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CD5 positive follicular lymphoma: prognostic significance of this aberrant marker?
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PATHOLOGY 2013 ABSTRACT SUPPLEMENT
Aim: High dose therapy and autologous haematopoietic stem cell (AHSC) transplantation is an important treatment for many haematological malignancies. AHSCs can be harvested during remission or consolidation treatment for subsequent transplantation if required (‘rainy day’ collection). Although the practice is widespread, evidence base is minimal. We investigated the eventual transplantation of ‘rainy day’ collections, delay to transplantation and patient outcomes. Methods: This was a retrospective audit of practice between 1/1/2001 and 31/12/2010. ‘Rainy day’ harvest was defined as collection of AHSCs where transplantation was not anticipated in the next 6 months. Results: 532 collections were performed in 474 patients for haematological indications. 342 (71%) patients had rainy day AHSCs collected. Disease indications included non-Hodgkin lymphoma (NHL; n = 205, 60%), multiple myeloma (MM; 45, 13%), Hodgkin lymphoma (HL; 38, 11%), acute myeloid leukaemia (AML; 20, 6%), chronic myelogenous leukaemia (CML; 5, 1%), acute lymphoblastic leukaemia (ALL; 6, 2%), other myeloproliferative neoplasms (21, 6%), chronic lymphocytic leukaemia (CLL; 3, 1%). Overall transplantation rate was 14%. For MM collections 27% were transplanted, compared to 16% for HL and 14% for NHL. Only 5% of collections for AML were transplanted and there were no transplants for CML. The median delay to transplantation was 18 months (range 6.3–112); 81% of patients transplanted engrafted within specified limits. Of the 296 patients who had ‘rainy day’ AHSC collections that have not been transplanted, 255 (85%) are still alive Discussion: ‘Rainy day’ AHSC collection is resource intensive. We found high rates of eventual usage for certain indications (MM, HL) and low rates for others (AML, CML). Findings from this study may help to inform guidelines for ‘rainy day’ AHSC collection.
ETHNIC SPECIFICITY OF BETA-GLOBIN GENE MOLECULAR DEFECTS AMONG BETA-THALASSAEMIA MAJOR PATIENTS IN THE INDIGENOUS POPULATION OF SABAH Elizabeth George1, Lai Kuan Teh1, Mei I. Lai1, Mary Anne Tan Jin Ai2 1Haematology Unit, Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, and 2Department of Molecular Medicine, University of Malaya Medical Centre, Malaysia Beta-thalassaemia is the most common inherited disease in Malaysia with a carrier rate of 4.5%. The spectrum of β-globin mutations has been well documented in the major ethnic groups in West Malaysia. Sabah in East Malaysia has over 1000 cases of transfusion dependent β-thalassaemia major patients. The complete spectrum of β-thalassaemia mutations in Sabah is still unknown. This study was done to characterise these β-thalassaemia mutations incorporating PCR techniques. A total of 253 β-thalassaemia major patients were recruited in this study following institutional clearance and informed consent. Homozygosity of the Filipino β-thalassaemia deletion was found in 217 (85.8%) patients, comprising of 136 Kadazandusuns, 19 Rungus, 10 Murut, 9 Sungai, 4 Bajau, 2 Bisaya and 1 Kedayu. Compound heterozygosity of Filipino β-thalassaemia deletion was found in 24 (9.5%) patients. Mutations common in West Malaysia were found in 11 (4.34%) patients
Pathology (2013), 45(S1)
(6 Chinese, 2 Brunei, 1 Banjar, 1 Bajau and 1 Malay). This study indicates ethnicity is informative in assisting β-thalassaemia diagnosis in Sabah. The indigenous population in Sabah had a unique mutation, the Filipino deletion. This study provides a platform in developing a simple and accurate molecular diagnosis protocol for β-thalassaemia mutations identification in the indigenous population of Sabah. NON-INVASIVE PRENATAL DIAGNOSIS OF FETAL RhD BLOOD GROUP STATUS FOR D NEGATIVE PREGNANT WOMEN: NEW STRUCTURES FOR CLINICAL MANAGEMENT Catherine A. Hyland1, Glenda Millard1, H. O’Brien1, K. Gibbon2, Anne Tremellen2, Glenn Gardener2, Robert