20/20 PATHOLOGY REPORTS

Transcription

1 20/20 PATHOLOGY REPORTS

2 Improving the Physician Experience. Enhancing the Patient Experience. We are LabTest Diagnostics. LabTest Diagnostics has a full-service laboratory with state-of-the-art equipment that operates to the highest standards of quality and precision. LabTest Diagnostics is a high complexity laboratory accredited by both College of American Pathologists and Clinical Laboratory Improvement Amendments, national accreditation agencies.

3 Reports Offered 1. Flow Cytometry 2. Morphology 3. Cytogenetics 4. Fluorescence In-Situ Hybridization (FISH) 5. Molecular 6. 20/20 Core Evaluation

4 FLOW CYTOMETRY

5 Cedar Plaza, Suite 200, St. Louis, MO Phone: 314.LAB.TEST ( ) Fax: Patient: DOB: Gender: MRN/ID: Facility: Physician: LTD ID: Collected: Received: Reported: Specimen: Peripheral Blood Clinical Indication: Macrocytic Anemia. FLOW CYTOMETRY REPORT DIAGNOSIS No Abnormal Hematolymphoid Populations are Identified No Circulating Blasts are Noted CD45/SSC COMMENTS The peripheral blood demonstrates predominantly granulocytes with a normal mature pattern of antigen expression. There is normal expression of CD13, CD33, CD15, CD11c, CD10, and CD16/56. The monocytes are normal in number and have a normal expression of dim CD4, CD13, CD33, CD14, CD11c, and HLA-DR. Lymphocytes are predominantly T cells with normal expression of CD2, CD3, CD5, CD7 and a normal CD4:CD8 ratio. No increase in NK cells or T/NK cells is present. No evidence for a clonal hematopoietic or lymphoid neoplasm is identified. Clinical correlation is advised. CD33/CD13 FLOW CYTOMETRY DIFFERENTIAL -PERIPHERAL BLOOD CELL TYPE % COMMENTS B LYMPHOCYTES 0% Polyclonal T LYMPHOCYTES 1.5% No aberrant antigen expression CD4:CD8 RATIO 1.8 Normal NK CELLS 0.3% Not increased GRANULOCYTES 96.1% Normal pattern MONOCYTES 1.4% Not increased; normal pattern BLASTS 0% Not increased DEBRIS 0.7% FSC/SSC TESTING INFORMATION Gating Technique: CD45/SSC Cells Analyzed: Mononuclear cells Viability: ND Method: RBC Lysis Panel: CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11C, CD13, CD14, CD15, CD16, CD19, CD20, CD22, CD23, CD25, CD33, CD34, CD45, CD56, CD57, FMC-7, HLA-DR, Kappa, Lambda Electronically signed on 05/16/2017 Aamir Ehsan, MD Hematopathologist This test was developed and its performance characteristics determined by CorePath Laboratories PA. It has not been cleared or approved by the US Food and Drug Administration and FDA does not require this test to go through premarket FDA review. 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. PAGE 1 OF 1

