Emeritus Faculty-Med Ctr Line, Pathology
1. Flow Cytometry of Hematopoietic Neoplasms.
2. Automated Hematology Instrumentation.
3. Wright-Giemsa Cytology of CSF and Body Fluids.
4. Blood/Bone Marrow Pathology
Genome-wide expression studies using complementary DNA microarrays recently suggested a number of intriguing candidate genes for distinguishing plasma cell dyscrasias. Our objective was to test select markers using immunohistochemical analysis and a tissue microarray from paraffin-embedded bone marrow core biopsy specimens obtained from 8 patients with monoclonal gammopathy of undetermined significance, 17 with plasmacytoma, 160 with multiple myeloma, and 15 with plasma cell leukemia (PCL). We immunostained serial sections for CD138, CD27, CD56, p27, Ki-67, CD3, and CD20. Each core was scored in duplicate by observers blinded to phenotype and reported as the average percentage of CD138+ cells. The Mann-Whitney U test was used to determine significance between groups. PCL showed significantly less immunostaining for CD27 (P < .01) and p27 (P < .05) compared with plasmacytoma and multiple myeloma. Low CD27 expression also was associated with plasmacytoma progression to multiple myeloma (P <.05). Our results support the hypothesis that low CD27 expression correlates with high-risk disease, including primary PCL and decreased progression-free survival in solitary plasmacytoma.
View details for DOI 10.1309/ELGMGX81C2UTP55R
View details for PubMedID 16938662
Enumeration of band neutrophils has a long clinical tradition as a diagnostic test for bacterial infection. Yet, the band count is a nonspecific, inaccurate, and imprecise laboratory test. Review of the literature provides little support for the clinical utility of the band count in patients greater than 3 months of age. The white blood cell count and the automated absolute neutrophil count are better diagnostic tests for adults and most children. Absolute numbers of bands are required for the Rochester criteria, a diagnostic algorithm for acutely ill, febrile children less than 3 months of age. No studies, however, assess the independent contribution of bands to the performance of the algorithm, or the use of the automated total neutrophil count as a replacement for the band count. Band counts also are required to calculate an immature to total neutrophil ratio (I:T ratio), an index widely used to aid in the diagnosis of neonatal sepsis. Studies, however, show a wide range of sensitivity and specificity for the I:T ratio, indicating variable performance. In the near future, rapid analysis of inflammatory factors, adhesion molecules, cytokines, neutrophil surface antigens, or even bacterial DNA may be superior alternative tests for the early diagnosis of sepsis.
View details for Web of Science ID 000174935800008
View details for PubMedID 11933571
Lymphoma/leukemia derived from immature natural killer (NK) cells occur most commonly in adults and are characterized by blastic cytologic features and an aggressive outcome. Predilection for extranodal sites and absence of the Epstein-Barr virus associated with mature NK cell malignancies further distinguish this entity. We present a NK precursor acute lymphoma presenting with multiple masses in an infant without circulating blasts or marrow replacement by disease. The diagnostic difficulty arose from several factors, including young age, presentation with multiple masses, blastic cytologic features mistaken for a small, round, blue cell tumor, and the absence of lineage-specific markers. The CD56+, CD34+, CD33+, MPO-, cytoplasmic CD3+, CD45-, CD7-, HLA-DR-, and TdT- immunophenotype of this neoplasm overlaps with previously reported cases of myeloid/NK precursor acute leukemia and blastic NK cell lymphoma/leukemia. This case emphasizes the need for a strong index of suspicion to recognize this rare entity and to distinguish it from solid tumors and other hematolymphoid neoplasms that occur in infancy.