Flower1 1Australian Red Cross Blood Service, and 2Mater Health Services, Brisbane, Qld, Australia Aims: To report on the accuracy and clinical application of noninvasive prenatal diagnosis for fetal RHD genotyping. Methods: Blood samples (n = 788) were collected from n = 603 non-selected RhD negative pregnant women, gestation age 7–38 weeks (median age 19 weeks). Samples from n = 110 isoimmunised D negative pregnant women were referred from across Australia. Cell free fetal DNA was isolated and qPCR used to amplify fetal RHD sequences from exons 4,5 and 10. Test outcomes were measured against cord blood serology. Results: Among the 788 samples the predicted fetal RHD assignment was negative in 292 (37.1%), positive in 485 (61.5%) and inconclusive in 11 (1.4%). Cord blood RhD results for n = 758 showed a strong association between genotype and phenotype (p < 0.001; Fisher’s exact test). Positive predictive value was 99.4% (95%CI 98.6–100%). Negative predictive value was 100%. Among 110 isoimmunised pregnant women, the predicted fetal RHD assignment was negative in 26 (23.6%), positive in 78 and inconclusive in 6. Inconclusives arose from maternal RHD variants. Discussion: The maternal blood test is safe and accurate for assessing fetal RHD status. It has been used to guide clinical management of isoimmunised D negative pregnant women from across the country.
CD5 POSITIVE FOLLICULAR LYMPHOMA: PROGNOSTIC SIGNIFICANCE OF THIS ABERRANT MARKER? Eleni Mayson, Josobel Saverimuttu, Kimberley Cartwright Haematology Department, Wollongong Hospital, Wollongong, NSW, Australia Follicular lymphoma is a heterogeneous entity that includes tumours derived from germinal centre B cells, and is the most common of the clinically indolent non-Hodgkin lymphomas. The immunophenotypic pattern of follicular lymphoma classically demonstrates the B-cell markers CD19, CD20, CD22, surface immunoglobulin and CD10. The tumour cells are usually negative for CD5. Two cases of CD5 positive follicular lymphoma have been diagnosed in the last 6 months at Wollongong Hospital, which was demonstrated on immunophenotyping of involved bone marrow. This has not previously been described.
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
ABSTRACTS
Aim: To discuss the two cases of CD5 positive follicular lymphoma. Methods: Case histories, laboratory results and personal correspondence were used to summarise each case. Review of bone marrow biopsies showing involvement with follicular lymphoma was performed spanning the last 24 months at Wollongong Hospital. The flow cytometry results of each was studied for the presence of CD5 positivity, and compared to the result of CD5 positive immunohistochemistry on the trephine. Results: Two cases of 8 (25%) of follicular lymphomas with marrow involvement were found to be CD5 positive. Discussion: CD5 positive follicular lymphoma has not previously been described. The clinical and therapeutic significance of this remains uncertain, and more research into such cases would be helpful to establish whether the presence of this aberrant marker bears any prognostic significance for the patient. TWO FACED HLH: COMPARATIVE REVIEW OF TWO CASES OF ADULT HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS Eleni Mayson, Josobel Saverimuttu, Pauline Warburton Haematology Department, Wollongong Hospital, Wollongong, NSW, Australia Haemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal disease of children and adults. Cytokine dysfunction, uncontrolled accumulation of activated T-cells and histiocytes, and the inability to turn off the immune response lead to the clinical manifestations of extreme inflammation and end-organ damage. HLH is notoriously under-reported because of its ability to mimic many other common diseases. With improvements in molecular genetics and a better understanding of the pathogenesis of the disease, a set of diagnostic criteria can aid the clinician in recognising the disease early and instituting prompt management to prevent significant morbidity and mortality. Aim: To compare two