XN-SERIES. Hematology Case Studies: Every Picture Tells a Story

Transcription

1 Hematology Case Studies: Every Picture Tells a Story Jill Crist MT(ASCP)Field Product Specialist OBJECTIVES Explain how scattergrams and histogram pictures can provide great insight into abnormal hematology samples Describe the technology and the operational benefits of the Sysmex XN automated hematology analyzer. Utilize case studies to demonstrate how enhanced technologies can benefit the patient and clinician, as well as provide efficiency in your hematology workflow XN-SERIES Up to 100 /hr /module Common Software System Common Reagent System Common QC System XN-1000 XN-2000 XN-3000 XN

2 SYSMEX FOUNDATIONAL TECHNOLOGY RBC & Platelet DC Detection / Hydrodynamic Focusing Hemoglobin Absorbance / Sulfolyser CASE STUDY : RBC DUAL POPULATION Patient received transfusion of packed RBCs. What would you expect to see in the histogram? 2

3 FLUORESCENT FLOW CYTOMETRY Side Fluorescent Light DNA/RNA information Dichroic Mirror Side Scattered Light Cell inside structure information Laser Beam wavelength=633nm Forward Scattered Light Cell size information 3

4 WDF Channel Copyright 2012 by Sysmex America, Inc All rights reserved WDF CHANNEL Scattergram - Normal Pattern MONO IG LYMPH NEUT+BASO Debris Copyright 2012 by Sysmex America, Inc. All rights reserved. EO 4

5 IG% & IG# reportable on every diff 2012 Sysmex America, Inc. All rights reserved LEFT SHIFT FLAG Immature Grans are shown by the blue arrow and Left Shift is in the red circle. 5

6 ATYPICAL LYMPH FLAG Manual Diff Neuts: 14% Bands: 9% Lymphs: 18% Monos: 49% Metas: 1% Myelos: 3% Blasts: 6% 6

7 Manual Diff Neuts: 16% Bands: 21% Lymphs: 19% Monos: 12% Eos: 1% Metas: 4% Myelos: 12% Pros: 11% Blasts: 4% CASE STUDY : HEART DEFECT PATIENT Patient is 7 year old boy who was born with a heart defect. Presented with extremely elevated WBC count. 7

8 CBC RESULTS FROM XN Manual 1:2 dilution of WBC = VERY HIGH WBC COUNT CASE STUDY : PATIENT WITH CML Patient is 17 year old male with CML. Patient is BCR/ABL Positive. 8

9 CBC RESULTS FROM XN Increased Basophil Count 9

10 WNR CHANNEL Scattergram - Normal Pattern FSC BASO NRBC WBC Debris SFL Copyright 2012 by Sysmex America, Inc. All CASE STUDY : ORGAN TRANSPLANT PATIENT Patient is a 2 year old male with a history of multiple organ transplants who presented with weakness and fevers. Patient was anemic, with elevated WBC, IG and NRBCs. CBC RESULTS FROM XN 10

11 VERY HIGH NRBC, ABNORMAL INDICES PLT-F Channel Copyright 2012 by Sysmex America, Inc. All rights reserved. PLT-F CHANNEL Reportable Parameters PLT-F IPF. 11

12 INTERFERENCES IN IMPEDANCE PLATELET COUNTING Falsely Increased RBC fragments Falsely Decreased Giant platelets Microcytes Bacteria Platelet clumps Immune complexes WBC fragments POSSIBLE MECHANISMS OF THROMBOCYTOPENIA Production Disorders Myeloablative Therapy Bone Marrow Transplant Acute Myeloid Leukemia (AML) Stasi, R. How to approach thrombocytopenia. Hematology :191; /asheducation 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) PLT CLUMPS AND REAGENT REACTION PLT Clumps in reagent / reaction WNR ch WDF ch PLT-F ch Discretely according to reaction time Keep the shape PLT Clumps can keep the shape, because the detergent of CELLPACK DFL is weaker than other channel. 12

13 FSC-Width Normal Platelets PLT Clumps FSC FSC Laser Laser Direction of Sheath Flow FSC FSC FSC_W FSC_W FSC Width Leukocytes PLT Clumps FSC FSC Laser Laser FSC FSC FSC_W FSC_W 13

14 CASE STUDY : OB PATIENT WITH GIANT PLTS Giant platelets in pregnant patients can be a normal phenomenon. The problem with this is the failure of impedance technology to accurately recover a reportable number resulting in the technologist needing to manually intervene. MICROSCOPIC IMAGES OF SLIDE Doc. No CFL, Rev 1, June

15 OB PATIENT WITH GIANT PLATELETS Printout Doc. No CFL, Rev 1, June 2014 OB PATIENT WITH GIANT PLATELETS XN-IPU Browser Doc. No CFL, Rev 1, June 2014 CASE STUDY : CF PATIENT Patient is a newborn male with Down Syndrome and Cystic Fibrosis. Patient presented with decreased Platelet count. 15

16 PLT Abnormal Distribution Reflex PLT F CASE STUDY : SEVERE BURN PATIENT Expected findings usually show spherocytosis and increased osmotic fragility of RBCs. Peripheral blood fibrocytes are adherent cells from peripheral blood mononuclear cells (PBMC). These are an important source for healing of burn wounds. 16

