ICCS e-Newsletter CSI Fall 2010
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Transcript of ICCS e-Newsletter CSI Fall 2010
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ICCS e-Newsletter CSI Fall 2010
David D. Grier, M.D.Department of Pathology.
Wake Forest University
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e-CSI - Clinical History:
• 61 year old man with no significant past medical history presented to his primary care physician complaining of fatigue, easy bruising, mild dyspnea on exertion, and headache for 3 weeks.
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e-CSI - Peripheral Blood:
• CBC Normal Range– WBC: 24.0 x 109/l (4.8 – 10.8)– RBC: 3.51 x 1012/l (4.7 – 6.1)– Hgb: 11.2 g/dl (14.0 – 18.0)– Hct: 31.5 % (42.0 – 52.0)– MCV: 89.8 fl (80.0 – 94.0)– MCH: 32.0 pg (27.0 – 31.0)– MCHC: 35.6 g/dl (33.0 – 37.0)– RDW: 15.4% (11.5 – 14.5)– Plts: 19.0 x 109/l (160 – 360)
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e-CSI - Peripheral Blood:
• CBC Differential – Granulocytes: 11%– Bands: 1%– Lymphocytes: 6%– Monocytes: 1% – Basophils: 2% – Eosinophils: 0%– Blasts/Promyelocytes: 72%
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e-CSI – Clinical History
• Bone marrow aspirate and biopsy were received for evaluation.
• Flow cytometric immunophenotyping was performed on a portion of the bone marrow aspirate and the results from selected 3-color and 5-color tubes are provided for review.
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e-CSI - Flow Cytometric Studies
• Acquired with a FC500 and initially analyzed with CXP Analysis 2.0 and then with FSC Express version 3
• Tube 1: CD34~FITC/ CD2~PE/ CD117~PC5/ CD45~PC7
• Tube 2: CD7~FITC/ CD33~PE/ CD45~PC7• Tube 3: HLA-DR~FITC/ CD13~PE/ CD45~PC7
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e-CSI - Flow Cytometric Analysis
CD45-PC7
SS
Lin
100
101
102
103
104
0
256
512
768
1024
Large population of atypical cells with increased side scatter. There are very few events in the “blast gate”.
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e-CSI - Flow Cytometric Analysis
CD33-PE
CD
7-F
ITC
100
101
102
103
104
100
101
102
103
104
The atypical cell population has uniform expression of CD33
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e-CSI - Flow Cytometric Analysis
CD13-PE
HL
AD
R-F
ITC
100
101
102
103
104
100
101
102
103
104
There is no expression of HLA-DR and variable expression of CD13.
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e-CSI - Flow Cytometric Analysis
CD34_FITC
CD
2-P
E
100
101
102
103
104
100
101
102
103
104
There is expression of CD2 and CD34.
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e-CSI – Key immunophenotypic findings
• The atypical cells have high side scatter and fall in the “myeloid gate”.
• Few events are seen in the “blast gate”.
• The cells express CD34, CD117, and CD2.
• CD13 expression is heterogenous.
• CD33 expression is homogenous.
• There is no expression of HLA-DR.
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Numerous atypical cells were seen. The nuclei were indented and overlapping.
Few cytoplasmic granules were seen. No Auer rods were identified.
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The bone marrow core biopsy was 100% cellular with the
marrow space almost completely replaced by blasts.
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Molecular cytogenetic analysis with DNA probes specific for the 15;17 translocation [PML-15q22 and RARA-17q21] was performed and revealed that a total of 82.5% of
the interphase nuclei had a PML/RARA fusion event.
Two fused signals, one red and one green, indicating the
fused PML-RARA (yellow).
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e-CSI Fall 2010– Diagnosis
• Acute promyelocytic leukemia (APL), microgranular variant (Acute myeloid leukemia with t(15;17)(q22;q12)).
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e-CSI – APL characteristic immunophenotype
• Absent or low expression of HLA-DR, CD34, CD11a, CD11b, CD15, and CD64.
• Homogenous expression of CD33
• Heterogenous expression of CD13
• Expression of CD117, but it may be weak.
• CD56 is seen in approximately 20% of cases.
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e-CSI – APL characteristic immunophenotype
• Strong myeloperoxidase expression.
• Microgranular variant can express CD34 and CD2.
• By CD45/side scatter the leukemic cells are typical found in the “myeloid gate”. Occasionally there is a “hockey stick” configuration. Microgranular variant tends to have lower side scatter.
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e-CSI – APL characteristic immunophenotype
• Lack of HLA-DR and CD34 is not specific for APL and can be seen in other types of acute myeloid leukemia.
• Immunophenotyping can suggest a diagnosis of APL, but it is NOT diagnostic.
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e-CSI – APL clinical presentation
• Fatigue, weakness, and dyspnea related to anemia.
• Easy bruising or bleeding caused by thrombocytopenia or coagulopathy.
• Most cases present with pancytopenia.– Microgranular variant can have very high
WBC counts.
• Risk of disseminated coagulopathy.
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e-CSI – APL Diagnosis
• Suspicion for APL is typically raised by morphologic assessment.– Abnormal promyelocyte morphology– Abundant cytoplasmic granules– Microgranular/hypogranular variant can have few to
no visible granules.– Frequent Auer rods– Irregular nuclei: bilobed and kidney shaped.
• More frequently seen in microgranular variant.
• The diagnosis is confirmed by cytogenetics (FISH).
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e-CSI – APL Differential diagnosis
• Acute myeloid leukemia– HLA-DR negative leukemia is not limited to APL– Cytogenetics essential for diagnosis– APL is sometimes mistaken, especially the
microgranular variant, for monocytic leukemia due to the nuclear features
• Growth factor effect– Lower blast counts– Lacks atypical nuclei– No t(15;17) abnormality
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e-CSI – APL Treatment
• The correct diagnosis is essential since the treatment is very different from other types of AML.
• Treatment consists of all-trans retinoic acid (ATRA) and anthracycline-based chemotherapy for induction and ATRA plus arsenic trioxide for consolidation.
• Some cytogenetic variants are ATRA resistant.– ZBTB16 (11q23), STAT5B (17q11.2)
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e-CSI – references
• Nagendra S, Meyerson H, Skallerud G, et al. Leukemias resembling acute promyelocytic leukemia, microgranular variant. American journal of clinical pathology 2002:117(4):651-657.
• Orfao A, Chillon MC, Bortoluci AM, et al. The flow cytometric pattern of CD34, CD15 and CD13 expression in acute myeloblastic leukemia is highly characteristic of the presence of PML-RARalpha gene rearrangements. Haematologica 1999:84(5):405-412.
• Redner RL. Variations on a theme: the alternate translocations in APL. Leukemia 2002:16(10):1927-1932.