ICCS e- Newsletter CSI ICCS e- Newsletter CSI Summer 2013Summer 2013

Bioq. Mariela B Monreal Dra. Marina Narbaitz Dra. Cecilia Cabral

Division of HematopathologyFUNDALEU - Buenos Aires - ARGENTINA

Clinical History - Presentation Clinical History - Presentation

Previously healthy 63 y/o female, presenting with chills asthenia , constipation and weight loss of 14 kg (30 lbs) in one month.

Abdominal ultrasound & CT scan revealed multiple retroperitoneal and supraclavicular lymphadenopathies.

Complete blood count & Laboratory results Complete blood count & Laboratory results CBC parameter Result Units

Reference range

WBC 10,40 x109/L  4.6-10.2

RBC 3,20 x1012/L  4.0-5.48HGB 8,90 g/dl  12.2-16.2HCT 27,00 %  37.7-47.9MCV 85,00 fl  80-97MCH 28,00 pg  27-31MCHC 32,80 gm/dl 31.8-35.4RDW 13,50 % 11-14PLT 309,00 142-424

WBC differential %Neutrophils 89 50-68Lymphocytes 7 21-30Monocytes 4 4-8Eosinophils 0 2-4Others 0 0

ESR 70 mm 0-15LDH 667 UI/l 260-460

Work – up and EvaluationWork – up and EvaluationLymph node biopsy was submitted for morphology and flow cytometry, for initial evaluation.

Flow Cytometry analysis:

Selected files (8-color antibody tubes) are provided for review:Tubes #1 - 4 tested in Lymph node ; Tube BM : tested in Bone marrow aspirate

Data Acquisition : FACS CANTO II and DIVA softwareData Analysis: Infinicyt (Cytognos)

FITC PE PerCP-Cy5 PE Cy7 APC APC H7 V 450 V500

Tube #1 LAMBDA KAPPA CD5 CD19 CD38 CD10 CD20 CD45

Tube #2 CD23 CD7 CD5 CD123 CD2 CD3 HLA DR CD45

Tube #3 CD4 CD13 CD5 CD123 CD33 CD3 HLA DR CD45

Tube #4 CD36 CD64 CD34 CD117 IREM CD14 HLA DR CD45

Tube BM CD4 CD7 CD5 CD56 CD2 CD8 CD3 CD45

FITC PE PerCP-Cy5 PE Cy7 APC APC H7 V 450 V500

LAMBDA KAPPA CD5 CD19 CD38 CD10 CD20 CD45

Tube #1 : B cell markers

In this first tube , an abnormal population of LARGE CELLS (in grey) is identified . Cells are NEGATIVE for all B cell markers tested; and also for CD5 and CD10. Very bright CD45 intensity and dim/neg CD38 exclude plasmacytic differentiation.

FITC PE PerCP-Cy5 PE Cy7 APC APC H7 V 450 V500

Tube #2 CD23 CD7 CD5 CD123 CD2 CD3 HLA DR CD45

Tube #2 : T cell markers / Lymphoplasmacytoid DC

ABNORMAL POPULATION is shown here in RED

br HLA DR++ and dim/interm CD123+CD7, CD2 and CD3 are NEGATIVE

LYMPHOPLASMACYTOID DENDRITIC CELLS (DC2) are CD123++ HLA DR++

1

Tube #3 : Myeloid markers & CD4 CD56 HLA DR

FITC PE PerCP-Cy5 PE Cy7 APC APC H7 V 450 V500

Tube #3 CD4 CD13 CD5 CD123 CD33 CD3 HLA DR CD45

ABNORMAL CELLS are br HLA DR+++ and br CD33+++ br CD4++ and dim CD13+ CD56 NEGATIVE (additional tube)

MONOCYTES are distinguished from large abnormal cells, showing normal FSC/ SSC features ; br CD13++ and dim CD4 expression

FITC PE PerCP-Cy5 PE Cy7 APC APC H7 V 450 V500

Tube #4 CD36 CD64 CD34 CD117 IREM CD14 HLA DR CD45

e CSI Tube #4 : Monocytic maturation. Immature markers

Bright CD64+ expression allows the identification of MONOCYTIC LINEAGE.In this case, mature monocytes:CD36++ CD14++ and IREM-2 ++.

