ADx Bone Marrow Report. Patient Information Referring Physician Specimen Information

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1 ADx Bone Marrow Report Patient Information Referring Physician Specimen Information Patient Name: Specimen: Bone Marrow Site: Left iliac Physician: Accession #: ID#: Reported: 08/19/ CHRONIC MYELOGENOUS LEUKEMIA WITH 1% CD34 POSITIVE BLASTS AND GRANULOCYTIC HYPERPLASIA IN HYPERCELLULAR MARROW Comments: RT-PCR for BCR/ABL and conventional cytogenetics detected t(9;22). Flow cytometry revealed atypical granulocytes and monocytes which can be seen in myeloproliferative neoplasms. CD34 immunostain shows 1% blasts (within normal limits). Special stains reveal grade 0 fibrosis with focal grade 1 fibrosis (scale of 0 to 3). Morphologic evaluation reveals a hypercellular marrow for age (90% cellularity) with trilineage hematopoiesis, markedly increased and left-shifted granulocytes, decreased erythroid precursors, and increased eosinophils and basophils without significant morphologic abnormality. The findings show myeloproliferative neoplasm (MPN) and the overall features are consistent with chronic myelogenous leukemia in chronic phase..case was discussed with the doctor. Flow Cytometry - NO B-CELL CLONALITY OR ABERRANT T-CELL ANTIGEN EXPRESSION - NO INCREASE IN BLASTS - GRANULOCYTIC AND MONOCYTIC ATYPIA - INCREASED CD4 TO CD8 T-CELL RATIO Cytogenetics 46,XY,t(9;22)(q34.1;q11.2)[20] Granulocytes (red) and monocytes (blue) with partial aberrant expression of CD56 Granulocytic hyperplasia ABNORMAL KARYOTYPE WITH THE PHILADELPHIA CHROMOSOME REARRANGEMENT BETWEEN 9q34.1 AND 22q11.2 IN 20 CELLS Molecular BCR/ABL t(9;22) Analysis by RT-PCR based on International Standards: Positive for Major Breakpoint Region BCR-ABL: 29.28% Positive for Minor Breakpoint Region m-bcr-abl: 0.03% Morphology - CHRONIC MYELOGENOUS LEUKEMIA WITH 1% CD34 POSITIVE BLASTS AND GRANULOCYTIC HYPERPLASIA IN HYPERCELLULAR MARROW Hypercellular marrow for age The Technical and Professional components were performed at Applied Diagnostics - Main Lab, 1140 Business Center Dr., Suite 370, Houston, TX Please refer to individual test report for more detailed information This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 1 of 1

2 Patient Information Referring Physician Specimen Information Patient Name: Specimen: Bone Marrow Site: Left iliac Flow Cytometry Report Physician: Accession #: ID#: Reported: 08/14/ NO B-CELL CLONALITY OR ABERRANT T-CELL ANTIGEN EXPRESSION - NO INCREASE IN BLASTS - GRANULOCYTIC AND MONOCYTIC ATYPIA - INCREASED CD4 TO CD8 T-CELL RATIO Comment: No flow cytometric features of non-hodgkin lymphoma or acute leukemia were identified. Granulocytic and monocytic atypia are nonspecific findings, which may be either reactive or due to a myeloproliferative process. Increased CD4:CD8 ratio is a nonspecific finding which can be reactive. Morphologic evaluation, conventional cytogenetics and RT-PCR for BCR/ABL are in process. Results Populations Identified Myeloblasts: <1% B-Cells: <1% surface-kappa:lambda ratio 1.2:1 (consistent with polyclonal B- Cell population) Hematogones: 0% T-Cells: 3% CD4:CD8 ratio 4.9:1 (slightly high, nonspecific) NK-Cells: <1% Plasma cells: <1% Granulocytes: 75% with partial aberrant expression of CD56 (atypical feature) Monocytes: 6% with partial aberrant expression of CD56 (atypical feature). Flow cytometry scatter plot The remaining events consist of debris and non-staining forms. Evaluated Markers Granulocytes (red) and monocytes (blue) with partial aberrant expression of CD56 CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11b, CD13, CD14, CD16, CD19, CD20, CD33, CD34, CD38, CD45, CD56, CD117, HLA-DR, surface kappa, surface lambda, PI (Total markers: 23) CPT Code(s): 88184,88185(x22),88189 The technical component was performed at Applied Diagnostics and the professional component was performed by the signer of this report. This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 1 of 1