cases of HLH presenting within 6 months at Wollongong Hospital in 2012, to highlight the differences between primary and secondary HLH and the complications which may arise from each. Method: Case histories, laboratory results and personal communication with diagnostic institutions were used to summarise the cases. A review of the current literature was performed to supplement the discussion. Results: Cases of primary and secondary HLH were compared in terms of clinical features and pathogenesis, as well as triggers and complications. Discussion: A review of the literature was performed to identify trends in current diagnostics including the advent of sophisticated genetic testing, to provide a schema for recommended diagnostic testing and to discuss therapeutic principles and emerging concepts. CASE STUDY: HAEMOGLOBIN ROTHSCHILD IN A CASE PRESENTING WITH CYANOSIS Nazeer A. Alli1, P. Wessels2, N. Rampersad1, B. Clark3, S. W. Thein3 1Department of Molecular Medicine & Haematology, School of Pathology, NHLS/Wits University, and 2Department of Haematol-
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ogy, Ampath Laboratories, South Africa; 3Department of Haematology, Cell Biology Division, Kings College Hospital, London, United Kingdom Introduction: Here we describe a case presenting with episodic cyanosis in the absence of any evidence of cardio-pulmonary disease. Case: The patient was a 27-year-old female who sought medical attention for a productive cough. On examination she was cyanosed but not in distress. Systematic examination, notably cardiorespiratory system, revealed no abnormalities. A positive family history of episodic cyanosis in one of the siblings, but not the parents, was obtained. Results: The full blood count, renal and liver functions were essentially normal. A normal haptoglobin level effectively excluded haemolysis. The oxygen saturation at the time of examination was 87%. An abnormal band was noted on Hb electrophoresis confirming the presence of an Hb variant. Gene sequencing revealed a cod 37 (Tryp>Arg) mutation in exon 2 of the beta-globin gene, identified as Hb Rothschild. Discussion: Tryptophan at β37 is recognised as an important α1β2 contact point of the haemoglobin molecule. Disruption of the β37 contact point favours a T-quaternary (low oxygen affinity) state of the haemoglobin tetramer. Premature oxygen off-loading decreases the percentage oxygen saturation and may lead to cyanosis. Causes of cyanosis include cardio-respiratory disease, methaemoglobinaemia, sulfhaemoglobinaemia and low oxygen affinity haemoglobin variants.
A CASE REPORT OF AN ETV6-ABL1 [t(6;9;12)] POSITIVE MYELOPROLIFERATIVE NEOPLASM Tennille Pelly, Yasmin Harvey, Ross Brookwell, Helen Wordsworth, Tee Beng Keng Department of Haematology, Sullivan Nicolaides Pathology, Qld, Australia Aim: To describe a rare case of morphologically typical chronic myeloid leukaemia which was BCR-ABL1 negative. It was ultimately found to have complex translocations involving chromosomes 6, 9 and 12 which resulted in an ETV6-ABL1 fusion gene. Method: Following the unexpected negative FISH and molecular results for the BCR-ABL1 fusion gene, further investigations were undertaken. These included conventional cytogenetic analysis, FISH and molecular testing. JAK2 V617F and translocations involving PDGFRA, PDGFRB, FGFR1 and DEK/ NUP214 were excluded. Results: The conventional karyotype revealed a complex rearrangement involving chromosomes 6, 9, and 12 in 27/30 cells. The remaining 3/30 cells were normal. Directed FISH demonstrated that the chromosomal rearrangement resulted in an ETV6-ABL1 gene fusion. Discussion: ETV6-ABL1 gene fusion has been described infrequently in the literature and has been associated with chronic myeloid leukaemia and other myeloproliferative neoplasms as well as in acute leukaemias. There are case reports suggesting that the disease is imatinib responsive and as such the patient has commenced treatment with a plan to monitor cytogenetics and ETV6-ABL1 PCR transcripts to assess response to therapy.
