Sysmex XN2000: experiences and case studies

Craig Mabbett

2016

2016

Add pic of XN2000 setup now.

2016

XN-2000

• Automatic reflexing

• Customisable rules

• No sensitivity calibration

• Customisable printout

• Film review rate?

Dislikes?

• Aged sample flag > disabled!

• Suspect sample flag > ? Necessary with

experienced staff and delta checks

• ”Analyser is not ready” alarm > annoying!

• QC -printing to PDF would be nice

-QC comments do not print

-file delivery system

• XbarM > more errors compared to XT (this may be

related to IPU settings)

WDF

• Not much change in function from XT

• improved scatter separation/gating

• Left shift flag = improved specificity

• Blasts/Abn Lympho?

now reflexes to >

• PLT Clumps?

now reflexes to >

WNR

• Automated NRBC

>reduced TAT for some films

• automatic film review >1%

• LIS limitations (would be nice if

TNC-N was a reportable parameter!)

RET

• No Change in function but now have

access to RET-He feature

• Other useful pararmeters RBC-O,

Hb-O, MCHC-O, PLT-O

• RET channel can be used as an

alternative to warming for cold aggs

(reaction chamber incubated at 41°C

for ~21sec)

• Available on all XNL models

RET-He

• In house study 2017 n = 178

• Aim to assess RET-He as a screening

tool for iron deficiency

• Ret-He reported in pg and is a function

of RBC size (FSC)

• Reference range 30.0 - 35.0 pg

• Cut off for iron deficiency <26 pg

• Screening tool only (not diagnostic) but

could be enhanced by using an

algorithm.

Normal

Fe deficient

PLT-F

• Reflexed if PLT IP flag or if

PLT-I <30 x109/L

• PLT Clumps? flag very specific

• PLT Abn Distribution flag

– Giant PLT (MPD/MDS)

– Large PLT (pregnancy, ITP)

– PLT Anisocytosis

– PLT clumps don’t seem to trigger

• PLT Abn Scattergram

– WBC fragments

• IPF

– Measure platelet production

Onboard Rules

• Extremely customisable

• Great feature for smaller labs, or labs that don’t have

access to middleware.

REACTIVE LYMPHS

COLD AGGS RULE

No more 20min warming! R-MFV = MCV RBC-O = RBC

WPC

• White Precursor Cell Channel

Reflexed if: Blasts/Abn Lympho?

WBC>30 or WBC <2

WPC

WPC

• 2016 WPC Qflag study to asses

> Blasts/Abn Lympho? (WDF)

> Blast? (WPC)

> Abn Lympho? (WPC)

• Analysed 2 months of WPC data (279 samples)

• Films reviewed and classified by gold standard

morphologists…

• Film correlated with clinical details (and/or cell

markers and bone marrow report if available)

>Classified as positive (sepcific abnormal cell present)

or negative (specific abnormal cell absent)

WPC

• Data used to predict cut-offs for each IP flag

that would result in the most improved

specificity without sacrificing sensitivity (ie.

false negatives are unacceptable)

RESULTS:

• WDF Blasts/Abn Lympho? = low specificity

> Qflag changed to 110

• WPC

>Blasts? Results suggest Qflag of 140

>Abn Lympho? Results suggest Qflag of 140

Abn Lympho? Final Qflag = 120>Specificity inferior to Blast flag

(Can be triggered by reactive lymphocytes)

Blast? Final Qflag = 120

>Better specificity than Abn Lymph?

P.V. ?transforming to MF

Blast? Qflag = 300

PV patient with occ blast

14/07/2017

Blast? Qflag = 300

17/07/2016

Abn Lympho? Qflag = 300

Hairy Cell Leukaemia

Abn Lymph? Qflag = 250

CLL

Abn Lymph? Qflag = 300

Mantle Cell Lymphoma

Abn Lymph? Qflag = 300

Dengue

Blast? Qflag = 300

Atypical lymph ? Qflag =300

AMML

Blast? Qflag = 160

WPC

• Limitations of study:

Negative films (Qflag <100) were not reviewed

Data set could be larger (but study ongoing)

Did not encompass all possible neoplastic conditions

Morphologist bias

WPC bottom line:

Great as a support tool to assist morphologists

>Specificity vs sensitivity

>?usefulness with Cellavision

>?usefulness to an experienced morphologist

>cost

Case Study

• 24 day old Female (full term gestation)

• Admitted for jaundice investigation

• Bloods indicate severe anaemia…

Case Study

??

Film comment:

Occasional immature cell present;

spherocytes +; polychromasia +;

occasional red cell fragment

Case Study

• MCHC does not correct with warming

• Bilirubin 611µmol/L ?Hb interference

>Hb 67 / Hb-O 60

>MCHC 427 / MCHC-O 380

>MCH 53.6 / RBC-He 30.9

Possibly, but doesn’t explain RBC histogram

• ?Agglutination, ?Haemolysis

• Film reviewed by Charge scientist = ?mild agglutination

Case Study

Red cell indices incorrect ?solution

Use RBC-O, R-MFV, Hb-O

And recalculate others:

Spun HCT = corrected HCT (confirms calculation)

Uncorrected Corrected

Hb 67 60

RBC 1.25 1.83

HCT 0.157 0.176

MCV 125.6 96.0

MCH 53.6 32.6

MCHC 427 341

Case Study

• Futher testing:

>Parvovirus B19 serology: IgM negative

> G6PD studies: negative

>Blood bank: DAT: positive

Group: Coating IgG and C3d. Blood group cannot be

determined

>NZBS reference lab: After DTT treatment, blood group appears to be

A positive. Strong C3d coating on red cells is

causing interference with serological testing.

Repeat at 6 months of age if indicated.

Older Sibling was noted to have a rash at the time this occurred. Tested

negative for Parvovirus serology, but positive for CMV.

>Diagnosis??

Thank youReferences:

1. Various Sysmex XN documents -Roche diagnostics

2. Sysmex Corporation Japan. (2012). Sysmex XN2000 instructions for use.

3. Brugnara C, Schiller B, Moran J. Reticulocyte hemoglobin equivalent (Ret-He) and assessment of

iron-deficient states. Clin Laboratory Haematol, 2006. 28, 303-308.

4. Mast A, Blinder M, Quing L, Flax S, Dietzen D. Clinical utility of the reticulocyte hemoglobin

content in the diagnosis of iron deficiency. Blood, 2002. 99(4), 1489-1491.

It’s not the size of your track that

matters, it’s how you use it!