3/31/2017 OBJECTIVES CASE STUDY #1 MANUAL REVIEW. Hematology Case Studies: Every Picture Tells a Story

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1 OBJECTIVES Hematology Case Studies: Every Picture Tells a Story Jason Anderson, MPH, MT(ASCP) Field Product Specialist Discuss how scattergram and histogram pictures can provide insight into abnormal hematology samples Utilize case studies to demonstrate how enhanced technologies can benefit the patient and clinician, as well as enhance efficiency in your hematology workflow. CASE STUDY #1 CBC results post transfusion of 2 units packed RBCs A 59 y/o male patient presents to the E.R. with a complaint of increasing weakness, shortness of breath, headache and recent onset of dark-colored urine. The initial CBC result indicates that patient has severe anemia of unknown etiology. Patient is admitted and transfused with 2 units of packed RBCs. The following CBC result is 24 hours post transfusion. What issues do you see with the results? MANUAL REVIEW What do you see? Schistocytes Manual PLT Estimate= 21 Dx: Idiopathic Autoimmune Hemolytic Anemia 1

2 3/31/2017 W DF CHANNEL SCATTERGRAM - NORMAL PATTERN Mono Metas + Myelos + Pros IG Neut + Baso WDF Channel Lymph EO Debris Copyright 2012 by Sysmex America, Inc. All rights reserved. SIGNIFICANCE OF LEFT SHIFT? W DF CHANNEL WDF Channel IP Messages WBC Flags WBC Abn Scattergram Neutropenia Neutrophilia Lymphopenia Lymphocytosis Monocytosis Eosinophilia IG Present Blasts/Abn Lympho? Left Shift? Atypical Lympho? RBC Flags- None PLT Flags - PLT Clum Atypical Lymph Blast IG Abnormal Lymph BlastsMONO LYMPH NRBC Debris Left Shift NEUT+BASO EO Appearance pattern on Abnormal WDF LEFT SHIFT FLAG W HY BAN THE BAND?..The clinical folklore of the band persists despite little mention of its diagnostic utility in current textbooks. Textbooks in internal medicine, hematology, and laboratory medicine do NOT recommend band counts for the diagnosis of infection, other than to mention that neutrophilia and left-shift typically accompany infection or inflammation. Cornbleet, PJ., Clinical Utility of the Band Count. Clinics in Laboratory Medicine :1,

3 IG% & IG# REPORTABLE ON EVERY DIFF INCREASED IG COUNT; POSITIVE SAMPLE IG =27% INCREASED IG COUNT: POSITIVE SAMPLE Manual Diff Neutrophils: 16% Bands: 21% Lymphs: 19% Monocytes: 12% Eosinophils: 1% Metamyelocytes: 4% Myelocytes: 12% Promyelocytes: 11% Blasts: 11% IMMATURE GRANULOCYTES DIAGNOSTIC PERFORMANCE TO PREDICT INFECTION ROC characteristic to compare the ability of the parameters to predict infection Absolute IG (IG#) showed the highest sensitivity (89.2%) and specificity (76.4%) to detect infections (N=70) XN IG = 23.4% Nierhaus, A., et al. Revisiting the white blood cell count: immature granulocyte count as a diagnostic marker to discriminate between SIRS and sepsis a prospective, observational study. BMC Immunology :8 CASE STUDY #2 A 71 y/o female presents to her family practitioner with increasing concerns of persistent fatigue, diffuse pain in her chest and back and more bruising than normal. She also states that she has experienced recurring sinus and respiratory infections over the past 6 months. Upon examination, the patient was found to have an enlarged liver. Chemistry testing was unremarkable aside from a moderately elevated serum Calcium, Creatinine and Microalbumin level. Following is the initial CBC results What concerns do you see 3

4 DI60 IMAGES CASE STUDY #2 DIAGNOSIS? CASE STUDY #3 Plasma Cell Leukemia (PCL) Primary PCL is rare (1 in 1 million population). Secondary PCL affects ~ 4 out of a 100 Multiple Myeloma patients. 1.5x more common in men than in women The causes of PCL are not fully known, but risk factors such as age and exposure to industrial and environmental elements are thought to play important roles. Current treatments for PCL are the same as those for Multiple Myeloma and include chemotherapy drugs, Proteasome inhibitors, steroids and in younger and healthier patients, stem cell transplantation is an option. A 67 y/o male presented to his family physician for a routine wellness check. The patient states that he has experienced moderate unexplained weight loss and feels more run down than usual. Physical examination reveals swollen lymph nodes and mild bruising on extremities. Following is the initial CBC results What concerns do you see 4

