Flow cytometric analysis of B-cell lymphoproliferative disorders

Transcription

1 Flow cytometric analysis of B-cell lymphoproliferative disorders David M. Dorfman, M.D., Ph.D. Department of Pathology Brigham and Women s Hospital and Harvard Medical School Boston, MA

2 Objectives Review basic principles of flow cytometric immunophenotypic analysis of B cell lymphoproliferative disorders Discuss recent studies to overcome limitations and shortcomings New markers New methods

3 Incidence of B-cell neoplasms, United States Subtype Incidence rate New cases, 2016 per 100,000 Lymphoid neoplasms ,960 Lymphoid neoplasms, B % 117,470 B-LL/L % 4,930 CLL/SLL ,980 FL ,960 DLBCL ,650 MM ,280 Lymphoid neoplasms, T/NK 2.1 8,380 T-LL/L 0.3 1,070 T-PLL < T-LGL ATL/L < Teras et al. CA Cancer J Clin 2016; 66: (North American Association of Central Cancer Registries) SS < Teras et al. CA Cancer J Clin 2016; 66: (North American Association of Central Cancer Registries) Teras et al. CA Cancer J Clin 2016; 66: (North American Association of Central Cancer Registries)

4 94% WHO revised 4 th ed., 2017

5 Flow cytometric analysis of B-cell lymphoproliferative disorders B-cell antigen expression (CD19, CD20, CD22) Monoclonal surface immunoglobulin κ or λ light chain expression (or absence of surface immunoglobulin) Expression of additional B-cell antigens or other antigens, including abnormal expression levels Presence of cells with abnormal light scatter characteristics ( high forward scatter or side scatter)

6 B-ALL MCL FL, HL MZL, CLL, MM LPL DLBCL DLBCL WHO revised 4 th ed.

7 Case year old woman with lymphocytosis (WBC = 12,720/μl, 60% lymphocytes)

8 CD45+, CD19+, CD20 dim+, CD5+, CD11c dim+, CD23+, sig lambda+ CD10-, sig kappa- Chronic lymphocytic leukemia/small lymphocytic lymphoma [Older adults; 5000/ul; PB, BM, lymphoid tissues]

9 CLL/SLL CD20 bright+ CD20 dim+ reactive B cells neoplastic B cells

10 Subpopulation gating based on differential staining for pan-b-cell markers (CD19, CD20, CD22) can be helpful to distinguish neoplastic B-cell populations from reactive, polyclonal background cells Normal Lymph Node B-CLL/SLL Follicular lymphoma reactive neoplastic reactive neoplastic Mantle cell lymphoma Follicular lymphoma Marginal zone lymphoma Huang et al, Ohio State University, Am J Clin Pathol 2005; 123:

11 Case year old man with lymphadenopathy underwent a staging bone marrow biopsy

12 CD19+, CD20+, CD5+, sig lambda+ CD10-, CD11c-, CD23-, sig kappa- Mantle cell lymphoma (t(11;14) CCND1) [older adults; LNs>spleen>BM>extranodal; 3-5 yr survival]

13 CD20 x CD5 CLL MCL sig κ x sig λ CD23 x CD79b Dr. M. Linden, University of Minnesota 13

14 Percentage of CLL/SLL cases deviating from classical antigenic patterns Classic antigenic pattern % of cases deviating CD20 dim positive 11-38% CD22 dim positive 0-8% CD23 negative 3-5% FMC7 negative (CD20 epitope) 7-14% CD79b negative 5-18% Surface immunoglobulin dim positive 5-42% CD5 positive? S. Kroft and A. Harrington, Clin Lab Med 2017; 37: 697

15 CD200 (Ig superfamily membrane glycoprotein) distinguishes CLL/SLL from Mantle cell lymphoma CLL/SLL 79/79 + MCL 0/ >20%+ Palumbo et al., Catania, Leuk Res 2009; 33:1212

16 Case 3. A 54-year-old woman with a history of non-hodgkin s lymphoma presented with inguinal lymphadenopathy. An FNA was performed.