3 Patient Information Referring Physician Specimen Information Patient Name: Specimen: Bone Marrow Site: Left iliac Morphology Report Physician: Accession #: ID#: Reported: 08/19/ CHRONIC MYELOGENOUS LEUKEMIA WITH 1% CD34 POSITIVE BLASTS AND GRANULOCYTIC HYPERPLASIA IN HYPERCELLULAR MARROW Comments RT-PCR for BCR/ABL and conventional cytogenetics detected t(9;22). Flow cytometry revealed atypical granulocytes and monocytes which can be seen in myeloproliferative neoplasms. CD34 immunostain shows 1% blasts (within normal limits). Special stains reveal grade 0 fibrosis with focal grade 1 fibrosis (scale of 0 to 3). Morphologic evaluation reveals a hypercellular marrow for age (90% cellularity) with trilineage hematopoiesis, markedly increased and left-shifted granulocytes, decreased erythroid precursors, and increased eosinophils and basophils without significant morphologic abnormality. The findings show myeloproliferative neoplasm (MPN) and the overall features are consistent with chronic myelogenous leukemia in chronic phase..case was discussed with the doctor. Granulocytic hyperplasia Stains Immunohistochemistry On core biopsy and clot section: CD34 marks 1% blasts in single form (within normal limits). Hypercellular marrow for age Special Stains On core biopsy: Reticulin stain reveals focal increase in reticulin fibers. Trichrome stain is negative for collagen fibrosis. Iron Stain On core biopsy, clot section and aspirate smear: Overall the 3 stains show: Iron stores: Not detected. However, only decalcified marrow is available for iron stain. Ring sideroblasts: Absent; however, few erythroid precursors are present for evaluation Gross Description - 1 bony core, totaling 0.8 x 0.2 cm, lightly decalcified, all as A1-0.1 ml of dark red clot, all as A2-7 aspirate smears (3 made in house) - 2 touch imprints of core biopsy This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 1 of 3

4 - 2 peripheral blood smears (made in house) - 2 sodium heparin tubes and 1 EDTA tube labeled as bone marrow aspirate - 1 EDTA tube labeled as peripheral blood Microscopic Description PERIPHERAL BLOOD SMEAR Red blood cells: Normocytic, normochromic White blood cells: Neutrophils are markedly increased and left-shifted; lymphocytes are increased and do not show significant morphologic atypia; eosinophils and basophils are increased (4%) without abnormality; rare blasts of medium cell size with slightly convoluted nuclei, dispersed chromatin pattern, one or a few nucleoli, and small amount of cytoplasm, without Auer rods are present Platelets: Increased with no significant abnormality; a few large and giant platelets are present Accompanying CBC report (08/13/2014): WBC: 61.1 K/micL, Hgb: 12.4 g/dl, MCV: 87.9 fl, RDW: 19.7%, Plt: 713 K/micL 100 cell manual differential count was performed:..... Neut: 72%, Meta: 5%, Myelo: 5%, Pro: 0%, Blast: 0%, Lymph: 9%, Mono: 1%, Eos: 4%, Baso: 4% BONE MARROW Adequacy and general findings Core biopsy: Adequate with crush artifact Clot section: Contains only minute amount of marrow Aspirate smears: Hemodiluted; contain marrow cells and no marrow particles Touch imprints: Contain scattered marrow elements Cellularity: 90%, hypercellular for age Bone abnormality: Absent Hematopoietic elements Myeloid: Granulocytes are increased and left shifted; eosinophils and basophils are increased without abnormality Erythroid: Decreased without abnormality Megakaryocytes: Adequate in number and show occasional small hypolobated forms Infiltrates Blasts: Not increased Monocytic cells: Comprise 5% of marrow cellularity and mainly consist of mature forms Plasma cells: Not increased Lymphoid aggregates: Absent Granulomas: Absent Metastasis: Absent Fibrosis: Not identified on routine H&E stain Amorphous materials such as amyloid: Not identified on routine H&E stain Percentages of 200 cells counted (Reference ranges are in parentheses): Blasts: 1 (0-3) Promyelocytes: 2 (2-8) Myelocytes: 11 (10-13) Metamyelocytes: 20 (10-15) Neutrophils/Bands: 41 (25-40) Eosinophils: 7 (1-3) Basophils: 2 (0-1) Lymphocytes: 11 (10-15) Plasma Cells: 0 (0-1) Monocytes: 5 (0-1) Pronormoblasts: 0 (0-2) Erythroblasts: 2 (15-25) M:E ratio: N/A Aspirate appears hemodiluted with peripheral blood. This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 2 of 3

