complex malignant hematology includes a variety of disorders and cancers of the blood. These conditions start in the bone marrow or in the cells of the immune system.

What are the types of blood cancers?

Complex malignant hematology is divided into two main types: lymphoid and myeloid.

Lymphoid cancers affect the lymphocytes – part of the immune system. It may originate in the bone marrow or the lymph nodes.

Myeloid cancers start in the bone marrow. Bone marrow is a spongy tissue inside some of our bones that contains stem cells. Stem cells are immature cells that can develop into blood cells.

The conditions are further classified as “acute” or “chronic”. Acute conditions mean that the cancer cells are splitting and growing quickly, and affecting the immature cells. Chronic conditions mean the cells are reproducing more slowly, and typically involve more mature cells. Sometimes chronic conditions can transform into acute conditions.

Acute conditions may be life threatening left untreated and generally require the treatments to start within 1 week.

To better understand blood cancers, it is helpful to visualize how they are classified. While not an exhaustive list, the starred conditions would fall under the jurisdiction of Complex Malignant Hematology.

The goal of therapy in most CMH conditions is cure.

Lymphoid Conditions

Acute:
Acute lymphoblastic leukaemia (ALL)*
Lymphoblastic lymphoma (LL)*

Chronic:
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma – many types, including:

• Burkitts lymphomas*
• High grade B-cell lymphomas double hit*
• Primary CNS Lymphomas*

Myeloid Conditions

Acute:
Acute Myeloid Leukemia (AML)*
Granulocytic sarcoma*

Chronic:
Myelodysplastic syndromes (MDS)
Myeloproliferative neoplasms (MPN)
Aplastic Anemia (AA)*
Paroxysmal Nocturnal Hemoglobinuria (PNH)*

What are the symptoms of blood cancers?

The symptoms of blood cancers or conditions can be different because of all the different types of condition.

Some of common symptoms of blood cancer, according to the Canadian Cancer Society, are:

• Unexplained weight loss
• Fatigue
• Shortness of breath
• Easy bruisability or bleeding
• Enlarged lymph nodes in the neck, underarm, groin or above the collarbone
• Swollen stomach or abdominal discomfort
• Frequent and repeated infections
• Fever/night sweats

Why do these conditions require such specialized care?

As a general rule, these conditions require management in specialized cancer centres. Many people require chemotherapy and or immunotherapy, and some may only be cured by a bone marrow transplant. The transplant can come either from ones own stem cells (autologous) or from an external donor’s (allogeneic). These treatments essentially wipe out the immune system, putting patients at risk for infection and at higher risk for needing blood transfusions. So, a very specialized care team and treatment space is needed to deliver the best and safest care.

More resources: 

Lymphoma Canada

Leukemia and Lymphoma Society of Canada

Learn more about Sunnybrook’s facility for treating complex malignant hematology.

This post was reviewed and updated Sept. 15, 2021.

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The Answer: There are more than 40 different types of lymphoma, a cancer of the lymphatic system, that are typically divided into two main types: Hodgkin lymphoma and Non Hodgkin lymphoma. Since the medical protocols for treating these forms of cancer are standard, most can be easily managed in community and teaching hospitals, according to Eugenia Piliotis, a hematologist who specializes in lymphoma at Sunnybrook.

“In the majority of cases there is no need to be sent to a teaching hospital for treatment,” said Dr. Piliotis, who is also associate professor in University of Toronto’s department of medicine. “Exceptions to that would be if there is a potential for a clinical trial you may be eligible for that you and your physician think you would be a good fit.”

The other exception is if you have a rare type of cancer, such as cutaneous t-cell lymphoma, high-grade lymphomas, or other rare, aggressive types of lymphoma that require super specialized treatment by clinicians as well as pharmacists and nurses most familiar with them.

What I am wondering, though, is if this is a treatment issue or one if you are lacking confidence or are having trouble trusting the oncologist. When a patient has been diagnosed with cancer, it is almost always the worst thing that has ever happened to them. It’s not a surprise, then, if you are wondering whether the treatment your father is obtaining represents the best possible care.

If your father does not have a favorable response that may be due to a cancer that is not responding to treatment and requires another protocol, rather than a clinician who is not providing the best care.

Having said all that, it is reasonable to ask for a second opinion if you are having doubts or you want to confirm the diagnosis and treatment plan. However, to obtain that second opinion, it is best to ask the treating oncologist to arrange it – not your family physician. Just having this conversation with the oncologist may help dissolve some of your concerns.

If you want a second opinion and you are concerned about offending the oncologist, don’t be. So long as you word it politely, it should not be an issue – oncologists are used to being asked for second opinions.

You may want to word your question something along these lines: “I have faith in you but I’m anxious. This is a big diagnosis and I want to make sure I’m doing the right thing for myself. Is it possible to get a second opinion?”

That oncologist is the best person to facilitate the second opinion as she or he can tell the other cancer specialist what treatments, tests and scans you have had.

“Most often patients get here and we tell them the exact same thing that their primary oncologist has already explained, so usually we are just reassuring,” said Dr. Piliotis. “Everyone deserves a second opinion if they have concerns.”

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