6 MORPHOLOGY

7 Cedar Plaza, Suite 200, St. Louis, MO Phone: 314.LAB.TEST ( ) Fax: Patient: DOB: Gender: MRN/ID: Facility: Physician: LTD ID: Collected: Received: Reported: Specimen: Bone Marrow Clinical Indication: Leukocytosis and thrombocytosis. MORPHOLOGY REPORT Bone Marrow, Core Biopsy, Clot Section, Touch Imprints and Aspirate: Hypercellular Bone Marrow (95% Cellular) with Trilineage Hyperplasia (See Comment) No Dysplasia is Identified Lymphoid Aggregates (See Comment) Iron Stores are Adequate Peripheral Blood (CBC Only): Thrombocytosis (Platelets 491 K/uL) Neutrophilia (WBC 18.8 K/uL; ANC 15.1 K/uL) Aspirate Smear Bone Marrow Core Bone Marrow Core COMMENTS Clinical History: 47-year-old with a clinical history of right ovarian cyst, diabetes mellitus, hypertension, high cholesterol, and menorrhagia is being evaluated for leukocytosis and thrombocytosis. Denies infections, fever, chills or night sweats. A bone marrow biopsy on 2015 showed no evidence of malignancy or neoplasm. Her WBC reportedly normalized and did not return for follow-up. Lab work on 1/14/2017 showed significant leukocytosis, neutrophilia, lymphocytosis and monocytosis. Further work up showed K. pneumonia UTI, which was treated with Bactrim (2nd infection in 2-3 months). Blood sugar has been increasing recently. Currently on Janumet daily. The bone marrow is mildly hypercellular due to mild trilineage hyperplasia. Blasts are not increased (1% blasts). No atypical megakaryocytes or clusters of megakaryocytes are present to suggest a myeloproliferative neoplasm. No significant fibrosis is present. FISH for BCR/ABL is normal. The overall morphologic findings do not meet criteria for a myeloproliferative neoplasm. Molecular tests for JAK2 V617F, CALR and MPL mutations has been ordered and will be reported separately. Correlation with the pending molecular studies is recommended. The morphology of the lymphoid aggregate is most consistent with a benign lymphoid aggregate. The accompanying flow cytometry concurs with the above diagnosis. PAGE 1 OF 3

8 Cedar Plaza, Suite 200, St. Louis, MO Phone: 314.LAB.TEST ( ) Fax: Patient: MRN/ID: LTD ID: MICROSCOPIC DESCRIPTION Peripheral Blood: A CBC dated 04/08/2017 was performed at facility. A peripheral blood smear is not submitted for evaluation. Review of the CBC data reveals the following: WBC 18.8 K/uL Neutrophils 81% Lymphocytes 15% Monocytes 3% Eosinophils 1% Basophils 0% RBC: 4.86 M/uL HGB: 13.9 g/dl HCT: 41.1% MCV: 85 fl MCHC: 33.8 g/dl RDW: 13.0% Platelets: 491 K/uL Bone Marrow Aspirate and Touch Imprints: The bone marrow aspirate appears hypercellular. Particles are adequate. Touch imprints are adequate for evaluation. Trilineage hematopoiesis is identified. A differential count performed on 500 cells from the aspirate smears show the following: Blasts 1% Myeloid Cells 76% Monocytes 0% Lymphocytes 4% Plasma Cells 0.2% Normoblasts 18.8% Other NA The M:E ratio is 4:1. Megakaryocytes are present and show no abnormal morphologic features. Myeloid precursors demonstrate orderly maturation with normal nuclear and cytoplasmic morphology. Blasts are not increased. Erythroid precursors show complete, progressive maturation with the majority having normal round nuclear contours and nuclear/cytoplasmic synchrony. Rare erythroid precursors have mild nuclear irregularities (<5%). No abnormal lymphoid cells are seen. Plasma cells are not increased and have normal morphology. PAGE 2 OF 3

9 Cedar Plaza, Suite 200, St. Louis, MO Phone: 314.LAB.TEST ( ) Fax: Patient: MRN/ID: LTD ID: Core Biopsy and Clot Section: The biopsy and clot section are adequate for evaluation. The bone marrow cellularity, estimated from the biopsy section is approximately 95%, which is hypercellular for the patient's age due to trilineage hyperplasia. There is a normal distribution of all three cell lines. Blasts are not increased. Megakaryocytes are adequate and are morphologically unremarkable. No atypical megakaryocytes or clusters of megakaryocytes are seen. The M:E ratio is confirmed as seen on the aspirate smears. Lymphoid aggregates are occasionally seen and are composed of predominantly small round lymphocytes. Plasma cells are not increased. No granulomas or metastatic disease are identified on H&E staining. The bony trabeculae are unremarkable. Special Stains: An iron stain run with an appropriately reacting positive control and performed on an aspirate smear and clot section reveals adequate iron stores. Ring sideroblasts are not seen. Trichrome and reticulin stains are done each with an appropriately reacting positive control and demonstrate no collagen fibrosis and focal reticulin fibrosis within the lymphoid aggregate. GROSS DESCRIPTION Received in a container of formalin labeled appropriately is a white-tan core of bone measuring 1.0 x 0.2 x 0.2 cm. After decalcification, the specimen is entirely submitted in cassette A1. Received in a container of formalin labeled appropriately are dark red to brown pieces of tissue that measure in aggregate 1.1 x 0.6 x 0.4 cm. The specimen is entirely submitted in cassette B1. Also received, and appropriately labeled, are 5 bone marrow aspirate smears, 5 touch imprints, bone marrow aspirate in each of 1 EDTA tube and 1 sodium heparin tube and a copy of the CBC report. END OF REPORT Electronically signed on 05/09/2017 Aamir Ehsan, MD Hematopathologist This test was developed and its performance characteristics determined by CorePath Laboratories PA. It has not been cleared or approved by the US Food and Drug Administration and FDA does not require this test to go through premarket FDA review. 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. PAGE 3 OF 3