17 CD19+, CD20+, CD10+, CD38+, sig kappa+ CD5-, sig lambda- Follicular lymphoma (t(14;18) BCL2) [Older adults; LN>spleen>BM>PB]

18 Wang and Zu Arch Pathol Lab Med 2017; 141:1236

19 CD5+, CD10+ B-cell neoplasms CD5+, CD10+ Mantle cell lymphoma Coexpression of CD5 and CD10 occurs in <1% of B cell lymphomas, including DLBCL, follicular lymphoma, mantle cell lymphoma, CLL/SLL, other small cell B cell lymphomas, and precursor B lymphoblastic leukemia/lymphoma, and is of uncertain clinical significance. [Dong et al. B-cell lymphomas with coexpression of CD5 and CD10. Am J Clin Pathol 2003; 119: ]

20 Surface immunoglobulin-negative B-LPDs B cells before (left) and after (right) 37C incubation and increased light chain reagent (Harrington and Kroft. Clin Lab Med 2017; 37:697)

21 Biclonal B-cell lymphoproliferative disorders account for <5% of cases (23/477 in study cited), and include CLL/SLL, acll, HCL, LPL, SMZL, FL, LCL Sanchez et al. Blood 2003; 102:2994

22 Case 4. A 58 year old woman presented with splenomegaly, and anemia CD45+, CD19+, CD20 dim+, CD23 var+, sig kappa+ CD5-, CD10-, CD11c-, sig kappa- Marginal zone lymphoma [Older adults; spleen>pb / MALT / LN; indolent]

23 , HCL-v Wang and Zu Arch Pathol Lab Med 2017; 141:1236

24 Case year old man with weakness, fatigue, progressive neuropathy, anemia, IgM kappa paraprotein (2.77 g/dl)

25 CD19+, CD20+, sig kappa+ CD5-, CD10-, CD11c-, CD23-, sig lambdaand

26 Plasma cell component: CD38+, CD138+ cig kappa+ CD19-, CD56-, cig lambda- Lymphoplasmacytic lymphoma (MYD88 L265P) [Older adults; BM; WMG = BM + IgM monoclonal gammopathy; indolent]

27 Case 6. A 43-year-old woman presented with slight leukopenia and thrombocytopenia. WBC= 4,200/ul with 59% lymphocytes, 4% atypical lymphocytes with cytoplasmic projections. Bone marrow examination revealed 65% lymphocytes, some with cytoplasmic projections.

28 negative control CD19+, CD20+, sig kappa+, CD11c+, CD25+, CD103+ CD5-, CD10- Hairy cell leukemia (BRAF V600E) [Older adults; BM, splenic red pulp, PB]

29 CD200 expression in B-cell lymphoproliferative disorders by flow cytometric analysis *HCL CD1d is a MHC class I-liCD1d is a * MHC class I-like CD1d is a MHC class I-like cell surface cell surface glycoprotein expressed in a wide glycoprotein expressed in a wide range range of cells, with increased expression in of cells, with increased expression in resting, naïve, and marginal zone B cells vs. resting, naïve, and marginal zone B activated and memory B cells cells vs. activated and memory B cells Expression in CLL/SLL is less than in MCL; expression in MZL but not LPL/WMG Expression in CLL/SLL is less than in MCL; expression in MZL but not LPL/WMG ke cell surface glycoprotein expressed in a wide range of cells, with increased expression + in resting, naïve, and marginal zone B cells vs. activated and memory B cells Expression in CLL/SLL is less than in MCL; expression in MZL but not LPL/WMG Pillai et al Am J Clin Pathol 2013; 140: HCL-V

30 CD200 and CD1d expression in CD5-, CD10- B-cell lymphoproliferative disorders Hairy cell leukemia Hairy cell leukemiavariant Lymphoplasmacytic lymphoma Marginal zone lymphoma CD11c CD103 CD200 CD1d Mason et al. Am J Clin Pathol 2017; 148:33

31 Pattern of CD200 and CD1d expression in CD5-, CD10- B-cell lymphoproliferative disorders % % Neg Dim 60.00% Pos Bright 40.00% 20.00% 0.00% HCL HCLv LPL MZL +/+: 94% sensitive and 98% specific for HCL +/-: 60% sensitive and 97% specific for LPL -/+: 41% sensitive and 100% specific for MZL Mason et al. Am J Clin Pathol 2017; 148:33

