HEMATOPATHOLOGY SUMMARY REPORT RL;MMR;

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1 HEMATOPATHOLOGY SUMMARY REPORT RL;MMR; Page 1 of 1 05/15/20XX HP XX 05/21/20XX (212) (51) (51) Age: 78 DOB: 0/05/19XX SS#: Clinical Information: 78 y/o female with history of breast cancer, rule out Myelodysplasia. FINAL DIAGNOSIS: ACUTE MYELOMONOCYTIC LEUKEMIA (M5A) COMMENTS: The morphologic, immunohistochemical, and cytogenetics findings are all consistent with acute myelomonocytic leukemia, M5a. This type of leukemia can occur in patients after chemotherapy with topoisomerases II inhibitors, including epipodophylotoxins, etoposide, and teniposide. Correlation with the patient's medication history is recommended. MORPHOLOGY: Sheets of blasts are observed in the biopsy sections, many of them show monocytic features in the aspirate smear. The blasts express CD34, CD117, and partially express the monocytic markers lyzozyme and CD8. FLOW CYTOMETRY A distinct blasts population (40% total cellularity) expressing CD34, CD117, and partially expressing the monocytic markers CD4, CD14, and CD5 is seen. CYTOGENETICS/FISH: Complex karyotypic abnormality including translocations of the long arm of chromosome 11 (11q23). FISH studies show translocations of the MLL locus on 11q23 in 83% of the cells analyzed. MOLECULAR: PCR studies were negative for both FLT3/ITD and FLT3 D835 mutations. Testing was performed at Acupath Laboratories, Inc. BONE MARROW FLOW CYTOMETRY CYTOGENETICS FISH Electronically signed by: John Brown, M.D. This test was developed and its performance characteristics determined by Acupath Laboratories, Inc. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval 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) as qualified to perform high complexity clinical laboratory testing.

2 Batch#: BONE MARROW BIOPSY REPORT RL;MMR;STPL Page 1 of 1 05/15/20XX HP XX 5/17/20XX (212) (51) (51) DOB: 0/05/19XX SS#: Clinical Information: 78 y/o female with history of breast cancer, rule out Myelodysplasia. Source of Tissue: Date Stained: Date Analyzed: BONE MARROW 5/15/20XX 8:00:00PM 5/15/20XX 12:30:00AM FINAL DIAGNOSIS: - HYPERCELLULAR MARROW FOR AGE INVOLVE WITH ACUTE MYELOID LEUKEMIA, MOST CONSISTENT WITH MYELOMONOCYTIC SUBTYPE. - NO MORPHOLOGIC OR IMMUNOPHENOTYPIC EVIDENCE OF LYMPHOMA OR MULTIPLE MYELOMA. COMMENTS: Dr Smith was contacted on 5/17/20XX and the results were discussed. Gross Description: Received in formalin is a bone marrow core biopsy measuring 1.2 cm. in length and attached clot. The specimen is submitted entirely for routine histology in two cassettes. Peripheral Blood: A CBC report is provided (05/15/XX). The CBC values are: WBC 1., Hgb 7.7, MCV 89, PLT 57. Bone Marrow Biopsy: The biopsy is hypercellular for age with patchy cellularity at 40-50%. A considerable proportion of cellularity is contributed by a population of blasts with finely dispersed chromatin, round to irregular nuclear contours, and prominent nucleoli. The blasts have average and occasionally relatively abundant amount of amphophilic granular cytoplasm. These blasts involve the marrow in the form of clusters as well as individual infiltrating sheets. The erythroid elements show complete maturation but are decreased in number. Megakaryocytes show occasional atypical features including nuclear hypolobation and hyperchromaticity. Occasional plasma cells are seen and focally form small clusters. Rare single lymphocytes are seen. Clot Sections: The clot sections show a few particles and reflect the same changes that are seen in the biopsy sections. Aspirate Smears: None received. Iron Stains: Stainable storage and sideroblastic iron are detected. Reticulin Stain: Normal reticulin content is observed. Immunohisto Chemistry: CD34 and CD117 highlight the blasts, comprising 40% of the total cellularity. The blasts are focally positive for lysozyme and are partially positive for MPO. PGM-1/CD8 also stains a proportion of the blasts. CD138 highlights 5% of the cells that are found to be polyclonal by kappa and lambda staining. Photomicrographs: BONE MARROW BIOPSY CYTOSPIN CD34 LYSOZYME