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
PATHOLOGY 2013 ABSTRACT SUPPLEMENT
Aim: High dose therapy and autologous haematopoietic stem cell (AHSC) transplantation is an important treatment for many haematological malignancies. AHSCs can be harvested during remission or consolidation treatment for subsequent transplantation if required (‘rainy day’ collection). Although the practice is widespread, evidence base is minimal. We investigated the eventual transplantation of ‘rainy day’ collections, delay to transplantation and patient outcomes. Methods: This was a retrospective audit of practice between 1/1/2001 and 31/12/2010. ‘Rainy day’ harvest was defined as collection of AHSCs where transplantation was not anticipated in the next 6 months. Results: 532 collections were performed in 474 patients for haematological indications. 342 (71%) patients had rainy day AHSCs collected. Disease indications included non-Hodgkin lymphoma (NHL; n = 205, 60%), multiple myeloma (MM; 45, 13%), Hodgkin lymphoma (HL; 38, 11%), acute myeloid leukaemia (AML; 20, 6%), chronic myelogenous leukaemia (CML; 5, 1%), acute lymphoblastic leukaemia (ALL; 6, 2%), other myeloproliferative neoplasms (21, 6%), chronic lymphocytic leukaemia (CLL; 3, 1%). Overall transplantation rate was 14%. For MM collections 27% were transplanted, compared to 16% for HL and 14% for NHL. Only 5% of collections for AML were transplanted and there were no transplants for CML. The median delay to transplantation was 18 months (range 6.3–112); 81% of patients transplanted engrafted within specified limits. Of the 296 patients who had ‘rainy day’ AHSC collections that have not been transplanted, 255 (85%) are still alive Discussion: ‘Rainy day’ AHSC collection is resource intensive. We found high rates of eventual usage for certain indications (MM, HL) and low rates for others (AML, CML). Findings from this study may help to inform guidelines for ‘rainy day’ AHSC collection.
ETHNIC SPECIFICITY OF BETA-GLOBIN GENE MOLECULAR DEFECTS AMONG BETA-THALASSAEMIA MAJOR PATIENTS IN THE INDIGENOUS POPULATION OF SABAH Elizabeth George1, Lai Kuan Teh1, Mei I. Lai1, Mary Anne Tan Jin Ai2 1Haematology Unit, Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, and 2Department of Molecular Medicine, University of Malaya Medical Centre, Malaysia Beta-thalassaemia is the most common inherited disease in Malaysia with a carrier rate of 4.5%. The spectrum of β-globin mutations has been well documented in the major ethnic groups in West Malaysia. Sabah in East Malaysia has over 1000 cases of transfusion dependent β-thalassaemia major patients. The complete spectrum of β-thalassaemia mutations in Sabah is still unknown. This study was done to characterise these β-thalassaemia mutations incorporating PCR techniques. A total of 253 β-thalassaemia major patients were recruited in this study following institutional clearance and informed consent. Homozygosity of the Filipino β-thalassaemia deletion was found in 217 (85.8%) patients, comprising of 136 Kadazandusuns, 19 Rungus, 10 Murut, 9 Sungai, 4 Bajau, 2 Bisaya and 1 Kedayu. Compound heterozygosity of Filipino β-thalassaemia deletion was found in 24 (9.5%) patients. Mutations common in West Malaysia were found in 11 (4.34%) patients
Pathology (2013), 45(S1)
(6 Chinese, 2 Brunei, 1 Banjar, 1 Bajau and 1 Malay). This study indicates ethnicity is informative in assisting β-thalassaemia diagnosis in Sabah. The indigenous population in Sabah had a unique mutation, the Filipino deletion. This study provides a platform in developing a simple and accurate molecular diagnosis protocol for β-thalassaemia mutations identification in the indigenous population of Sabah. NON-INVASIVE PRENATAL DIAGNOSIS OF FETAL RhD BLOOD GROUP STATUS FOR D NEGATIVE PREGNANT WOMEN: NEW STRUCTURES FOR CLINICAL MANAGEMENT Catherine A. Hyland1, Glenda Millard1, H. O’Brien1, K. Gibbon2, Anne Tremellen2, Glenn Gardener2, Robert Flower1 1Australian Red Cross Blood Service, and 2Mater Health Services, Brisbane, Qld, Australia