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Diagnosis of a T-lineage acute lymphoblastic leukemia through digitalized cell analysis of the pleural effusion.

Peruzzi B, Cutini I, Gelli AM, Rondelli T, Statello M, Bencini S, Mannelli F, Caporale R, Bosi A, Fanelli A - Int Med Case Rep J (2013)

Bottom Line: A cord blood transplantation procedure was performed at the first hematological remission following chemotherapy regimens.The patient died of septic shock.The case we reported underlines the usefulness of using automated instruments to identify abnormal lymphoid cells in body fluids.

View Article: PubMed Central - PubMed

Affiliation: General Laboratory Unit (Microscopy and Clinical Cytometry Unit), Firenze, Italy.

ABSTRACT

Introduction: Pleural effusion as the first clinical manifestation of acute lymphoblastic leukemia (ALL) is a relatively rare event. An early and accurate diagnosis of this clinical picture is very important for adequate patient management.

Case presentation: We report the atypical onset of T-lineage ALL in a 31-year-old man. The patient was admitted to the emergency room due to lung failure; at that moment, the patient's initial blood count was normal; the chest X-ray radiography showed a massive pleural effusion and a thoracentesis was carried out. Routine investigations performed on the pleural fluid using a new technology system and digitalized cell analysis demonstrated infiltration by immature cells. Therefore, bone marrow aspirate and flow cytometry analyses were performed, leading to the diagnosis of T-lineage ALL. A cord blood transplantation procedure was performed at the first hematological remission following chemotherapy regimens. The patient died of septic shock.

Conclusion: The case we reported underlines the usefulness of using automated instruments to identify abnormal lymphoid cells in body fluids.

No MeSH data available.


Related in: MedlinePlus

Flow cytometry analysis of the pleural fluid.Notes: Blasts are shown in red, and lymphocytes are shown in blue. Blasts were CD45+/−, CD3−, CD7++, CD5+, CD2−, CD34+/−, CD1a−, CD3Cy+, and TdTCy+.Abbreviations: SSC, side scatter cells; FITC, fluorescein isothiocyanate; CD3, surface CD3; CD3Cy, cytoplasmic CD3; TdTCy, cytoplasmic TdT.
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f4-imcrj-6-077: Flow cytometry analysis of the pleural fluid.Notes: Blasts are shown in red, and lymphocytes are shown in blue. Blasts were CD45+/−, CD3−, CD7++, CD5+, CD2−, CD34+/−, CD1a−, CD3Cy+, and TdTCy+.Abbreviations: SSC, side scatter cells; FITC, fluorescein isothiocyanate; CD3, surface CD3; CD3Cy, cytoplasmic CD3; TdTCy, cytoplasmic TdT.

Mentions: The Sysmex XE-5000™ (Sysmex Corporation, Kobe, Japan) hematology analyzer, equipped with the body fluid module, was used as previously described1 to obtain the patient’s cell count, and to achieve white blood cell differentiation into mononuclear (MN) and polymorphonuclear cells; we obtained a cell count of 14,000 cells/μL (90% MN cells, and 10% polymorphonuclear cells). Cell cluster spreading from the MN area into the high-fluorescence area was observed (Figure 2A); this cell cluster had higher forward and side scatter than normal cells (Figure 2B), meaning that those cells were bigger and more complex. Cytospin preparation (CytoFuge2; IRIS International, Chatsworth, CA, USA) was performed with the pleural fluid using 250–300 μL of the cell suspension (20 cells/μL) to obtain a cell pellet of approximately 5,000 cells. The slides were air-dried and stained with the modified Wright-Giemsa method. Slides were analyzed using the CellaVision® DM96 (CellaVision AB, Lund, Sweden).2 Morphological examination (Figure 3) of the pleural fluid revealed a massive infiltration of immature cells, with large and clefted nuclei; the cytoplasm was basophilic without granules, and was scant in volume, large in size, presenting with fine chromatin and evident nucleoli. To clarify the nature of the immature cells observed in the pleural fluid, flow cytometry analysis was performed. A panel of antibodies including surface CD3 (CD3), cytoplasmic CD3 (CD3Cy), CD7, CD4, CD8, CD2, CD5, cytoplasmic TdT (TdTCy), CD45, and CD1a was used. The analysis was performed using a FACSCanto™ II flow cytometer (BD Biosciences, San Jose, CA, USA). Cytograms (Figure 4) showed that the cells (in red; P1) were CD45+/−, CD3−, CD7++, CD5+, CD2−, CD34+/−, CD1a−, CD3Cy+, TdTCy+, which were immature T-lineage cells. Therefore, a bone marrow aspirate was performed (Figure 5), which showed an infiltration of lymphoblast cells. Flow cytometry analysis on peripheral blood and bone marrow (Figure 6) were also performed; according to the European Group for the Immunological Classification of Leukemia (EGIL) criteria, the malignancy was classified as Pro T-lineage acute lymphoblastic leukemia (T-ALL) (EGIL T1).3 Cytogenetic and fluorescence in situ hybridization analyses showed a normal karyotype.