View details for Web of Science ID 000167405000023
View details for PubMedID 11231495
Progression of follicular lymphoma to a higher-grade malignancy frequently heralds a poor prognosis. Clinical transformation is variably accompanied by a spectrum of histologic changes characterized by alteration in growth and cytology. Although several cytogenetic events and potential oncogenes have been documented in this progression, the underlying molecular mechanisms are largely unknown. We present five patients with an unusual histologic transformation of follicular lymphoma manifested by blastic/blastoid morphology. This transformation is histologically distinct from other types of transformation of follicular lymphoma. All five cases exhibited the t(14;18) translocation and expressed the BCL-2 protein. In addition, two of the five patients showed increased levels of the p53 protein within neoplastic cells implicating a possible role for this oncogene in blastic/blastoid transformation. The lack of BCL-1 and myeloid antigens by immunohistochemistry and flow cytometry studies served to distinguish blastic/blastoid transformation of follicular lymphoma from its morphologic mimics. This distinction is clinically important because lymphoblastic and myeloid leukemias require significantly different therapeutic modalities and show better prognosis. Moreover, the lack of Epstein-Barr virus-specific mRNA suggests that this virus is unlikely to participate in blastic/blastoid transformation of follicular lymphoma.
View details for Web of Science ID 000086211700006
View details for PubMedID 10757399
NK-like T-cell malignancies are part of a spectrum of lymphoproliferative diseases that complicate immunosuppression associated with solid organ transplantation. We describe 2 patients with long-standing immunosuppression following solid organ transplantation. Both patients had systemic symptoms that included fever, myalgia, and weight loss. Organ involvement and lymphadenopathy were not initially observed. Unique to these 2 cases are the initial leukemic symptoms, which led to further characterization and identification of NK-like T-cell malignancies. Both patients exhibited an anomalous T/NK phenotype, CD56 positivity, and atypical blastic architecture of the large granular lymphocytes. Clonal rearrangement of T-cell receptor genes was detected in both patients. In 1 patient, a cytogenetic abnormality involving 8q24 was demonstrated. The disease course in both patients was aggressive, with involvement of multiple sites and rapid demise. This study emphasizes the importance of including NK-like T-cell malignancies in the differential diagnosis of lymphoproliferative disorders associated with immunosuppression and recognizing that an aggressive clinical course may follow leukemic presentation of disease.
View details for Web of Science ID 000079920500011
View details for PubMedID 10230357
Immunoglobulin (Ig)M myeloma is a distinct subtype of multiple myeloma (MM) displaying clinical and pathologic features of both MM and Waldenström's macroglobulinemia (WM). Although the immunophenotypic characteristics of classic MM and WM have been reported, the surface antigen expression of IgM myeloma has not been reported. We report a case of IgM myeloma and describe its immunophenotypic profile using flow cytometry. The cells showed a hybrid MM-WM phenotype, strongly expressing CD38 but lacking CD45 and DR, typical for plasma cells; however, pan-B cell antigens CD20 and FMC7 as well as weak monoclonal surface Ig also were positive, resembling B-cell lymphoproliferative malignancies. Discordant B-cell antigen expression was present, in that pan-B antigens CD19 and CD22 were absent. In addition, B-cell activation antigen CD23, early B-precursor antigen CD10, and pan-T antigen CD5 were not expressed. Although CD20 and weak surface Ig expression have been reported in MM, FMC7 positivity has not been seen. The data therefore suggest that IgM myeloma may have a unique phenotype with characteristics of both MM and WM.
View details for Web of Science ID 000077138200006
View details for PubMedID 9840911
View details for Web of Science ID 000071122800012
View details for Web of Science ID A1997YJ77000012
View details for Web of Science ID A1997YC98300021
View details for PubMedID 10166880
Chimeric anti-CD4 monoclonal antibody was administered intravenously as a single dose to eight patients with mycosis fungoides. The dose was escalated throughout the study between patients groups, and individual patients received 50, 100, or 200 mg per dose. Seven of eight patients responded to treatment with an average freedom from progression of 25 weeks (range, 6 to 52 weeks). The treatment was well tolerated, and there was no clinical evidence of immunosuppression. Following treatment, there was significant suppression of peripheral blood CD4 counts in all patients for 1 to 22+ weeks. Only one patient made a very low titer human antichimeric antibody response. All but two patients made primary antibody and T-cell proliferative responses to a foreign antigen administered 24 hours after antibody infusion. However, there was generally marked, but temporary suppression of T-cell proliferative responses in vitro to phytohemagglutinin (PHA), tetanus toxoid, and normal donor lymphocytes. We conclude that at the dose levels studied, this antibody (1) had clinical efficacy against mycosis fungoides; (2) was well tolerated; (3) had a low level of immunogenicity; (4) decreased T-cell proliferative responses in vitro, and (5) did not induce tolerance to a foreign antigen.