32 CD5-negative, CD10-negative B-cell lymphoproliferative disorders Cytogenetics/Molecular Treatment HCL BRAF V600E; MAP2K1 Purine analogs (cladribine, pentostatin) HCL-V MAP2K1 Purine analogs +Rituximab (anti-cd20), anti-cd22, or anti-cd52 immunotherapy LPL MYD88 Rituximab ± (multi-agent) chemotherapy MZL -7q (SMZL), NOTCH2, MLL2, KLF2, PTPRD (NMZL) Rituximab ± (multi-agent) chemotherapy? + anti-cd200 immunotherapy in HCL, LPL/WMG

33 Case year old woman with a history of DLBCL, now with WBC = 69,110/ul with 57% atypical cells

34 [Elderly and younger; nodal and extranodal>bm; 60-65% 5 year survival] CLL/SLL CD19+, CD20+, sig kappa+ CD5-, CD10-, sig lambda- Large B cell lymphoma (5-10% are CD5+ de novo or arising from CLL/SLL)

35 Expression of T-cell markers in B-LPDs (Tsuyama et al. Oncotarget 2017; 8: ) CD2, CD3, CD4, CD5, CD7, CD8 expression was evaluated in 501 B- LPDs, including 225 DLBCLs, by flow cytometry T-cell markers other than CD5 were expressed in 27/501 patients (5%), all large B cell lymphomas: 25 DLBCL and 2 IVLBCL CD8 > CD7 > CD2 > CD4; 8 cases had >1 T-cell marker; no CD3+ cases CD5 was present in 31/225 DLBCLs (15%); CD5 was coexpressed with other T-cell markers in 5/31 CD5+ DLBCLs (16%) Poorer survival in CD5+ DLBCL vs. CD5- DLBCL, but no differences in survival with expression of other T-cell markers CD8 previously reported in CLL (0.5-3% of cases)

36 Case year old man with a right parapharyngeal mass and leukocytosis (WBC = 17,830/ul; 14% lymphocytes, 30% atypical lymphocytes

37 CD45+, CD19+, CD20+, CD10+, CD38+, sig kappa+ CD5-, sig lambda- Burkitt lymphoma/leukemia (MYC translocation) [Children and young adults; extranodal>ln; highly aggressive but curable]

38 Bright CD38 staining is an indicator of MYC rearrangement MYC rearrangement Numerical MYC aberrations Normal MYC 106 cases of CD10+ high grade lymphomas Maleki et al. Leuk Lymph 2009;50:

39 Burkitt lymphoma vs. Double-hit lymphoma with MYC and BCL translocations Burkitt lymphoma: CD19+, CD20+, CD10+, CD38 bright+ Double-hit lymphoma: Roth et al. Oncol Res 2016; 23:137 CD45, CD19+, CD20, CD10+, CD38+

40 Immunophenotypic findings for mature B-cell neoplasms 1, 2 3, , 10+ Pan-B (CD19/ CD20) sig Κ v. λ CD5 CD10 CD23 CD11c other CLL/SLL +/ +/ v CD79b-, CD200+ MCL CD79b+, CD200-, Cyclin D1+, Sox 11+ Follicular v - CD38, Bcl-2+, Bcl-6+ MZL v v CD200-, CD1d+ LPL CD200+, CD1d-, cig+ plasma cells HCL CD25+, CD103+, CD200+, CD1d+ HCL-V CD25-, CD103+, CD200-, CD1d- DLBCL + +/- -/+ +/- v Bcl-2+, Bcl-6+/- Burkitt CD38+, TdT-, Myc+, Bcl-6+, Bcl-2- DHL +/ +/ - +/- - - CD38, CD45, TdT-, Myc+, Bcl-6+, Bcl-2+

41 Conventional flow cytometric analysis: problems and limitations Flow cytometric analysis is expensive and labor intensive Reactive, polyclonal background cells CD5-negative, CD10-negative B LPDs (lack of good markers for differential diagnosis) Neoplasms may exhibit phenotypic variation Definitive (clonality) markers may be unclear Interpretation of the immunophenotype may be subjective (poor reproducibility) additional markers (for example, CD23, CD79b, CD43, CD103, CD200, CD1d) and approaches may be helpful

42 New methods for flow cytometric analysis Cytoplasmic and nuclear antigens cig in MM, TdT in ALL, bcl-2 in FL, MPO in AML, ccd3 in T-ALL Markers of clonality by gene expression usage TCR β chain usage in T-NHL Scoring systems diagnosis and subclassification CLL, AML-M0 vs. ALL, MDS Customized panels for minimal residual disease CLL, ALL, AML, MM Enzymatic amplification of staining catalyzed tyramide reporter deposition cyclin D1 in MCL Analysis of neoplasms not traditionally studied by flow cytometric immunophenotyping (epithelial neoplasms) Ber-EP4 Multiplex analysis Value-based (cost effective) analysis New (automated) approaches for data analysis