5 CASE STUDY #3 DIAGNOSIS? Hairy Cell Leukemia (HCL) HCL is a chronic leukemia where the bone marrow produces a surplus of B-lymphocytes, which often present with hair-like, irregular cytoplasmic projections. Relatively rare disorder, but one of the most successfully treated of all leukemias (median remission of 15 years). HCL is a very indolent disease. Progression is slow and may not be diagnosed after several months or even years of illness. Front-line treatment agents for HCL are Pentostatin and Cladribine. WNR CHANNEL Scattergram - Normal Pattern FSC BASO NRBC Debris SFL WBC CASE STUDY #4 A 66 y/o male presents to his family practitioner for a routine check-up. During the examination, the patient states he is feeling generally ok, but when questioned further admits a recent history of : Weakness Fatigue Extreme night sweats Moderate weight loss Following is the initial CBC results What concerns do you see? 5

6 INCREASED BASOPHIL COUNT CASE STUDY #4 DIAGNOSIS? Chronic Myelogenous Leukemia (CML) ~ 1 person in 555 will get CML in their lifetime Occurs mainly in adults Slightly more common in men than in women Most cases of CML start when a "swapping" of chromosomal material (DNA) occurs between chromosomes 9 and 22. This translocation gives rise to a chromosome 22 that is shorter than normal (Philadelphia Chromosome). The swapping of DNA between the chromosomes leads to the formation of an oncogene called BCR-ABL. This gene then produces the BCR-ABL protein, which is the type of protein called a tyrosine kinase. This protein causes CML cells to grow and reproduce out of control. CASE STUDY #3 CML is classified into 3 groups or phases that help predict prognosis. These phases are based mainly on the number of myeloblasts that are seen in the blood or bone marrow. Chronic phase Less than 10% blasts in their blood or bone marrow. Patients usually have fairly mild symptoms (if any). Most patients are diagnosed in the chronic phase. CASE STUDY #3 Accelerated phase Patients are considered to be in accelerated phase if any of the following are true: The bone marrow or blood samples have more than 10% but fewer than 20% blasts High blood basophil count (basophils making up at least 20% of the white blood cells) High white blood cell counts that do not go down with treatment Very high or very low platelet counts that are not caused by treatment Blast phase (also called acute phase or blast crisis) BM and/or blood samples have more than 20% blasts. The blast cells often spread to tissues and organs beyond the bone marrow. PLATELET MEASUREMENT FSC RBC IPF PLT-F Channel PLT-F Impedance Platelet SFL Fluorescent Platelet Copyright 2012 by Sysmex America, Inc. All rights reserved. 6

7 INTERFERENCES IN IMPEDANCE PLATELET COUNTING Falsely Increased RBC fragments Microcytes Bacteria Immune complexes Falsely Decreased Giant platelets Platelet clumps CASE STUDY : OB PATIENT WITH GIANT PLATELETS Giant platelets in pregnant patients can be a normal phenomenon. Low platelet count complicates decision of placing a labor epidural due to risk of spinal hematoma. (plt cut-offs vary by institution). The problem with this is the failure of impedance technology to accurately recover a reportable number resulting in the technologist needing to manually intervene, which could prolong time to epidural decision. WBC fragments MICROSCOPIC IMAGES OF SLIDE OB PATIENT WITH GIANT PLATELETS Doc. No CFL, Rev 1, June 2014 Doc. No CFL, Rev 1, June 2014 Manual PLT Estimate= 141,000 CASE STUDY : CF PATIENT PLT Abnormal Distribution Patient is a newborn male with Down Syndrome and Cystic Fibrosis. Patient presented with decreased Platelet count. 7