ABNORMAL CELLS are:CD64dim+ CD14neg/dim+ CD36neg/dim+Additional tube demonstrates that MPO is NEGATIVE

Abnormal cells : CD45++ CD33++ HLA DR++ CD123+ CD4++ ,dimCD64+ ,dim/variable CD14+ , dim/variable CD36+ , IREM neg/dim+ MPOneg CD15neg CD56neg Lymph node (and BM , see below plots on the right) infiltrated by large / pathological cells , with phenotypic features that suggests monocytic / monocytic-related dendritic cell subset.

LYMPH NODE BM ASPIRATE

Summary - Immunophenotypic findings (FCM) Summary - Immunophenotypic findings (FCM)

LYMPH NODE

Lymph node biopsy demonstrates a diffuse proliferation of pleomorphic large cells. The nuclei are irregular, often folded, with occassional nucleoli. The cytoplasm is abundant and eosinophilic.

Reactive eosinophils were observed in the background.

Immunophenotype Immunophenotype

CD45 + MPO -

CD68 +

(KP-1 Clone, stains also

myeloid cells)

CD68 +

(PGM-1 Clone)

VIMENTIN +

(Intermediate filament protein

present in cells of mesenchymal

origin)

KI67 - 75%

(high proliferation

index)

CD163 +

CD43 +

(Sialoglycoprotein on the surface of

monocytes)

Histiocytic markers

Unspecific staining

BONE MARROW

Bone marrow core biopsy demonstrates marrow infiltration by neoplastic cells with similiar features as observed in lymph node.

CD45 + CD43 +

MPO -CD163 +

Preliminary DiagnosisPreliminary Diagnosis

LYMPH NODE & BONE MARROW involvement :

Hematologic malignancy with expression of Mono/Histiocytic markers.

Given this immunophenotypic profile….Given this immunophenotypic profile….Lineage Assignment possibilitiesLineage Assignment possibilities

Immunohistochemistry

CD45 + CD43 + CD68 + CD163 +

MPO - CD34 - CD20 - CD3 -

Immunohistochemistry

CD45 + CD43 + CD68 + CD163 +

MPO - CD34 - CD20 - CD3 -

Flow cytometry:

HLA DR+++, CD33+++,CD123+,CD4+,CD64+w, CD14+w.

NG2 -, T y B -, CD13 -, CD1a -, MPO – CD56 --

Flow cytometry:

HLA DR+++, CD33+++,CD123+,CD4+,CD64+w, CD14+w.

NG2 -, T y B -, CD13 -, CD1a -, MPO – CD56 --

MYELOID STEM CELL

MYELOID STEM CELL

PLASMOCYTOID DENDRITIC CELL (DC2)

INTERSTITIAL DC

LANGHERHANS DC

MACROPHAGE

MYELOID DENDRITIC CELL (DC1)

CD14-CD11c+CD1a+CLA+

MonocyteCD14+CD11c+CD68+CD1a-CLA-

CD4+CD56+CD123+CD13+CD33+CD14+CD15+MPO+/-LISOZIMA+BDCA3+

CD14+CD11c+CD1a-BDCA2+CD123+BDCA4+

Differential DiagnosisDifferential Diagnosis• HISTIOCYTIC SARCOMA.- Must express two or more monocyte/macrophage lineage antibodies (CD14, CD11c, CD13, CD68,

CD163).- CD4 (cytoplasmic), CD15, CD43, CD45, CD45RO, CD33, lysozyme +/-- WHO 2008 definition: Express monocyte/macrophage markers. Myeloid lineage antibodies (CD33,

CD13) MUST BE NEGATIVE.

• AML WITH MONOCYTIC DIFFERENTIATION/ MYELOID SARCOMA.- > = 20% myeloid blasts, with less than 20% of cells with monocytic differentiation.

AML M4; M5. - M4: The PB or BM has more than 20% blast (including promonocytes), neutrophils and their

precursors and monocytes and their precursors.- M5: Myeloid leukaemia in which 80% or more of the leukaemic cells are monocytic lineage including

monoblast, promonocytes and monocytes; a minor neutrophil component, <20%, may be present.

• PLASMACYTOID DENDRITIC CELL NEOPLASM/ BLASTIC NK-CELL LYMPHOMAHEMATODERMIC NEOPLASM.