10 CYTOGENETICS

11 Cedar Plaza, Suite 200, St. Louis, MO Phone: 314.LAB.TEST ( ) Fax: Patient: DOB: Gender: MRN/ID: Facility: Physician: LTD ID: Collected: Received: Reported: Specimen: Bone Marrow Clinical Indication: Thrombocytopenia; Anemia. CYTOGENETICS REPORT ISCN: 46,XY[20] RESULTS NORMAL MALE chromosome complement. No clonal acquired abnormality was detected at the available resolution. COMMENTS This analysis does not rule out any submicroscopic abnormalities or abnormalities in non-dividing cells. 46,XY Culture Methods: Unstimulated Culture Sources: 2 Cells Counted: 20 Cells Analyzed: 20 Karyotyped: 2 Banding Methods: GTW END OF REPORT Electronically signed on 05/04/2017 Vijay S. Tonk, Ph.D.; FACMG Consultant ABMG Certified Clinical Cytogeneticist Electronically signed on 05/04/2017 Aamir Ehsan, MD Hematopathologist This test was developed and its performance characteristics determined by CorePath Laboratories PA. It has not been cleared or approved by the US Food and Drug Administration and FDA does not require this test to go through premarket FDA review. 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. PAGE 1 OF 1

12 FISH

13 Cedar Plaza, Suite 200, St. Louis, MO Phone: 314.LAB.TEST ( ) Fax: Patient: DOB: Gender: MRN/ID: Facility: Physician: LTD ID: Collected: Received: Reported: Specimen: Bone Marrow Clinical Indication: History of AML FLUORESCENCE IN-SITU HYBRIDIZATION (FISH) REPORT RESULTS All the probes in the AML/MDS panel showed a NORMAL signal pattern. TES/RELN INTERPRETATION Within limits of the resolution of FISH technology and the cutoff values established in this laboratory, there was no evidence of the deletion of 5q, 7q, 17p, 20q or trisomy 8. This analysis also rules out MLL, AML1/ETO, RARA/PML rearrangements and inversion 16. Correlation with other test results is recommended. TEST Fluorescence in-situ Hybridization (FISH) using the manual method was performed on the tissue specimen provided. 200 interphase nuclei were examined for each probe. PROBES USED Based on the patient's history of acute myeloid leukemia, a total of 8 FISH probes were hybridized to accurately diagnose disease, evaluate the prognostic factors and to categorize disease in the presence of abnormal findings. 5p15.3/EGR1 to evaluate defect in erythropoiesis and monosomy TES/RELN to evaluate chromosome 7 defect, presence of denovo and secondary AML AML1/ETO to evaluate the presence of translocation t(8;21)(q22;q22) in AML PML/RARa to evaluate the presence of translocation t(15;17) in AML so ATRA can be initiated CBFB/MYH11 to evaluate the presence of the inversion of chromosome 16 and translocation t(16;16) in AML with better prognosis D17Z1/p53 to evaluate tumor suppressor gene p53 MYBL2/PTPRT to evaluate another tumor suppressor gene in MDS MLL to evaluate mixed leukemia/lymphoma gene and adverse prognosis Electronically signed on 05/08/2017 Aamir Ehsan, MD Hematopathologist END OF REPORT This test was developed and its performance characteristics determined by CorePath Laboratories PA. It has not been cleared or approved by the US Food and Drug Administration and FDA does not require this test to go through premarket FDA review. 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. PAGE 1 OF 1