Aims: To report on the accuracy and clinical application of noninvasive prenatal diagnosis for fetal RHD genotyping. Methods: Blood samples (n = 788) were collected from n = 603 non-selected RhD negative pregnant women, gestation age 7–38 weeks (median age 19 weeks). Samples from n = 110 isoimmunised D negative pregnant women were referred from across Australia. Cell free fetal DNA was isolated and qPCR used to amplify fetal RHD sequences from exons 4,5 and 10. Test outcomes were measured against cord blood serology. Results: Among the 788 samples the predicted fetal RHD assignment was negative in 292 (37.1%), positive in 485 (61.5%) and inconclusive in 11 (1.4%). Cord blood RhD results for n = 758 showed a strong association between genotype and phenotype (p < 0.001; Fisher’s exact test). Positive predictive value was 99.4% (95%CI 98.6–100%). Negative predictive value was 100%. Among 110 isoimmunised pregnant women, the predicted fetal RHD assignment was negative in 26 (23.6%), positive in 78 and inconclusive in 6. Inconclusives arose from maternal RHD variants. Discussion: The maternal blood test is safe and accurate for assessing fetal RHD status. It has been used to guide clinical management of isoimmunised D negative pregnant women from across the country.
CD5 POSITIVE FOLLICULAR LYMPHOMA: PROGNOSTIC SIGNIFICANCE OF THIS ABERRANT MARKER? Eleni Mayson, Josobel Saverimuttu, Kimberley Cartwright Haematology Department, Wollongong Hospital, Wollongong, NSW, Australia Follicular lymphoma is a heterogeneous entity that includes tumours derived from germinal centre B cells, and is the most common of the clinically indolent non-Hodgkin lymphomas. The immunophenotypic pattern of follicular lymphoma classically demonstrates the B-cell markers CD19, CD20, CD22, surface immunoglobulin and CD10. The tumour cells are usually negative for CD5. Two cases of CD5 positive follicular lymphoma have been diagnosed in the last 6 months at Wollongong Hospital, which was demonstrated on immunophenotyping of involved bone marrow. This has not previously been described.
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.
ABSTRACTS
Aim: To discuss the two cases of CD5 positive follicular lymphoma. Methods: Case histories, laboratory results and personal correspondence were used to summarise each case. Review of bone marrow biopsies showing involvement with follicular lymphoma was performed spanning the last 24 months at Wollongong Hospital. The flow cytometry results of each was studied for the presence of CD5 positivity, and compared to the result of CD5 positive immunohistochemistry on the trephine. Results: Two cases of 8 (25%) of follicular lymphomas with marrow involvement were found to be CD5 positive. Discussion: CD5 positive follicular lymphoma has not previously been described. The clinical and therapeutic significance of this remains uncertain, and more research into such cases would be helpful to establish whether the presence of this aberrant marker bears any prognostic significance for the patient. TWO FACED HLH: COMPARATIVE REVIEW OF TWO CASES OF ADULT HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS Eleni Mayson, Josobel Saverimuttu, Pauline Warburton Haematology Department, Wollongong Hospital, Wollongong, NSW, Australia Haemophagocytic lymphohistiocytosis (HLH) is a rare but potentially fatal disease of children and adults. Cytokine dysfunction, uncontrolled accumulation of activated T-cells and histiocytes, and the inability to turn off the immune response lead to the clinical manifestations of extreme inflammation and end-organ damage. HLH is notoriously under-reported because of its ability to mimic many other common diseases. With improvements in molecular genetics and a better understanding of the pathogenesis of the disease, a set of diagnostic criteria can aid the clinician in recognising the disease early and instituting prompt management to prevent significant morbidity and mortality. Aim: To compare two cases of HLH presenting within 6 months at Wollongong