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Case 6 - Discussion

Hematopathology Case

 

MICROSCOPIC EXAM:
 

PERIPHERAL BLOOD        

Severe neutropenia is present. Numerous blasts are seen and are medium size to large in size. The blasts have mildly condensed to fine chromatin, prominent nucleoli, increased N/C ratio, and mild amount of basophilic cytoplasm. Mild normocytic normochromic anemia is noted with mild anisopoikilocytosis and polychromasia. Few tear-drop cells and target cells are seen. Mild thrombocytopenia with unremarkable platelet morphology is noted. 

     

BONE MARROW CORE BIOPSY AND CLOT SECTION:

The overall cellularity is 95% and the cellularity ranges from 90 to 100%. Sheets of blasts comprising 90% of overall cellularity are noted. The blasts are positive for CD79a and TdT, but negative for MPO, CD3 and CD20.     

     

BONE MARROW ASPIRATE SMEAR AND TOUCH IMPRINTS:

Numerous blasts are seen, comprising about 90% of the overall cellularity. The blasts have similar features to those described in the peripheral blood. 

     

DIFFERENTIAL:

       Blasts: 90%, Promyelocytes: 1%, Myelocytes: 1%, 

       Metamyelocytes: 2%, Bands: 2%, Neutrophils: 1%, 

       Eosinophils: 1%, Lymphocytes: 1%, Plasma cells: 1%.

FLOW CYTOMETRY INTERPRETATION
 

The blasts express CD34, TdT, CD79, CD13, CD19, CD10, CD38, and HLA-DR.

                                            

     Total events       H gate Dim CD45+          A gate Bright CD45+

     analyzed = 51524   events = 44325 (89% of    events=1571 (3% of

                        totalnucleated cells)     total nucleated cells)

 

        CD45+/CD14-          98%                       98%

        TOTAL CD14+          <2%

        TOTAL CD13+          73%

        CD34+/CD13+          73%

        TOTAL CD15+          <2%

        CD34+/CD15+          <2%

        TOTAL CD33+          5%

        CD34+/CD33+          5%

        TOTAL CD34+          99%

        TOTAL CD11b+         17%

        TOTAL CD41+          <2%

        CD34+/CD71+          51%

        CD34+/CD117+         12%

        TOTAL HLA DR+        99%

        CD34+/HLA DR+        99%

        TOTAL CD19+          95%                      30%

        CD19+/CD20+          <2%                      29%

        CD19+/CD38+          96%                      28%

        CD19+/CD10+          87%                       3%

        CD2+/CD7+            <2%                      59%

        CD3+/CD5+            <2%                      62%

        CD3+/CD4+            <2%                      33%

        CD3+/CD8+            <2%                      29%

        CD3-/CD56+           <2%                       6%

        cCD3+                <2%

        cCD79a+              80%

        cMPO+                <2%

        nTdT+                90%

 

Cytogenetic and FISH studies:

 

Cytogenetic results: 48,XY,t(9;22)(q34;q11.2),+21,+der(22)t(9;22)

INTERPRETATION: Cytogenetic analysis revealed the presence of an abnormal hyperdiploid clone characterized by t(9;22)(q34;q11.2), an extra copy of the Philadelphia chromosome, and trisomy 21.

 

FISH results: Positive for variant BAR/ABL fusion in 98% of cells.

INTERPRETATION: ABNORMAL. Molecular cytogenetic studies revealed the presence of the molecular rearrangement associated with the Philadelphia chromosome in 98% of the interphase nuclei from this specimen. Specifically, this patient's signal pattern was characterized by a deletion of 9q34 and 22q11 along with an extra copy of the Philadelphia chromosome. These deletions cannot be visualized cytogenetically.

Paraffin immunohistochemical staining:

 
CD20 CD3
CD79a MPO
 
TdT  

Diagnosis:

  B-cell acute lymphoblastic leukemia, transformed from CML