- Expression of CD4, CD56 and CD123 antigens with concomitant negativity for other myeloid and lymphoid associated markers.

• ACUTE MYELOID DENDRITIC CELL LEUKAEMIA.- Expression of CD4, CD56 and CD123 antigens with concomitant positivity for myeloid markers

(CD13,CD33, CD64, 7.1, IREM).

ACUTE MYELOID DENDRITIC CELL LEUKAEMIAACUTE MYELOID DENDRITIC CELL LEUKAEMIA

• Acute dendritic cell leukemias are very uncommon and have a lymphoplasmacytoid dendritic cell (DC2) phenotype more often than a myeloid dendritic cell phenotype (DC1).

• Myeloid dendritic cell leukaemia is exceptional, and it would differentiate from plasmacytoid dendritic cell leukaemia by the expression, as well as of CD4, CD56 and CD123, of some myeloid makers [CD13, CD14, CD15, CD33, myeloperoxidase (MPO), lysozyme] and specific myeloid dendritic cell antigens (BDCA3) instead of plasmacytoid dendritic cell antigens (BDCA2, BDCA4).

• Spontaneously occurring acute myeloid dendritic cell leukemia is very infrequent. It has been estimated, based on the study of 392 cases of AML, that 0.8% of cases had overt features of a dendritic cell malignancy.

• Anemia, thrombocytopenia, and blood, marrow, and skin involvement with dendritic-like blast and more mature appearing dendritic cells are characteristic findings. Lymph node and spleen enlargement from leukemic cell infiltration usually is present.

• Blast cells do not display myeloperoxidase or esterases by cytochemistry.

• The main differential diagnosis of acute myeloid dendritic cell leukaemia is acute myeloid leukaemia (AML). In fact, some authors consider myeloid dendritic cell leukaemia as a morphological variant of AML. AML blast cells frequently express the dendritic cell-associated marker CD86, especially among acute monocytic leukaemia cells. Dendritic cell features can be found in AML cells after chemotherapy. In addition, using cytokines and CD40 ligands, a dendritic cell phenotype strikingly similar to the blast cells of myeloid dendritic cell leukaemia can be induced from AML blast cells.

ACUTE MYELOID DENDRITIC CELL LEUKAEMIAACUTE MYELOID DENDRITIC CELL LEUKAEMIA

ReferencesReferences

• Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: (IARC; 2008).

• Marshall A. Lichtmana, b, George B. Segelc Uncommon phenotypes of acute myelogenous leukemia: Basophilic, mast cell, eosinophilic, and myeloid dendritic cell subtypes: A review. Blood Cells Mol Dis.2005 Nov-Dec;35(3):370-83

• Martín-Martín L, Almeida J, Hernández-Campo PM, Sánchez ML, Lécrevisse Q, Orfao A Br J Dermatol Immunophenotypical, morphologic, and functional characterization of

maturation-associated plasmacytoid dendritic cell subsets in normal adult human bone marrow. Transfusion 2009 Aug;49(8):1692-1708

• M. Ferran, F. Gallardo, A.M. Ferrer,A. Salar, E. Perez-Vila,N. Juanpere, R. Salgado, B. Espinet, A. Orfao,–L. Florensaand R.M. Pujol Acute myeloid dendritic cell leukaemia with specific cutaneous involvement: a diagnostic challenge.  Br J Dermatol 2008 May;158(5):1129-33.

• Orfao A. Neoplasias of dentritic cells: are they the counterpart of one or more cell lineages? Lab Hematol 2004;10(3):171.

• Elizabeth L Courville, Yue Wu, Jihen Kourda, Christine G Roth, Jillian Brockmann, Alona Muzikansky, Amir T Fathi, Laurence de Leval, Attilio Orazi and Robert P Hasserjian Clinicopathologic analysis of acute myeloid leukemia arising from chronic myelomonocytic leukemia modern Pathology , (11 January 2013)

• Rollins-Raval MA, Roth CG. The value of immunohistochemistry for CD14, CD123, CD33, myeloperoxidase and CD68R in the diagnosis ofacute and chronic myelomonocytic leukaemias. Histopathology. 2012 May;60(6):933-42.