8 Reflex PLT-F PLT MEASUREMENT OVER TIME IN A SEVERE BURN INJURY PATIENT PLT COUNT OVER TIME IN A BURN PATIENT PLT COUNT OVER TIME IN A BURN PATIENT PLT-F PLT-I Day 3 PLT-F PLT-I Day 2 PLT-F PLT-I Day 4 PLT-F PLT-I POSSIBLE MECHANISMS OF THROMBOCYTOPENIA DIFFERENTIATE PHYSIOLOGICAL MECHANISMS Production Disorders Myeloablative Therapy Bone Marrow Transplant Acute Myeloid Leukemia (AML) Destruction Disorders Immune Thrombocytopenic Purpura (ITP) Thrombotic Thrombocytopenic Purpura (TTP) Infections (HIV, Hepatitis C, CMV) Disseminated Intravascular Hemolysis (DIC) Autoimmune Disease Bacteremia Heparin Induced Thrombocytopenia (HIT) Sepsis Pregnancy Drug-Induced Thrombocytopenia (DIT) Low PLT + Normal/Low IPF (Consistent with production disorder) Normal Low PLT+ High IPF (Consistent with destruction disorders) Stasi, R. How to approach thrombocytopenia. Hematology :191; /asheducation

9 IPF CASE STUDY 48 YEAR OLD MALE WITH PANCREATIC CANCER CBC Cycle 1 Cycle 3 Cycle 3 Day 8 Units Normal Range WBC Low X10^3µl 4-11 RBC Low 3.97 Low X10^6µl HgB 13.1 Low 12.1 Low 10.9 Low g/dl HCT 36.3 Low 30.6 Low % PLT Low 42 Low X10^3µl IPF 0.0 Low % IPF CASE STUDY 48 YEAR OLD MALE WITH PANCREATIC CANCER CBC Cycle 1 Cycle 3 Cycle 3 Day 8 Next Day WBC Low X10^3µl 4-11 Units Normal Range RBC Low 3.97 Low X10^6µl HgB 13.1 Low 12.1 Low 10.9 Low g/dl HCT 36.3 Low 30.6 Low % PLT Low 42 Low 6 Low X10^3µl IPF 0.0 Low 0.0 Low % Value of IPF Relevant data that may contribute to treatment decisions Results can be obtained quickly without additional drain on resources Minimal cost and no discomfort compared to invasive diagnostic testing The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Cancer and Hematology of Western Michigan. The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Cancer and Hematology of Western Michigan. IPF CASE STUDY 59 YEAR OLD FEMALE WITH STAGE IV METASTATIC BREAST CANCER CBC Cycle 1 Cycle 3 Cycle 3 Day 8 Units Normal Range WBC Low 2.1 Low X10^3µl 4-11 RBC Low 2.99 Low X10^6µl HgB Low 10.6 Low g/dl HCT Low 31.1 Low % PLT Low 17 Low X10^3µl IPF High % IPF CASE STUDY 59 YEAR OLD FEMALE WITH STAGE IV METASTATIC BREAST CANCER CBC Cycle 1 Cycle 3 Cycle 3 Day 8 Cycle 4 Units Normal Range WBC Low 2.1 Low 2.6 Low X10^3µl 4-11 RBC Low 2.99 Low 3.41 Low X10^6µl HgB Low 10.6 Low 10.0 Low g/dl HCT Low 31.1 Low 30.0 Low % PLT Low 17 Low 119 Low X10^3µl IPF High % Value of IPF Relevant data that may contribute to treatment decisions Part of CBC, using the same lavender tube Results can be obtained quickly without additional drain on resources Minimal cost and no discomfort compared to invasive diagnostic testing The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Cancer and Hematology of Western Michigan. The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Cancer and Hematology of Western Michigan. IMMATURE PLATELET FRACTION TO ASSESS BONE MARROW RECOVERY RETICULOCYTE CHANNEL IRF Study Objective How well can IPF help the clinician predict bone marrow recovery following peripheral blood HPC transplantation? (N=50) A persistently low IPF in this setting would suggest failure of thrombopoietic recovery. RBC LFR MFR RET HFR IRF PLT Zucker, M., et al. Immature Platelet Fraction as a predictor of platelet recovery following hematopoietic progenitor cell transplantation. Laboratory Hematology :