Hospital in 2012, to highlight the differences between primary and secondary HLH and the complications which may arise from each. Method: Case histories, laboratory results and personal communication with diagnostic institutions were used to summarise the cases. A review of the current literature was performed to supplement the discussion. Results: Cases of primary and secondary HLH were compared in terms of clinical features and pathogenesis, as well as triggers and complications. Discussion: A review of the literature was performed to identify trends in current diagnostics including the advent of sophisticated genetic testing, to provide a schema for recommended diagnostic testing and to discuss therapeutic principles and emerging concepts. CASE STUDY: HAEMOGLOBIN ROTHSCHILD IN A CASE PRESENTING WITH CYANOSIS Nazeer A. Alli1, P. Wessels2, N. Rampersad1, B. Clark3, S. W. Thein3 1Department of Molecular Medicine & Haematology, School of Pathology, NHLS/Wits University, and 2Department of Haematol-
S95
ogy, Ampath Laboratories, South Africa; 3Department of Haematology, Cell Biology Division, Kings College Hospital, London, United Kingdom Introduction: Here we describe a case presenting with episodic cyanosis in the absence of any evidence of cardio-pulmonary disease. Case: The patient was a 27-year-old female who sought medical attention for a productive cough. On examination she was cyanosed but not in distress. Systematic examination, notably cardiorespiratory system, revealed no abnormalities. A positive family history of episodic cyanosis in one of the siblings, but not the parents, was obtained. Results: The full blood count, renal and liver functions were essentially normal. A normal haptoglobin level effectively excluded haemolysis. The oxygen saturation at the time of examination was 87%. An abnormal band was noted on Hb electrophoresis confirming the presence of an Hb variant. Gene sequencing revealed a cod 37 (Tryp>Arg) mutation in exon 2 of the beta-globin gene, identified as Hb Rothschild. Discussion: Tryptophan at β37 is recognised as an important α1β2 contact point of the haemoglobin molecule. Disruption of the β37 contact point favours a T-quaternary (low oxygen affinity) state of the haemoglobin tetramer. Premature oxygen off-loading decreases the percentage oxygen saturation and may lead to cyanosis. Causes of cyanosis include cardio-respiratory disease, methaemoglobinaemia, sulfhaemoglobinaemia and low oxygen affinity haemoglobin variants.
A CASE REPORT OF AN ETV6-ABL1 [t(6;9;12)] POSITIVE MYELOPROLIFERATIVE NEOPLASM Tennille Pelly, Yasmin Harvey, Ross Brookwell, Helen Wordsworth, Tee Beng Keng Department of Haematology, Sullivan Nicolaides Pathology, Qld, Australia Aim: To describe a rare case of morphologically typical chronic myeloid leukaemia which was BCR-ABL1 negative. It was ultimately found to have complex translocations involving chromosomes 6, 9 and 12 which resulted in an ETV6-ABL1 fusion gene. Method: Following the unexpected negative FISH and molecular results for the BCR-ABL1 fusion gene, further investigations were undertaken. These included conventional cytogenetic analysis, FISH and molecular testing. JAK2 V617F and translocations involving PDGFRA, PDGFRB, FGFR1 and DEK/ NUP214 were excluded. Results: The conventional karyotype revealed a complex rearrangement involving chromosomes 6, 9, and 12 in 27/30 cells. The remaining 3/30 cells were normal. Directed FISH demonstrated that the chromosomal rearrangement resulted in an ETV6-ABL1 gene fusion. Discussion: ETV6-ABL1 gene fusion has been described infrequently in the literature and has been associated with chronic myeloid leukaemia and other myeloproliferative neoplasms as well as in acute leukaemias. There are case reports suggesting that the disease is imatinib responsive and as such the patient has commenced treatment with a plan to monitor cytogenetics and ETV6-ABL1 PCR transcripts to assess response to therapy.
Copyright © Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.