View details for Web of Science ID A1996TT48400008
View details for PubMedID 8562959
Hematogones (HGs) comprise a B-lineage lymphoid precursor cell population in the bone marrow (BM) that may simulate acute lymphoblastic leukemia or lymphoma. Increased numbers of HGs have been noted in children, but few reports describe their occurrence in adults. We identified 13 adult patients with significant numbers of BM lymphoid cells with the morphologic and immunophenotypic features of HGs. Common features in these patients included (1) presence of small numbers of lymphoid cells in the BM aspirate with morphologic features of HGs; (2) absence of cytologic atypia or abnormal localization of lymphoid cells in the BM biopsy; (3) absence of abnormal morphology or CD10 (common acute lymphoblastic leukemia antigen) expression in circulating lymphocytes; (4) normal BM karyotype; (5) persistence of cytopenia(s) without apparent cause, often for a prolonged period of time; and (6) no evidence of neoplastic marrow involvement, confirmed by clinical follow-up. Flow cytometry demonstrated surface expression of CD10, CD19, a lower percentage of CD20, minimal expression of CD22, and limited but polyclonal immunoglobulin light chain. Nine patients had received previous immunosuppressive therapy or BM transplantation or both, seven for hematolymphoid neoplasia. However, four patients with cytopenias of unknown etiology had no antecedent history of malignancy or marrow suppressive therapy. These findings demonstrate the clinical, morphologic, and immunophenotypic features of HGs in adults, and emphasize the difficulty in distinguishing these cells from residual marrow blasts after chemotherapy.
View details for Web of Science ID A1994PA50000014
View details for PubMedID 8042590
View details for PubMedID 10147368
Chronic lymphocytic leukemia (CLL) and hairy cell leukemia (HCL) are differentiated B-cell leukemias with well-described clinical, morphologic, and immunologic characteristics. We encountered two patients with indolent chronic B-cell leukemia showing overlapping features of these malignancies. The patients had progressive splenomegaly, minimal lymphadenopathy, and abnormal lymphoid cells with abundant cytoplasm and villi, which were strongly positive for surface antigens CD22 and CD11c, features associated with HCL. However, blood counts showed lymphocytosis without neutropenia and monocytopenia, and the bone marrow biopsies demonstrated tightly aggregated nodules of lymphocytes. In addition, the lymphoid cells were dual positive for CD19 and CD5, displaying weak-to-moderately positive monoclonal surface immunoglobulin, findings strongly suggestive of CLL. One patient failed to respond to therapy with chlorambucil and prednisone. The second patient showed a partial response to treatment with 2-chlorodeoxyadenosine. We compare our patients with similar variants of differentiated B-cell leukemias reported in the literature, including disorders described as hairy cell variant (HCL-V) or splenic lymphoma with villous lymphocytes (SLVL).
View details for Web of Science ID A1994PD00100004
View details for PubMedID 7527021
Questionnaires addressing laboratory practices in cerebrospinal fluid and body fluid (serous, synovial) microscopy were distributed to participants in the Clinical Microscopy Survey of the College of American Pathologists, Northfield, Ill, in 1985 and 1989. In both Surveys, cell enumeration was performed primarily by hemocytometry, while nearly all respondents used Wright-stained microscopy. There was little formal quality control to assess the accuracy of counts or differential cell count. Less than 55% of laboratories used the cytocentrifuge. About half of respondents performed a differential cell count on every sample. Slides with atypical or malignant cells were usually (> 85%) reviewed by physicians without automatic referral to the cytopathology section. Only about half of respondents examined every synovial fluid specimen with polarized microscopy for crystals. Other than a modest increase in use of the cytocentrifuge, the 1989 Survey showed little interval change in practices. In 1989, there was equal dependence on Wright's and Papanicolaou's stains for an infrequent diagnosis of malignancy. The low rate of positives may have related to the high prevalence of wedge smears, a suboptimal technique. The Hematology and Clinical Microscopy Resource Committee of the College of American Pathologists makes recommendations for optimal laboratory handling of body fluid specimens for microscopy.