10 3/31/2017 RETICULOCYTES IRON DEFICIENCY PREVALENCE IN INFANTS AND TODDLERS Adverse consequences in pediatric patients: Increased lead absorption Impaired immunity Anemia Impaired neurocognitive development Ret%= Quantity IRF=Rate of Production Ret-He=Quality of Retics % of infants and toddlers in the US have iron deficiency anemia; 10% have iron deficiency without anemia. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey Data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. CONDITIONS AFFECTING TEST RESULTS Test Serum Iron Falsely Increased Results CASE STUDY : ANEMIA IN PREGNANCY Falsely Decreased Results Infection/Inflammation Sample late in the day Meal iron intake Supplement iron intake Hemolysis Diurnal variation Transferrin Saturation Oral contraceptive Infection/Inflammation Serum Ferritin Infection/Inflammation Hyperthyroidism Aging Liver disease (HCV) Malignancy Alcohol consumption Oral contraceptives Vitamin C deficiency Hypothyroidism Exercise Lab WBC g/dl RBC x 106/µl Hgb Normal Range ng/ml Hct % MCV mcg/dl MCH pg MCHC g/dl RDW mcg/dl Patient History/Presentation: Pregnant female presents to physician for a scheduled evaluation. Routine CBC is within normal limits. The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Dr. Pambrum, Dalhousie University Hospital, Nova Scotia. CASE STUDY : ANEMIA IN PREGNANCY Lab MCH 28.3 MCHC g/dl RDW mcg/dl Reticuloytes (%) 1.54 H % Reticulocytes (#) 64.8 H x106/µl IRF % RET-He 20.6L pg/cell SMEAR REVIEW & FERRITIN RESULTS Normal Range pg Smear Review no evidence if IDA Ferritin Results confirms diagnosis of IDA Reticulocyte panel provides additional insight regarding diagnosis. Ferritin 6.8 L g/dl Diagnosis: Iron deficiency anemia secondary to pregnancy (based upon reticulocyte panel data) The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Dr. Pambrum, Dalhousie University Hospital, Nova Scotia. The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Dr. Pambrum, Dalhousie University Hospital, Nova Scotia. 10

11 3/31/2017 CASE STUDY : INFANT W ITH LETHARGY Lab CASE STUDY : INFANT W ITH LETHARGY Normal Range Lab RBC x 106/µl MCH 17.5 L HgB 7.0 L ng/ml MCHC 295 L Normal Range g/dl HCT 23.7 L % RDW 19.3 H mcg/dl MCV 59.1 L pg mcg/dL Reticulocyte (%) 0.68 L % MCH 17.5 L pg Reticulocyte (#) 27.3 L x 106/µl MCHC 295 L g/dl IRF 4.8L % RDW 19.3 H % RET-He 11.9 L pg/cell Reticulocyte panel provided additional data that enhanced plan of care Patient History/Presentation: 5 month old presents to ER with lethargy and decreased appetite Diagnosis: Severe iron deficiency anemia secondary to poor intake and nutrition Treatment Plan: Started on oral iron therapy and instructed to see pediatrician in 7 day for repeat labs and evaluation The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Dr. Pambrum, Dalhousie University Hospital, Nova Scotia. The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Dr. Pambrum, Dalhousie University Hospital, Nova Scotia. CASE STUDY : INFANT W ITH LETHARGY Lab Day 7 Normal Range CASE STUDY : INFANT W ITH LETHARGY Lab Day 7 RBC x 106/µl MCH 17.5 L 18.2 L pg HgB 7.0 L 7.20 L ng/ml HgB 7.0 L 7.20 L ng/ml HCT 23.7 L 24.1 L % HCT 23.7 L 24.1 L MCV 59.1 L 60.9 L mcg/dl Reticulocyte (%) 0.68 L % MCH 17.5 L 18.2 L pg Reticulocyte (#) 27.3 L x 106/µl MCHC 295 L 299 L g/dl IRF 4.8 L 45.5 H % RDW 19.3 H 23.3 H mcg/dl RET-He 11.9 L 24.6 L pg/cell Reticulocyte (%) 0.68 L % Is therapy working? Caregiver noncompliance vs non-responder to therapy What is the next step? Admit to hospital for intravenous iron therapy Recommend gastrointestinal consult to rule out an malabsorption issue The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Dr. Pambrum, Dalhousie University Hospital, Nova Scotia. CLINICAL APPLICATIONS OF RETICULOCYTE HEMOGLOBIN Wellness Pediatrics - Iron deficiency and Iron Deficiency Anemia Prevention Surgical patients pre and post surgical assessments Chronic Disease Management Normal Range % Reticulocyte panel provided clinically significant data that enhanced care Is therapy working? Yes - RET-He shows an appropriate increase What is the next step? Continue on oral iron therapy with routine follow up The views expressed in the following slide are those of the author and their healthcare facility. Results of case studies are not predictive of other cases and results may vary. With permission from Dr. Pambrum, Dalhousie University Hospital, Nova Scotia. CLINICAL VALUE OF RET-He PARAMETER Value of RET-He May show iron was absorbed and treatment was effective Well-defined lower range cut off provides accurate treatment target Stable parameter that is not affected by inflammation/infection Less expensive than traditional iron tests without extra resources needed Quick and clinically relevant data for iron treatment decisions End Stage Renal Disease - anemia management Monitoring response to therapy with ESA and/or iron Cancer- anemia status 11