17 PLT MEASUREMENT OVER TIME IN A SEVERE BURN INJURY PATIENT PLT COUNT OVER TIME IN A BURN PATIENT Day 1 PLT-F PLT-I Day 2 PLT-F PLT-I PLT COUNT OVER TIME IN A BURN PATIENT Day 3 PLT-F PLT-I Day 4 PLT-F PLT-I 17

18 IMMATURE PLATELET FRACTION TO ASSESS BONE MARROW RECOVERY Study objective: How well can IPF help the clinician predict bone marrow recovery following peripheral blood HPC transplantation? A persistently low IPF in this setting would suggest failure of thrombopoietic recovery. Zucker M., Murphy CA, Rachel JM, Martinez GA, Abhyankar S, McGuirk JP. Immature Platelet Fraction as a Predictor of Platelet Recovery following Hematopoietic Progenitor Cell Transplantation. Laboratory Hematology, : RET CHANNEL RET RBC LFR MFR HFR IRF PLT 18

19 NEXT GENERATION DIAGNOSTICS IRON DEFICIENCY PREVALENCE IN INFANTS AND TODDLERS Adverse consequences in pediatric patients: Increased lead absorption Impaired immunity Anemia Impaired neurocognitive development % 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. Reference Ranges IRF 3-18% Ret-He >29pg CASE STUDY : SICKLE CELL PATIENT Patient is 17 year old male with Sickle Cell Disease. What are some interferences we would expect to see? 19

20 CBC RESULTS FROM XN RETIC ABNORMAL SCATTERGRAM 20

21 NEXT GENERATION DIAGNOSTICS CLINICAL APPLICATIONS OF RETICULOCYTE HEMOGLOBIN Wellness Pediatrics - Iron deficiency and Iron Deficiency Anemia Prevention Surgical patients pre and post surgical assessments Chronic Disease Management End Stage Renal Disease - anemia management Monitoring response to therapy with ESA and/or iron Cancer- anemia status Body Fluids..Oh no!!! WHAT TYPES OF BODY FLUIDS ARE APPROVED? Body fluid mode (target species) HF-BF Cerebrospinal fluid (CSF) MN Pleural fluid Peritoneal fluid MO-BF LY-BF NE-BF PMN EO-BF Synovial fluid WDF Scattergram 21

22 Types of Fluids Collection Methods Clotted, viscous specimens Types of cells challenge tech skill level SMALL SAMPLE VOLUME MAXIMUM VOLUME ASPIRATED 88UL. BETTER PRECISION PRECISION WITHIN 10 30% DEPENDING ON THE RESULT QUICKER TAT REPORTABLE RANGE CAPABLE OF PROCESSING 40 SPECIMENS PER HOUR REPORTABLE RBC X 10^6 REPORTABLE WBC X 10^3 EASY TO PERFORM NO PREDILUTION OR ANALZER PREP SAFER CLOSED SAMPLE HANDLING 22

23 WHAT ARE YOU GETTING IN THE BODY FLUID COUNT? WBC S ONLY RBC COUNT SEMI QUANTITATIVE IN INCREMENTS OF 1,000 (.001) 2 PART DIFFERENTIAL MN AND PMN # AND %. EXPRESSED AS A PERCENTAGE OF THE WBC COUNT TNC BF. WBC BF PLUS ALL THE HIGH FLUORESCENT BODY FLUID CELLS INCLUDED IN THE TOTAL 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 WBCBF The total of the PMN and MN area Polymorphonuclear area part of the WBCBF area all segmented cells, Neutrophils and eosinophils RULES TO FOLLOW If there are clots in the fluid, take them out. You can still give an approximate count and make a smear. That s not what I was taught? What s really important is the cell type! 23

24 MORE RULES TO FOLLOW Synovial fluids are often too viscous to be properly aspirated. Add Hyaluronidase. It s like Magic! Add 5mg to a ml aliquot. SO WHAT IS IMPORTANT TO KNOW? 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 24

25 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 WBC Abnormal Scattergram Or when the ratio of high fluorescent body fluid cells is increased per 100 WBC s This is an operator programmable flag and is optional. **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 In either case above manual review is mandatory The Reality is that the type of cell is more important than the quantity of cells. 25

26 WHAT ARE WE REALLY AFRAID OF? THE SCARY CELLS MESOTHELIAL AND 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 And did you know? MESOTHELIAL CELLS ARE ONLY FOUND IN SEROUS FLUIDS (PLEURAL, PERITONEAL, PERICARDIAL) 26

27 Normal Body Fluid High Body Fluid Count 27

28 XE5000 Scattergram Body Fluid Flag: WBC Abn Scattergram 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. 28

29 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. Lung Cancer: Pleural Fluid 29

30 BF CASE STUDY : CSF A child presented in the ER with headache, fever and vomiting. He had recently been swimming in a pond. It was determined that a collection of CSF was indicated. 30

31 You can find more interesting Case Studies on My Sysmex! If you have any interesting case studies you would like to share with other customers: Send me a browser screen shot at cristj@sysmex.com Mahalo 31

32 Questions??? References: New England Journal of Medicine Volume 229, No. 19 Lab Invest, :