ADx Bone Marrow Report. Patient Information Referring Physician Specimen Information

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1 ADx Bone Marrow Report Patient Information Referring Physician Specimen Information Procedure: Reported: 01/14/2015 (203.00) Multiple myeloma; anemia, multiple lytic lesions; diagnosis of multiple myeloma on left pelvic biopsy (The Medical Center of Southeast Texas, S , 12/9/2014) - PLASMA CELL NEOPLASM, 25% CLONAL PLASMA CELLS IN NORMOCELLULAR MARROW Comments: Flow cytometry detected 2% kappa clonal plasma cells (underrepresented). Immunostains reveal approximately 25% kappa clonal plasma cells. Morphologic evaluation reveals a normocellular marrow for age (40% cellularity) with normal iron stores (2 on a scale of 0 to 4), trilineage hematopoiesis and mildly decreased erythroid precursors. Monoclonal protein in serum or urine, clonal plasma cells in bone marrow and related bone lesions would fulfill the criteria for symptomatic plasma cell myeloma. Clinical correlation is recommended. Myeloma FISH panel showed multiple abnormalities including deletion 17p13, which is an unfavorable prognostic indicator in plasma cell myeloma. Preliminary findings were discussed with the doctor. Flow Cytometry - 2% KAPPA CLONAL PLASMA CELLS IDENTIFIED Cytogenetics 46,XY[20] Kappa clonal plasma cells NORMAL KARYOTYPE FISH Normocellular marrow for age MULTIPLE MYELOMA PANEL: POSITIVE 1. TRISOMY 5 WAS DETECTED IN 16.5% OF ANALYZED CELLS 2. DELETION OF TP53 WAS DETECTED IN 15% OF ANALYZED CELLS 3. TRISOMY 9 WAS DETECTED IN 13.5% OF ANALYZED CELLS 4. DELETION OF 13q14.3 WAS DETECTED IN 10% OF ANALYZED CELLS Morphology - PLASMA CELL NEOPLASM, 25% CLONAL PLASMA CELLS IN NORMOCELLULAR MARROW CD138 marking increased plasma cells Jacqueline O'Hare, DO Please refer to individual test report for more detailed information This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 1 of 1

2 Patient Information Referring Physician Specimen Information Procedure: Flow Cytometry Report Reported: 01/08/2015 (203.00) Multiple myeloma - 2% KAPPA CLONAL PLASMA CELLS IDENTIFIED Comment: Flow cytometry detected 2% kappa clonal plasma cells; however, plasma cells are typically underrepresented in flow cytometry. Morphologic evaluation, conventional cytogenetics, and myeloma/mgus FISH panel are in process. Results Populations Identified Abnormal plasma cell population identified, of variable cell size, comprising 2% of events analyzed, with the following antigenic profile: POSITIVE FOR: CD38 (bright), CD45 (dim), CD56 (variable), CD138, intracellular kappa NEGATIVE FOR: CD5, CD10, CD19, CD20, CD34, CD117, intracellular lambda. Kappa clonal plasma cells Myeloblasts: <1% B-Cells: 2% surface-kappa:lambda ratio: 1.2:1 (consistent with polyclonal B-Cell population) Hematogones: 0% T-Cells: 1% CD4:CD8 ratio: 0.8:1 (slightly low, nonspecific) NK-Cells: <1% Plasma cells: 2% Granulocytes: 93% Monocytes: 1% Viability: 95% The remaining events consist of debris and non-staining forms. Evaluated Markers CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11b, CD13, CD14, CD16, CD19, CD20, CD33, CD34, CD38, CD45, CD56, CD117, CD138, surface kappa, surface lambda, intracellular kappa (p,m), intracellular lambda (p,m), HLA-DR, PI (Total markers: 28) This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. The above report was reviewed and interpretive comments are provided. The comments are approved for the medical records of the identified patient with my electronic signature. Jacqueline O'Hare, DO Page 1 of 2