View details for Web of Science ID A1994MR23800005
View details for PubMedID 8285829
Ciliocytophthoria are anucleate remnants of ciliated epithelial cells derived from the lower respiratory tract and female reproductive tract. We report a case of ciliocytophthoria found in the effluent dialysis fluid of a young woman undergoing long-term ambulatory peritoneal dialysis. Inability to identify these "organisms" initially led to an extensive search for parasitic contamination or infection of the peritoneum. After identifying these "organisms" as ciliocytophthoria, a prospective study showed that ciliated cell remnants occur frequently in the effluent dialysate of young women, but not in older women or men. With increasing use of peritoneal dialysis, laboratory personnel can expect to see ciliocytophthoria in peritoneal dialysate effluent and should recognize them as benign, normal findings in young women.
View details for Web of Science ID A1993KK44500023
View details for PubMedID 8427572
The authors evaluated the Coulter STKS (Coulter Corp., Hialeah, FL) five-part differential in a tertiary-care hospital using samples with a broad range of distributional and morphologic abnormalities. Particular attention was given to the performance of the instrument-generated suspect flags that occur as an aid to identify samples with abnormal leukocytes. A morphologically abnormal, or positive, blood smear was defined by the presence of any blasts, malignant lymphoid cells, grossly dysplastic neutrophils, nucleated red blood cells (nRBC), platelet clumps, or reactive lymphocytes of more than 5%. The presence of any white blood cell-related suspect flag, except for Immature Granulocyte/Bands (i.e., Blasts, Variant Lymph, NRBC, Platelet Clumps, Review Slide, or WBC*R), was considered to be a positive instrument result. The STKS showed excellent quantitative results for the WBC differential compared with the manual differential when these "morphologic abnormalities" were absent in a 400-cell manual differential or low in numbers (< or = 5%). Specificity of these non-immature granulocyte/band suspect flags was good, with a false-positive rate of only 11.7%. Overall sensitivity in 113 samples with morphologic abnormalities was 67.3%. Sensitivity to detection of > or = 1% abnormal WBCs or > or = 1 nRBC/100 WBCs (a subset of 78 samples) was 80.8%. Sensitivity to detection of more than 5% abnormal WBCs or more than 5 nRBC/100 WBCs (a subset of 53 samples) was 84.9%. The primary deficiency was the inability of the STKS to flag samples with lymphoma cells, lymphoid blasts, or more than 5% reactive lymphocytes.
View details for Web of Science ID A1993KG79100017
View details for PubMedID 8422021
The CELL-DYN 3000 (Unipath Corp., Mountain View, CA) differential was evaluated in a tertiary care hospital using samples with a broad range of distributional and morphologic abnormalities. Particular attention was directed to the performance of the instrument-generated suspect flags that occur as an aid to identify samples with abnormal leukocytes, as well as the estimates of abnormal cells that are made by the instrument. The CELL-DYN 3000 showed excellent quantitative results for the white blood cell differential compared with a 400-cell manual differential, in which morphologic abnormalities were absent or occurred in low numbers (< or = 5%). Specificity of the BLAST, VARIANT LYMPH, NRBC, WBC, or DIFF suspect flags (with the requirement that the blast estimate and variant lymphocyte estimate by the instrument be > or = 1%) was 82.6%. Sensitivity of these flags to detection of more than 5% "abnormal" leukocytes (blasts, malignant lymphoid cells, grossly dysplastic neutrophils, nucleated red blood cells, or reactive lymphocytes) or significant platelet clumping was 81.6%. The primary deficiency was the inability of the CELL-DYN 3000 to flag samples with small numbers (< or = 5%) of nucleated erythrocytes, lymphoid blasts, or hairy cells, or more than 5% reactive lymphocytes. Specificity of the IG flag (with immature granulocyte estimate > or = 3%) for immature granulocytes (metamyelocytes, myelocytes, or promyelocytes) was 94.9%. Sensitivity of the immature granulocyte flag varied from 41.7% for identifying IG > or = 1% to 100% for the three samples with immature granulocytes > or = 3%. Calculation of sensitivity and specificity to varying percentages of bands showed poor flagging performance, with many false-positive and false-negative results at all levels.