3 FLOW CYTOMETRY ANALYSIS REPORT STPL Page 1 of 1 05/15/20XX HP XX 5/17/20XX (212) (51) (51) DOB: 0/05/19XX SS#: Test Results B-Cells CD10 Negative CD19 Negative CD20 Negative CD22 Negative CD23 Negative S.Kappa Poly S.Lambda Poly Myeloid CD11c Sub. CD13 Positive CD14 Sub. CD33 Positive CD117 Positive cy.mpo Sub. T-Cells CD2 Negative CD3 Negative CD4 Negative CD5 Negative CD7 Negative CD8 Negative Miscellaneous CD25 Negative CD34 Positive CD38 Positive CD45 Dim CD5 Sub. HLA-DR Positive CD103 Negative Immunophenotypic analysis Interpretation: Involved by acute myeloid leukemia, the neoplastic population comprising 40% of the total cellularity. See bone marrow report for complete interpretation. Specimen Description: Bone marrow aspiration. A cytospin and smear preparations are examined. Viability and Analysis: The specimen has a viability of 98%. The above data were generated on a population of cells which cytometrically correspond to blasts. The gated population comprise 1% of the sample. The specimen appears cellular and examination of cytospin preparation confirms this impression. The histogram shows a distinct blast population. Phenotype: A distinct blast population is noted. These blasts express myeloid markers CD13 and CD33, as well as CD34 and CD117. They are negative for lymphoid markers and TdT. MPO is expressed in only a subpopulation (5% total) of cells. CD4, CD14, and CD5 are also partially expressed by blasts. The blasts comprise 40% of the total cellularity. The B cells are a minor population. They express the pan B-cell markers CD19, CD20 and CD22 and lack CD5 and CD10. The B cells are polyclonal with regard to light chain determinants. The T-cell population expresses pan-t cell antigens (CD2, CD3, CD5 and CD7) in a non-aberrant fashion. The CD4/CD8 ratio is normal. Electronically signed by: John Brown, M.D. These tests were developed and their performance characteristics determined by Acupath. These tests have not been cleared or approved by the US Food and drug Administration. These tests were performed in accordance with the recommendations of the US/Canadian Consensus Conference on the immunophenotypic analysis of hematologic neoplasia by flow cytometry.

4 CYTOGENETICS/FISH ANALYSIS REPORT RL;MMR; Page 1 of 2 Plainview,NY /1/20XX XX (212) (51) (51) DOB: 0/05/19XX SS#: Indications: Source of Tissue: Bone marrow 238.7; History of breast cancer Date Reported Cytogenetics: 05/21/20XX Date Reported FISH: 05/21/20XX FISH ANALYSIS DATA Assay # 1 Probe Region: MLL (11q23) No. of Cells Scored: 200 Process and limitations of use: This test was developed and its performance characteristics determined by Acupath Laboratories. It has not been cleared or approved by the U.S. Food and Drug Administration. Chromosome or Locus: Percentage: Normal Reference Range: 11q23 17% 9-100% Assay # 2 Probe Region: Chromosomes 5,7,8, and 20 No. of Cells Scored: 200 Process and limitations of use: This test was developed and its performance characteristics determined by Acupath Laboratories. It has not been cleared or approved by the U.S. Food and Drug Administration. Chromosome or Locus: Percentage: Normal Reference Range: D5S721/D5S23 100% 9-100% EGR % 9-100% METAPHASE ANALYSIS DATA BAND LEVEL: 375 STAINS: GTG Culture: Counted: Analyzed: Karyotyped: 24hr unstimulated hr synchronized MTX + THY Total: Note: Subtle chromosome rearrangements may not be detected by conventional cytogenetic analysis below the 450 band level. Low level mosaicism may not be detected. TEST RESULT: 42~4,XX,del(1)(p32),del(5)(q13q33),del(7)(q34),der(11)dup(11)(q23),-14,-17,-18,+19[20][cp20] nuc ish (D5S721,D5S23x2,EGR1x1)[1/200],(5'MLL,3'MLL,5'MLL con 3'MLL)x5~10[1/200] INTERPRETATION: 5/20/XX: Chromosome analysis was completed on bone marrow cells from 24 and 48 hour unstimulated cultures. A modal karyotype showed eight different clonal structural and numerical chromosomal abnormalities. The complex karyotype includes interstitial deletion of the long arm of chromosome 5, terminal deletion of the short arm of chromosome 1 and of the long arm of chromosome 7, duplication of part of the long arm of chromosome 11 as well as loss of chromosomes 14, 17, 18, and gain of chromosome 19. Combined deletion of chromosomes 5 and 7 is associated with therapy-related MDS or AML. 5/19/XX: Fluorescence in situ hybridization (FISH) was completed on bone marrow cells using 3 specific DNA probes for the following loci: D5S721/D5S23, EGR1 and MLL. Interphase FISH results are consistent with 30% of bone marrow cells exhibiting a deletion of the locus EGR1, and an amplification of the MLL locus in 83% of the cells.