14 MOLECULAR

15 Cedar Plaza, Suite 200, St. Louis, MO Phone: 314.LAB.TEST ( ) Fax: Patient: DOB: Gender: MRN/ID: Facility: Physician: LTD ID: Collected: Received: Reported: Specimen: Peripheral Blood Clinical Indication: Primary generalized (osteo)arthritis. Fibromyalgia. Dyspnea, unspecified. Pleurodynia. Chest pain, unspecified. Weakness. MOLECULAR REPORT RESULTS JAK2 V617F Mutation Not Detected INTERPRETATION The JAK2 V617F mutation has been reported in >80% of the patients with polycythemia vera (PV), 30-50% of patients with either essential thrombocythemia (ET) or primary myelofibrosis (PMF). This mutation is not detected in normal individuals. A small subset of patients with myeloproliferative neoplasms (MPN) that are negative for the JAK2 V617F mutation will harbor JAK2 mutations in exon 12. More rare mutations are detected in exons 13 and 14. JAK2 mutations can be used to differentiate reactive conditions from neoplastic process. References: 1. James C, et al. A unique clonal JAK2 mutation leading to constitutive signalling causes polycythaemia vera. Nature. 2005; 434: Kralovics R, et al. A gain-of-function mutation of JAK2 in myeloproliferative disorders. N Engl J Med. 2005; 352: TESTING INFORMATION Total nucleic acid was extracted from patient s plasma or PB/BM cells. The primer pair was designed to encompass the JAK 2 V617F point mutation located in chromosome 9p24. The PCR product was then purified and sequenced in both forward and reverse directions using highsensitivity Sanger sequencing which improves the lower detection limit to approximately 1% mutated DNA in a wild-type background. The resulting sequence was compared to GenBank Acc# NM sequence. Various factors including quantity and quality of nucleic acid, sample preparation and sample age can affect assay performance. END OF REPORT Electronically signed on 05/10/2017 Aamir Ehsan, MD Hematopathologist PAGE 1 OF 1

16 20/20 CORE EVALUATION

17 Cedar Plaza, Suite 200, St. Louis, MO Phone: 314.LAB.TEST ( ) Fax: Patient: DOB: Gender: MRN/ID: Facility: Physician: LTD ID: Collected: Received: Reported: Specimen: Bone Marrow Clinical Indication: Anemia 20/20 CORE EVALUATION REPORT FINAL MORPHOLOGICAL DIAGNOSIS (Report ID) Bone Marrow, Core Biopsy, Clot Section and Aspirate: Normocellular Bone Marrow (25% Cellular) with Complete Trilineage Hematopoiesis No Dysplasia or Malignancy is Identified Iron Stores are Decreased (See Comment) FLOW CYTOMETRIC DIAGNOSIS (Report ID) No Abnormal Hematolymphoid Populations are Identified Blasts are Not Increased CYTOGENETICS DIAGNOSIS (Report ID) NORMAL MALE chromosome complement. No clonal acquired abnormality was detected at the available resolution. FLUORESCENCE IN-SITU HYBRIDIZATION-FISH DIAGNOSIS (Report ID) All the probes in the MDS panel showed a NORMAL signal pattern. COMMENTS The bone marrow is normocellular (25% cellularity) with no evidence of a primary hematolymphoid neoplasm identified morphologically or by flow cytometry. FISH for MDS was done and is normal. A cytogenetics study shows a normal male karyotype. The biopsy shows decreased iron stores. Iron studies are recommended if clinically indicated. END OF REPORT Electronically signed on 05/09/2017 Aamir Ehsan, MD Hematopathologist This test was developed and its performance characteristics determined by CorePath Laboratories PA. It has not been cleared or approved by the US Food and Drug Administration and FDA does not require this test to go through premarket FDA review. 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. PAGE 1 OF 1

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