5 CPT Code(s): 85060,85097,88305(x2),88311,88313(x5),G0461(x2) The Technical and Professional components were performed at Applied Diagnostics - Main Lab, 1140 Business Center Dr., Suite 370, Houston, TX This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 3 of 3

6 Molecular Report Patient Information Referring Physician Specimen Information Name: Specimen: Peripheral Blood Name: Accession #: Reported: 08/19/2014 Peripheral Blood BCR/ABL t(9;22) Analysis by RT-PCR based on International Standards: Positive for Major Breakpoint Region BCR-ABL: 29.28% Positive for Minor Breakpoint Region m-bcr-abl: 0.03% A fusion transcript coding for p210 kda BCR-ABL protein is detected by real time quantitative PCR. The percentage of BCR-ABL to ABL (control gene) transcripts is 29.28%. A fusion transcript coding for p190 kda BCR-ABL protein is detected by real time quantitative PCR. The percentage of BCR-ABL to ABL (control gene) transcripts is 0.03%. No previous sample result is available for comparison. This assay is designed to measure qualitatively and quantitatively, BCR-ABL mrna transcripts from the major and minor breakpoints associated with t(9;22)(q34;q11.2) seen in either CML or ALL (b3a2, b2a2, e1a2). Patient sample RNA is isolated and purified. RNA is reverse transcribed to cdna, which is subsequently amplified using specific primers for BCR-ABL fusion transcripts and the ABL control gene. The amplicons are detected using a fluorescent hybridization dye, with quantitation based on standard curves and real time fluorescence monitoring with each amplification cycle. A specimen control RT-PCR reaction is also performed to assess sample RNA quality. Each assay includes a positive and negative control reaction. The standard curves were created using Asuragen provided RNA, calibrated to International Standard set by World Health Organization. The result is reported as a BCR-ABL to ABL percent ratio (Limit of detection at.001). Subsequent to completion of quantitative phase, the PCR product is subjected to Comparative CT (Δ Δ C T) to distinguish Major from minor BCR-ABL fusion transcripts and to verify specificity of the assay. Reference Intervals (explanation of results) Negative: Major or minor BCR-ABL fusion transcript not detected Positive: Major or minor BCR-ABL fusion transcript detected References White HE, et al Establishment of the first World Health Organization International Genetic Reference Panel for This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 1 of 2

7 quantitation of BCR-ABL mrna. Blood Nov 25;116(22):e Cross NC. Standardization of molecular monitoring for chronic myeloid leukaemia. Best Pract Res Clin Haematol Sep;22(3): Swerdlow, S. H. Who classification of tumours of haematopoietic and lymphoid tissues. Oxford Univ Pr., BCR/ABL History CPT Code(s): 81206,81207 The Technical and Professional components were performed at Applied Diagnostics - Main Lab, 1140 Business Center Dr., Suite 370, Houston, TX This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 2 of 2