5 CYTOGENETICS/FISH ANALYSIS REPORT Page 2 of 2 05/1/20XX XX (212) (51) (51) DOB: 0/05/19XX SS#: CYTOGENETICS FISH Electronically signed by: John Brown, Ph.D., Director, Cytogenetics Olga Falkowski, M.D., Medical Director

6 MOLECULAR PATHOLOGY REPORT RL;MMR; Page 1 of 1 05/1/20XX XX Indications: Source of Tissue: Date Reported: 05/21/20XX (212) (51) (51) DOB: 0/05/19XX SS#: MOLECULAR ANALYSIS DATA Assay # 1 Marker: FLT3 Method: Mutation detection Process and limitations of use: This test was developed and its performance characteristics determined by Acupath Laboratories, Inc. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. Pursuant to the requirements of CLIA 88, this laboratory has established the test s accuracy and precision. This test has been approved by New York State as a laboratory specific assay. This test cannot be used as sole evidence for or against cancer and has to be interpreted in the context of all available clinical and pathological information. TEST RESULT: Negative for FLT3 ITD Negative for FLT3 D835 INTERPRETATION: FLT3 ITD mutation are identified in 20-30% of the acute myeloid leukemias (AML). FLT3 point mutation D835 are identified in 5-10% of the acute myeloid leukemias (AML). Both mutations are detected together in rare cases of AML (~1%). Diagnostics Sensitivity: This assay detects 90-95% of the positive cases. Electronically signed by: John Brown, Ph.D., FACMG Olga Falkowski, M.D., Medical Director

7 MOLECULAR PATHOLOGY REPORT C:1;RL;MMR; Page 1 of Obtained: Plainview,NY /21/20 PHYSICIAN: JOHN G. SMITH Account # Indications: Leukocytosis Source of Tissue: Peripheral blood (oncology) Date Reported: 12/28/20 (212) (212) ANYWHERE,NY (51) DOB: 0/05/19 SS#: MOLECULAR ANALYSIS DATA Assay # 1 Marker: BCR-ABL p190/p210 Method: Real Time RT-PCR Process and limitations of use: This test was developed and its performance characteristics determined by Acupath Laboratories, Inc. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. Pursuant to the requirements of CLIA 88, this laboratory has established the test s accuracy and precision. This test has been approved by New York State as a laboratory specific assay. This test cannot be used as sole evidence for or against cancer and has to be interpreted in the context of all available clinical and pathological information. TEST RESULT: Negative for BCR-ABL (P190 and P210 type) INTERPRETATION: Negative for BCR-ABL (P190 and P210 type) RNA transcripts, indicating the absence of cells with either the ALL- or CML-type Philadelphia chromosome. Diagnostic sensitivity: This assay is negative in <1% of ALL or CML cases with BCR-ABL rearrangement.. Technical sensitivity: A clonal cell population < 0.001% may not be detected by this assay due to the RNA quality of the sample. Electronically signed by: John Brown, M.D., FACMG Olga Falkowski, M.D., Medical Director

