Transcript ICCS e_Newsletter CSI Spring 2014

ICCS e_Newsletter CSI
Spring 2014
Suzanne Vercauteren MD, PhD, FRCPC
Division of Hematopathology
BC Children’s Hospital, Vancouver
University of British Columbia
e-CSI - Clinical History
• 4 year old boy with a 4 week history of unexplained fevers,
massive hepatosplenomegaly, diffuse lymphadenopathy and
bicytopenia
•
Differential Diagnosis:
– Infection
– Lymphoma
– Primary/Secondary Hemophagocytic lympho-histiocytosis
(HLH)
e-CSI – Peripheral Blood
CBC
Reference Range
WBC: 14.4 x 109/L
(5.3 - 16.0 x 109/L)
RBC: 3.51 x 1012/L
(3.90 - 5.30 x 1012/L)
Hgb: 89 g/dL
(105 – 135 g/dL)
MCV: 76.9 fl
(75.0 – 87.0 fl)
RDW-CV: 0.149
(0.117 – 0.157)
Plts: 46 x 109/L
(200 – 490 x 109/L)
Differential Count
Reference Range
Neutrophils: 10.46 x 109/L
(1.50 – 8.50 x 109/L)
Lymphocytes: 3.29 x 109/L
(2.00 – 8.00 x 109/L)
Monocytes: 0.61 x 109/L
(0.00 – 0.90 x 109/L)
Eosinophils: 0.02 x 109/L
(0.00 – 0.50 x 109/L)
Basophils: 0.02 x 109/L
(0.00 – 0.20 x 109/L)
e-CSI – Biochemistry
Parameter
Value
Normal range
ALT
1.0
10 - 25 U/L
AST
340
10 - 25 U/L
G GT
127
10 - 25 U/L
LDH
1227
470 - 900 U/L
Ferritin
1190
9 – 30 ug/L
e-CSI –Work-Up
• Bone Marrow:
–
–
–
–
Normocellular marrow with trilineage hematopoiesis
Mild hemophagocytosis
Loose granulomas
CD20, CD3, CD4 and CD8 immunohistochemistry non
contributory
– Lymphoma screen panel ( see slide 18) by flow cytometry
→ normal
• Extensive infectious work up including TB as per
patients recent travel to Cambodia
e-CSI –Work-Up
• Work up for HLH:
–
–
–
–
–
–
–
–
Fever present
Splenomegaly present
Cytopenias present
Ferritin ↑ ↑
Triglycerides ↑ ↑
Soluble IL-2 receptor ↑ ↑
NK cell function → normal
Mild hemophagocytosis in BM
→ Criteria for HLH met (at least 5/8)
e-CSI –Work-Up
• Infectious work up continued:
– Tuberculosis work up as granulomas seen in BM →
pertinently negative
– EBV and all other viruses → negative
• Work up for primary immune deficiency → Flow
cytometric immunophenotyping on peripheral blood
e-CSI – Flowcytometric Studies
• Acquisition: Beckman Coulter Navios flow cytometer
• Data analysis: Beckman Coulter Kaluza (software
version 1.2)
• T+B cell panel on peripheral blood:
FITC
PC5
RD1
ECD
Tube 1
CD45
CD3
CD56
CD19
Tube 2
CD45
CD3
CD4
CD8
e-CSI – Flowcytometric Studies
Tube 1
e-CSI – Flowcytometric Studies
Tube 2
This is strange!!!!
(Repeat specimen showed same results)
Aberrant CD3 dim-neg/CD4+/CD8+
population
e-CSI – Differential Diagnosis
• Differential Diagnosis of aberrant T cell
immunophenotype in this child:
• Hemophagocytic Lymphohistiocytosis (aberrant
immunophenotype of CD8+ T cell (described)
• Pediatric T cell Lymphoma:
• T cell lymphoblastic Lymphoma
• Anaplastic Large Cell Lymphoma
• EBV positive T cell lymphoproliferative disorders of childhood
e-CSI – Flowcytometric Studies
• Lymphoma panel on peripheral blood:
PC5
PE
FITC
ECD
PC7
Tube 1
IgG1
IgG1
IgG1
IgG1
IgG1
Tube 2
CD45
CD4
CD8
CD20
CD34
Tube 3
CD45
CD30
CD25
CD3
CD5
Tube 4
IgG1
Cont PE
Cont FITC
IgG1
IgG1
Tube 5
CD45
Lambda
Kappa
CD10
CD19
Tube 6
IgG1
cIgG1
cIgG1
IgG1
IgG1
Tube 7
CD45
cCD79a
cTdT
CD3
CD19
cIgG1 = cytoplasmic IgG1
e-CSI – Flowcytometric Studies
e-CSI – Flowcytometric Studies
Tube 2
CD4+/CD8+
Tube 3
? some CD30, no CD25
? Normal T cells
e-CSI – Flowcytometric Studies
Tube 5
Tube 7
no TdT
No B or T cells
? aberrant population
e-CSI –Work-Up
• Blood specimen send for T and B cell clonality studies
by PCR → CLONAL T cell population
• Lymph node biopsy suggested but surgeons wary
about low platelet count (<20 x 109/L at this time)
e-CSI – Flowcytometric Studies
• Lymphoma screen panel on cells from supraclavicular
cervical lymph node biopsy:
PC5
PE
FITC
ECD
PC7
Tube 1
CD45
IgG1
IgG1
IgG1
IgG1
Tube 2
CD45
CD4
CD8
CD20
CD2
Tube 3
CD45
Lambda
Kappa
CD10
CD19
Tube 4
IgG1
cIgG1
cIgG1
IgG1
IgG1
Tube 5
CD45
cCD79a
cTdT
CD3
CD19
e-CSI – Flowcytometric Studies
Lymph Node
CD4+/CD8+
Bright CD2+
e-CSI – Flowcytometric Studies
Lymph Node
Dim CD3+
e-CSI – Lymph Node Results
• Sinus extended by large cells with convoluted nuclei