View details for Web of Science ID A1992KB87700012
View details for PubMedID 1462958
The multidrug resistance gene mdr1, encoding P-glycoprotein (P-gp), can be expressed at high levels in tumour cells derived from normal tissues with constitutive high expression of this gene. In myelogenous leukaemia, the incidence of increased expression of mdr1 gene contrasts with the low expression of this gene in normal bone marrow (b.m.). To detect cells expressing mdr1 gene in normal and post-chemotherapy b.m., we used in situ RNA hybridization and RNA phenotyping by the polymerase chain reaction for mdr1 mRNA detection. The presence of P-gp was evaluated by immunocytochemistry with MRK16. Fifteen b.m. (eight normal and seven post chemotherapy) were tested by in situ hybridization and either PCR (three b.m.) or immunocytochemistry (11 b.m.) or both (one b.m.). With in situ mRNA hybridization, a subset (7.7% +/- 3.1%) of b.m. cells expressed mdr1 mRNA in all cases tested, with no significant differences between normal b.m. and post chemotherapy b.m. 18% of myeloid recognizable cells and 7% of the cells with lymphoid morphology expressed mdr1 mRNA. By RNA phenotyping, the four samples tested for in situ hybridization and two additional post chemotherapy b.m. expressed mdr1. MRK16 was unable to detect a significant number of cells expressing P-gp either by immunocytochemistry in the 12 b.m. tested for in situ hybridization (0% in nine cases; 0.4%, 1% and 3% of positive cells in three cases), or by flow cytometry in six additional normal b.m. (0-1.4% positive cells).
View details for Web of Science ID A1992HY85200002
View details for PubMedID 1353683
The authors evaluated the Coulter S-Plus three-part differential and compared it with the total of component cells obtained by manual slide differential. The patient population (N = 989) was strikingly abnormal, in that 109 samples contained nucleated red blood cells, 118 samples contained one or more abnormal cells (blasts, promyelocytes, or lymphoma cells), and 95 samples had greater than 10% monocytes. The GRAN and LYMPH fractions were accurately measured in the specimens that did not display region (R) flags. The MONO fraction correlated poorly with the manual differential and underestimated monocytes when they were increased. Not all samples with small numbers of abnormal cells or nucleated red blood cells were flagged by the three-part differential. Specimens with eosinophilia and reactive lymphocytosis likewise did not always show R-flags. The following findings (prevalence = 23.9%) were arbitrarily defined to constitute an "abnormal" manual differential: nrbc greater than 0%, blasts greater than 0%, promyel greater than 0%, lymphoma cells greater than 0%, baso greater than 5%, myel greater than 5%, meta greater than 5%, eos greater than 10%, reactive lymphs greater than 10%. Sensitivity of R-flagging for these abnormalities was 81.7% and specificity 73.3%. The predictive value of an R-flagged ("positive") result was 48.3% and of an unflagged ("negative") result, 93.0%. Efficiency (accuracy) was calculated to be 75.5%.
View details for Web of Science ID A1985AUC1100008
View details for PubMedID 4061385
Red cell distribution width (RDW) on the Coulter S-Plus has many limitations. Normal values (mean +/- 2 SD) were found to be sex dependent: 10.7 +/- 2.4 for males, and 9.8 +/- 1.8 for females. These ranges are broader than the normal range of 10.0 +/- 1.5 given by Coulter. When these broader ranges were applied, none of 29 patients with iron deficiency anemia showed an elevated RDW. Furthermore, a decrease in RDW with room temperature storage was observed and may contribute to erroneous results. The Coulter S-Plus RDW may not be as useful in quantitating anisocytosis as other methods of measuring the dispersion of the red cell volume histogram.
View details for Web of Science ID A1983RV75400004
View details for PubMedID 6670664