8 Batch#: 0 FLOW CYTOMETRY REPORT - PNH EVALUATION RL;MMR; Page 1 of 1 Obtained: 10/28/20XX HP XX 8:00 am 10/28/20XX 11:52 am 10/29/20XX (212) (212) JOHN DOE 100 MAIN STREET PLAINVIEW, NY (51) Age: 32 DOB: 09/29/19XX Sex: Male Acct: Clinical Information: anemia, hemoglobinuria, R/O PNH Source of Tissue: Date Processed: PNH - PERIPHERAL BLOOD 10/28/XX 3:00 pm DIAGNOSIS: PNH CLONE IDENTIFIED IN BOTH WBC AND RBC. Comment: Flow cytometric analysis shows a PNH clone within the granulocytes (45%), monocytes (55-0%) and RBCs (30%). These findings are consistent with the diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). Any potential difference in clone size between the white blood and the red blood cells may be due to hemolysis and/or recent transfusion. The PNH clone in the monocytes and granulocytes showed a bimodal distribution, including Type II and Type III cells. The clinical significance of this finding is still under investigation. Flow Results: Immunophenotypic analysis was performed using gating antibodies GlycoA, CD45, CD15, CD33, GPI-linked antibodies CD59, CD14, CD24, as well as fluorescent aerolysin (FLAER). Cell Type Deficiency Result Type II (partial CD 59 deficiency) 1% RBC Type III (complete CD 59 deficiency) 29% PNH clone size (Type II & Type III combined) 30% WBC - Monocytes FLAER/CD14 deficiency 55-0% WBC - Granulocytes FLAER/CD24 deficiency 45% Electronically signed by: John Brown M.D., Ph.D. Acupath Laboratories Inc. is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity testing. The adequacy of the PNH assay is verified by appropriate positive & negative controls. Disclaimer: This assay has not been approved by the FDA (Food and Drug Administration). This test was developed and its performance charactristics were determined by the Flow Cytometry department of Acupath Laboratories Inc. and was approved by New York State DOH. This report includes one or more staining results that use analyte specific reagents. The assay is for clinical use and should not be viewed as experimental or for "research use only".

9 Batch#: 0 FLOW CYTOMETRY REPORT - PNH EVALUATION RL;MMR; Page 1 of 1 Obtained: 10/28/20XX Plainview,NY HP XX 8:00 am 10/28/20XX 11:51 am 10/29/20XX (212) (212) JOHN DOE 100 MAIN STREET PLAINVIEW, NY (51) Age: 32 Sex: Male DOB: 09/29/19XX Acct: XXXXX Clinical Information: anemia, hemoglobinuria, R/O PNH Source of Tissue: PNH - PERIPHERAL BLOOD Date Processed: 10/28/XX 3:00 pm DIAGNOSIS: NO PHENOTYPIC EVIDENCE OF PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH). Comment: Flow cytometric analysis does not show any evidence of a PNH clone based upon analysis of a variety of antibodies on red blood cells, monocytes and granulocytes. These findings do not support a diagnosis of PNH. Clinical correlation is recommended. Flow Results: Red Blood Cells: Monocytes: Granulocytes: Immunophenotypic analysis was performed using gating antibodies GlycoA, CD45, CD15, CD33, GPI-linked antibodies CD59, CD14, CD24, as well as fluorescent aerolysin (FLAER). No evidence of decreased or absent CD59 expression No evidence of decreased or absent expression of FLAER and CD14 No evidence of decreased or absent expression of FLAER and CD24 Electronically signed by: John Brown, M.D., Ph.D. Acupath Laboratories Inc. is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity testing. The adequacy of the PNH assay is verified by appropriate positive & negative controls. Disclaimer: This assay has not been approved by the FDA (Food and Drug Administration). This test was developed and its performance charactristics were determined by the Flow Cytometry department of Acupath Laboratories Inc. and was approved by New York State DOH. This report includes one or more staining results that use analyte specific reagents. The assay is for clinical use and should not be viewed as experimental or for "research use only".