3 CPT Code(s): 88184,88185(x27),88189 Page 2 of 2

4 Patient Information Referring Physician Specimen Information Procedure: Morphology Report Reported: 01/13/2015 (203.00) Multiple myeloma; anemia, multiple lytic lesions; diagnosis of multiple myeloma on left pelvic biopsy (12/9/2014) - PLASMA CELL NEOPLASM, 25% CLONAL PLASMA CELLS IN NORMOCELLULAR MARROW Comments Flow cytometry detected 2% kappa clonal plasma cells (underrepresented). Immunostains reveal approximately 25% kappa clonal plasma cells. Morphologic evaluation reveals a normocellular marrow for age (40% cellularity) with normal iron stores (2 on a scale of 0 to 4), trilineage hematopoiesis and mildly decreased erythroid precursors. Monoclonal protein in serum or urine, clonal plasma cells in bone marrow and related bone lesions would fulfill the criteria for symptomatic plasma cell myeloma. Clinical correlation is recommended. Myeloma FISH panel showed multiple abnormalities including deletion 17p13, which is an unfavorable prognostic indicator. Conventional cytogenetics is in process. Preliminary findings were discussed with the doctor. Normocellular marrow for age Stains Immunohistochemistry On core biopsy and clot section: CD138 reveals patchy interstitial and focal large and small clusters of plasma cells, averaging approximately 25% of cellular marrow. On clot section: Kappa and lambda in situ hybridization stains reveals kappa clonal plasma cells. CD138 marking increased plasma cells Dr. Lewis reviewed the stains and concurs. Iron Stain On core biopsy, clot section and aspirate smear: Overall the 3 stains show: Iron stores: 2 (scale of 0 to 4) Ring sideroblasts: Absent Gross Description - 1 bony core, totaling 1.0 x 0.2 cm, lightly decalcified, all as A ml of dark red clot, all as A2 and A3-5 aspirate smears (made in house) - 6 touch imprints of core biopsy This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 1 of 2

5 - 2 peripheral blood smears (made in house) - 2 sodium heparin tubes labeled as bone marrow aspirate - 1 EDTA tube labeled as peripheral blood Microscopic Description PERIPHERAL BLOOD SMEAR Red blood cells: Normocytic, normochromic with anisocytosis White blood cells: Neutrophils are increased and show cytoplasmic vacuolation and toxic granulation; lymphocytes are mildly decreased and do not show significant morphological atypia; other white blood cells are within normal limits; circulating blasts or plasma cells are not identified Platelets: Normal CBC was performed (01/08/2015): WBC: 16.9 K/micL, Hgb: 8.9 g/dl, MCV: 88.3 fl, RDW: 15.6%, Plt: 214 K/micL 100 cell manual differential count was performed: Neut: 96%, Lymph: 3%, Mono: 1%, Eos: 0%, Baso: 0% BONE MARROW Adequacy and general findings Core biopsy: Adequate Clot section: Adequate Aspirate smears: Adequate Touch imprints: Adequate Cellularity: 40%, normocellular for age Bone abnormality: Absent Hematopoietic elements Myeloid: Orderly and progressive maturation Erythroid: Mildly decreased and do not show significant atypia Megakaryocytes: Normal Infiltrates Blasts: Not increased Plasma cells: Increased plasma cells of variable cell size with occasional multinucleation and nucleolation Lymphoid aggregates: Absent Granulomas: Absent Metastases: Absent Fibrosis: Not identified on routine H&E stain Amorphous materials such as amyloid: Not identified on routine H&E stain Percentages of 200 cells counted (Reference ranges are in parentheses): Blasts: 1 (0-3) Promyelocytes: 4 (2-8) Myelocytes: 15 (10-13) Metamyelocytes: 10 (10-15) Neutrophils/Bands: 25 (25-40) Eosinophils: 4 (1-3) Basophils: 0 (0-1) Lymphocytes: 10 (10-15) Plasma Cells: 8 (0-1) Monocytes: 1 (0-1) Pronormoblasts: 3 (0-2) Erythroblasts: 10 (15-25) M:E ratio: 4.5:1 (1.5:1-4:1) Jacqueline O'Hare, DO CPT Code(s): 85060,85097,88305(x2),88311,88313(x3),88342(x2),88364,88365 This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 2 of 2