12 PERFORMANCE OF RET-He IN CANCER Patient Screening With RET-He N=200 Reduced Iron Studies by 80% RET-He <32 pg And Hgb <11 g/dl NPV 98.5% Rapid rule out of iron deficiency anemia Reduced unnecessary testing Cost savings for laboratory and health care system Body Fluids..Oh no!!! Peerschke, E., et al. Using the hemoglobin content of reticulocytes (RET-He) to evaluate anemia in patients with cancer. AJCP : WHAT TYPES OF BODY FLUIDS ARE APPROVED? THE CHALLENGES HF-BF Body fluid mode (target species) Cerebrospinal fluid (CSF) Types of fluids, collection methods, clotted, viscous specimens Types of cells challenges techs of every skill level. MN Pleural fluid Peritoneal fluid MO-BF LY-BF NE-BF PMN EO-BF Synovial fluid WDF Scattergram AND MORE CHALLENGES SO WHY AUTOMATE? Small Sample Volume Better Precision Fast TAT Reportable Range Easy to Perform Safer Only 88uL Aspirated Precision within 10-30% depending on the result Capable of processing 40 specimens per hour RBC as low as x 106 WBC as low as x 103 No Pre-dilution or Analyzer Prep required Closed Sample Handling 12

13 WHAT ARE YOU GETTING IN THE BODY FLUID COUNT WBC Count RBC Count 2-part Differential TNC Total Nucleated Cells THE BODY FLUID SCATTERPLOT TNBC all highly fluorescent body fluid cells. Mesothelial Cells, Macrophages, Atypical and malignant lining cells. Mononuclear area part of the WBCBF area small mononuclear cells lymphocytes and monocytes Polymorphonuclear area part of the WBCBF area all segmented cells, Neutrophils and eosinophils WBCBF The total of the PMN and MN area SUGGESTIONS FOR TOUGH SAMPLES MORE SUGGESTIONS If there are clots in the specimen, take them out. You can still give an approximate count and make a smear Synovial fluids are often too viscous to be properly aspirated. Add Hylauronidase (~5mg to a mL aliquot) That s not what I was taught? What s really important is the cell type! SO WHAT IS IMPORTANT TO KNOW? Background counts Scatterplots Flags WBC BG Counts acceptable </=.001 RBC BG Counts acceptable </=.003 WBC-BF counts that exceed 1.000X 10^3 and/or RBC-BF counts that exceed 1.000X 10^6 will automatically activate an auto rinse after the count is reported. This eliminates carry-over of the next specimen 13

14 WBC ABNORMAL SCATTERGRAM This BG count failed for WBC due to the previous fluid that had a high cellular count When there is abnormal or incomplete clustering in the WDF Channel When the ration of high fluorescent cells is increased per 100 WBCs Signals Manual review **NOTE: This flag should be used if the customer is reporting TNC and the two part differential. The flag will warn the customer of the presence of high fluorescent BF cells such as mesothelial and tumor cells. Manual review would be suggested. There are no Sysmex suggested values for this setting The type of cell is more important than the quantity of cells. WHAT ARE WE REALLY AFRAID OF? Mesothelial Malignant HOW TO TELL THEM APART Mesothelial Individual Uniform Flat clusters N/C ratio low Smooth nuclear membrane Minimal vacuolization Round/oval nuclei Malignant Cannibalism Bizarre Ball-like clusters N/C ratio high Irregular nuclear membrane Nuclear clefting/molding Dramatic vacuolization Did you know.? Mesothelial Cells are only found in Serous fluids? 14

15 NORMAL BODY FLUID HIGH BODY FLUID COUNT BF CASE STUDY : BACTERIAL MENINGITIS A 59 year old male with a craniotomy presented with subcutaneous leakage of CSF and it was determined that the patient had bacterial meningitis. BACTERIAL MENINGITIS : CSF SAMPLE BF CASE STUDY : LUNG CANCER PATIENT A 60 year old was receiving treatment for lung cancer when an accumulated amount of pleural fluid was noticed in the right lung. 15

16 LUNG CANCER : PLEURAL FLUID You can find more interesting Case Studies on My Sysmex! Thank You 16