43 Multiplexing: London Health Science Center custom design flow cytometry tube (12 markers, 10 fluorochromes, 14 parameters) Antigen Fluorochrome CD8 Kappa CD4 Lambda CD19 CD56 CD3 CD20 CD10 Near-IR Viability Dye CD5 CD45 FITC FITC PE PE ECD PE-Cy5.5 PE-Cy7 APC APC-Alexa700 Excitation: 633nm Emission 780nm Pacific Blue Krome Orange Hedley et al. Cytometry B 2015; 88B:361

44 Multiplexed 12-marker, 10-color flow cytometric analysis 10-color, 15-Ab, 17-parameter panel for LPDs: CD4/κ, CD8/λ, CD3/CD14, CD38, CD20/CD56, CD10, CD19, CD5, CD57/CD23, CD45 Rajab et al. Int J Lab Hematol 2017; 39(Suppl 1):76

45 Value-base flow cytometry testing of chronic lymphoproliferative disorders Retrospective analysis of peripheral blood samples submitted for flow cytometric analysis for LPD to develop a cost-effective testing strategy (multicenter study) 8/70 cases (11%) with normal range absolute lymphocyte counts were positive 2/20 cases (10%) with patients younger than 45 years were positive diagnostic algorithm for patients with low pre-test probability of a LPD (triage panel: CD3, CD4, CD5, CD19, sig κ, sig λ) and high pre-test probability of LPD (triage panel + additional B cell marker tube) reduction of 40% in antibody use Statistical analysis (classification tree approach; University of Calgary) Patients < 50 yrs with an absolute lymphocyte count <5,000/μl were nearly always negative (98.2%) for monoclonal B cells Patient s >50 years with an absolute lymphocyte count <5,000/μl and high ferritin level (450 µg/liter; acute phase reactant) were nearly always negative (97.1%) for monoclonal B cells 26% of cases were correctly predicted as negative with greater than 97% accuracy (recommend that testing should not be performed) Oberly et al. Am J Clin Pathol 2014; 142:411 Healey et al Leuk Lymphoma 2015; 56:2619

46 Peripheral blood samples submitted for flow cytometric analysis for LPD: absolute lymphocyte count and patient age 8/110 = 7.2% 2/110 = 1.8% Oberly et al. Am J Clin Pathol 2014; 142:411

47 New (data analysis) approaches Standardization of antibody panels, instrument settings, and data files, based on multicenter studies Euroflow consortium Standardized, lyophilized reagent tubes for uniformity of multi-institutional analysis Texas Medical Center (Texflo) Automated analysis: advanced, algorithmic approaches to population gating and data analysis of existing diagnostic marker panel CLL vs. Mantle cell lymphoma (Zare et al.)

48 SamSPECTRAL clustering algorithm 2. FeaLect method (~Bolasso algorithm) to identify flow cytometry features most useful to discriminate CLL and MCL A. Weng, University of British Columbia, Am J Clin Pathol 2012; 137:75

49 Automated analysis of flow cytometric findings to distinguish CLL/SLL from MCL 70 cases CLL/SLL 44 cases MCL Am J Clin Pathol 2012; 137:75

50 Identification of discriminative ratios (CD20/CD23, FMC7/CD23, and CD20/CD11c) =0 =1 composite diagnostic predictor with values of 0-1 (67/70 (96%) of CLL cases) vs. 2-3 (44/44 (100%) of MCL cases) Am J Clin Pathol 2012; 137:75

51 Summary: Flow cytometric analysis of B-cell lymphoproliferative disorders B-cell antigen expression (CD19, CD20, CD22) Monoclonal immunoglobulin κ or λ light chain expression (or absence of surface immunoglobulin) CD5+/CD10-, CD5-/CD10+, CD5-/CD10- categories and exceptions Presence of cells with abnormal light scatter characteristics (high forward scatter or side scatter) New markers and approaches to overcome limitations and shortcomings of conventional flow cytometric analysis Correlation with clinical, morphologic, and laboratory findings