6 Patient Information Referring Physician Specimen Information Procedure: FISH Report Reported: 01/13/2015 (203.00) Multiple myeloma; anemia, multiple lytic lesions; diagnosis of multiple myeloma on left pelvic biopsy (12/9/2014) MULTIPLE MYELOMA PANEL: POSITIVE 1. TRISOMY 5 WAS DETECTED IN 16.5% OF ANALYZED CELLS 2. DELETION OF TP53 WAS DETECTED IN 15% OF ANALYZED CELLS 3. TRISOMY 9 WAS DETECTED IN 13.5% OF ANALYZED CELLS 4. DELETION OF 13q14.3 WAS DETECTED IN 10% OF ANALYZED CELLS Comment: nuc ish(chd5,160h23)x2[180],(cen3x2)[197],(d5s630/d5s2064,egr1)x3[33/200],(cen9x3)[27/200], (D13S319/D13S25x1,D13S1825x2)[20/200],(IGHx2)[189],(TP53x1,D17Z1x2)[30/200] A total of 200 interphase nuclei were scored for each multiple myeloma (MM) probe set on a direct harvest of plasma cells magnetically isolated from the bone marrow aspirate and revealed a positive result. Three copies of 5p15.31 and 5q31.2, indicative of possible trisomy, were seen in 33 cells; a deletion of TP53 at 17p13 was seen 30 cells; three copies of the centromere region on chromosome 9, indicative of possible trisomy, were seen in 27 cells; and deletion on the long arm of chromosome 13, at 13q14.3 was seen in 20 cells. All other probes scored within normal reference ranges. Loss of TP53 is an adverse prognostic indicator whether seen as the sole abnormality or combined with other chromosome changes, such as deletion 13q, +5, and +9. These results should be interpreted within the context of all relevant testing on this patient. Follow-up FISH and/or chromosome studies are available as clinically indicated. 5p15.31 (green), EGR1 (red) TRISOMY 13q14.3 (red), 13q34 (green) DELETION of 13q14.3 Analyzed Probes: CHD5 (1p36) and 160H23 (1q44) probe set to detect gains of the long arm of chromosome 1 (1q); CEN 3 (3p11.1-3q11.1) to detect polysomy of chromosome 3; D5S630/D5S2064 (5p15.31) and EGR1 (5q31.2) probe set to detect polysomy of chromosome 5; CEN 9 (9p11.1-9q11.1) to detect polysomy of chromosome 9; D13S319/D13S25 (13q14.3) and D13S1825 (13q34) probe set to detect deletions of the long arm of chromosome 13 (13q); IGH (14q32.3) break apart probe set to detect rearrangements of IGH; and TP53 (17p13) and D17Z1 (CEN17) probe set to detect deletions of TP53 and aneusomy of chromosome 17. (All probes CytoCell) The scoring for this case was completed using a per cell nuclei approach to signal counting and was performed manually by a licensed technologist. Interphase FISH is performed to screen for the loci indicated above and does not detect other chromosomal abnormalities. Chr 3 (green), Chr 9 (red) GAIN of 9 This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Jacqueline O'Hare, DO CPT Code(s): 88368(x12) Page 1 of 1

7 Patient Information Referring Physician Specimen Information Cytogenetics Report Reported: 01/14/2015 (203.00) Multiple myeloma; anemia, multiple lytic lesions; diagnosis of multiple myeloma on left pelvic biopsy (12/9/2014) NORMAL KARYOTYPE KARYOTYPE: 46,XY[20] Chromosome analysis was performed on G-banded metaphase spreads prepared from an unstimulated 24 hour culture and a four day culture stimulated with interleukin-3 and interleukin-6. No clonal abnormalities were observed. Metaphases Counted: 20 Culture Type: 24 HR, IL36 Metaphases Analyzed: 20 Banding Technique: GTG Metaphases Karyotyped: 2 Banding Resolution: 425 Katy Phelan, PHD CPT Code(s): 88237(x2),88264,88280(x2),88291 This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 1 of 2

8 This test was developed and its performance characteristics determined by Applied Diagnostics. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high complexity clinical testing. Page 2 of 2