• Immunohistochemistry stains:
–
–
–
–
CD30 positive
ALK positive
CD3, CD4, CD8, CD68, CD1a and S100 negative
Brisk mitotic activity
• FISH shows NPM-ALK translocation
e-CSI – Case Conclusions
• Aberrant T cell population detected in blood and lymph node
but not bone marrow of this patient suggestive of mature T
cell lymphoproliferative disorder
• CD3 expression on aberrant population in lymph node
brighter compared to blood
• Immunohistochemistry studies differ from flow cytometry
studies in that the aberrant cells are CD4 and CD8 negative by
immunohistochemistry and CD30 positive in contrast to flow
cytometry studies
• Circulating cells of this case of Anaplastic Large Cell
Lymphoma were negative for CD30 and CD25 by flow
cytometry (unfortunately these markers were not run on the
lymph node)
e-CSI – Pediatric T cell lymphomas
• T cell lymphoblastic Lymphoma:
• 15% of childhood ALL
• BM always involved
• CD3+, CD2+, CD5+, CD7+, CD4 and CD8 often coexpressed
• BUT BONE MARROW NEGATIVE AND NO PERIPHERAL
BLASTS SEEEN
• EBV positive T cell lymphoproliferative disorders
of childhood:
• Mostly in Asia
• Sites of involvement: Liver, Spleen, LN, Bone marrow
• CD2+, CD3+, CD8+ (some CD4 and CD8 positive cases reported)
• BUT EBV serology NEGATIVE
e-CSI – Pediatric T cell lymphomas
• Anaplastic Large Cell Lymphoma
•
•
•
•
•
10-20% of childhood lymphomas
Often advanced disease with B symptoms
ALK+ in all pediatric cases
CD3 often negative
CD2, CD5 and CD4 often positive
BUT almost always CD8 negative
e-CSI – Pediatric ALCL
• Anaplastic Large Cell Lymphoma (ALCL) most common mature
T-cell neoplasm in children and adolescents.
• approximately 15% of all non-Hodgkin lymphomas (NHL) in
children and adolescents
• commonly present with advanced systemic disease
• nearly universally anaplastic large cell lymphoma kinase (ALK)
positive
• event free survival (EFS) rates of 65-75%
e-CSI – Flow Cytometric Findings in
ALCL
• 15 cases of pediatric ALCL
• High forward and side scatter (monocyte or granulocyte
region)
• Frequently expressed antigens: CD4 (85%), CD2 (77%), CD7
(62%), CD3 (54%) and CD5 (38%)
• CD3 often dimly expressed
• No CD8 expression!!!!!!
McCall CM et al. Am J Clin Pathol. 2012 May;137(5):786-94
e-CSI – Hemophagocytic
LymphoHistiocytosis
•
•
•
•
HLH is a hyperinflammatory syndrome
Impaired cytotoxic T cells and NK cells
Rare
Primary (familial, inherited) and secondary (infection,
hematological malignancy, rheumatological diseases)
• Often fatal
• Aberrant immunophenotype of T cells reported
e-CSI – Flow Cytometric Findings in
HLH
McCall CM et al. Am J Clin Pathol. 2012 May;137(5):786-94
e-CSI – Flow Cytometric Findings in
HLH
• 13/15 patients (87%) expressed activation marker HLA-DR on
cytotoxic T cells
• 6/9 (67%)EBV associated HLH had aberrant expansion of CD8+
T cells with variable loss of CD3, CD5 and CD7
• 5/8 (63%) of non EBV associated HLH had expansion of CD8+ T
cells but only one (familial HLH) had aberrant loss of markers
CD3 or CD5 or CD7
→ Care must be taken with diagnosing T cell
lymphomas based on aberrant CD8+ T cells in the
setting of HLH
e-CSI – Conclusions
• Aberrant CD8+ T cells are a common finding in
HLH
Therefore
• HLH can mask an underlying CD8+ T cell
lymphoma
• Although rare, CD8 expression can be seen on
ALCL
References
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•
•
Pediatr Blood Cancer. 2013 Nov;60(11):1916-7. doi: 10.1002/pbc.24638. Epub 2013 Jul 19. Pediatric
subcutaneous panniculitis-like T-cell lymphoma with features of hemophagocytic syndrome.Merritt BY1,
Curry JL, Duvic M, Vega F, Sheehan AM, Curry CV.
Pediatr Hematol Oncol. 2013 Sep;30(6):509-19. doi: 10.3109/08880018.2013.805347. Epub 2013 Jun 12.
Anaplastic large cell lymphoma in children and adolescents. Lowe EJ1, Gross TG.
Am J Clin Pathol. 2012 May;137(5):786-94. Flow cytometric findings in hemophagocytic
lymphohistiocytosis.McCall CM1, Mudali S, Arceci RJ, Small D, Fuller S, Gocke CD, Vuica-Ross M, Burns KH,
Borowitz MJ, Duffield AS.