Diagnosis of a T-lineage acute lymphoblastic leukemia through digitalized cell analysis of the pleural effusion.

Peruzzi B, Cutini I, Gelli AM, Rondelli T, Statello M, Bencini S, Mannelli F, Caporale R, Bosi A, Fanelli A - Int Med Case Rep J (2013)

Flow cytometry analysis of the pleural fluid.Notes: Blasts are shown in red, and lymphocytes are shown in blue. Blasts were CD45+/−, CD3−, CD7++, CD5+, CD2−, CD34+/−, CD1a−, CD3Cy+, and TdTCy+.Abbreviations: SSC, side scatter cells; FITC, fluorescein isothiocyanate; CD3, surface CD3; CD3Cy, cytoplasmic CD3; TdTCy, cytoplasmic TdT.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3818024&req=5

f4-imcrj-6-077: Flow cytometry analysis of the pleural fluid.Notes: Blasts are shown in red, and lymphocytes are shown in blue. Blasts were CD45+/−, CD3−, CD7++, CD5+, CD2−, CD34+/−, CD1a−, CD3Cy+, and TdTCy+.Abbreviations: SSC, side scatter cells; FITC, fluorescein isothiocyanate; CD3, surface CD3; CD3Cy, cytoplasmic CD3; TdTCy, cytoplasmic TdT.
Mentions: The Sysmex XE-5000™ (Sysmex Corporation, Kobe, Japan) hematology analyzer, equipped with the body fluid module, was used as previously described1 to obtain the patient’s cell count, and to achieve white blood cell differentiation into mononuclear (MN) and polymorphonuclear cells; we obtained a cell count of 14,000 cells/μL (90% MN cells, and 10% polymorphonuclear cells). Cell cluster spreading from the MN area into the high-fluorescence area was observed (Figure 2A); this cell cluster had higher forward and side scatter than normal cells (Figure 2B), meaning that those cells were bigger and more complex. Cytospin preparation (CytoFuge2; IRIS International, Chatsworth, CA, USA) was performed with the pleural fluid using 250–300 μL of the cell suspension (20 cells/μL) to obtain a cell pellet of approximately 5,000 cells. The slides were air-dried and stained with the modified Wright-Giemsa method. Slides were analyzed using the CellaVision® DM96 (CellaVision AB, Lund, Sweden).2 Morphological examination (Figure 3) of the pleural fluid revealed a massive infiltration of immature cells, with large and clefted nuclei; the cytoplasm was basophilic without granules, and was scant in volume, large in size, presenting with fine chromatin and evident nucleoli. To clarify the nature of the immature cells observed in the pleural fluid, flow cytometry analysis was performed. A panel of antibodies including surface CD3 (CD3), cytoplasmic CD3 (CD3Cy), CD7, CD4, CD8, CD2, CD5, cytoplasmic TdT (TdTCy), CD45, and CD1a was used. The analysis was performed using a FACSCanto™ II flow cytometer (BD Biosciences, San Jose, CA, USA). Cytograms (Figure 4) showed that the cells (in red; P1) were CD45+/−, CD3−, CD7++, CD5+, CD2−, CD34+/−, CD1a−, CD3Cy+, TdTCy+, which were immature T-lineage cells. Therefore, a bone marrow aspirate was performed (Figure 5), which showed an infiltration of lymphoblast cells. Flow cytometry analysis on peripheral blood and bone marrow (Figure 6) were also performed; according to the European Group for the Immunological Classification of Leukemia (EGIL) criteria, the malignancy was classified as Pro T-lineage acute lymphoblastic leukemia (T-ALL) (EGIL T1).3 Cytogenetic and fluorescence in situ hybridization analyses showed a normal karyotype.

Bottom Line: A cord blood transplantation procedure was performed at the first hematological remission following chemotherapy regimens.The patient died of septic shock.The case we reported underlines the usefulness of using automated instruments to identify abnormal lymphoid cells in body fluids.

View Article: PubMed Central - PubMed

Affiliation: General Laboratory Unit (Microscopy and Clinical Cytometry Unit), Firenze, Italy.

ABSTRACT

Introduction: Pleural effusion as the first clinical manifestation of acute lymphoblastic leukemia (ALL) is a relatively rare event. An early and accurate diagnosis of this clinical picture is very important for adequate patient management.

Case presentation: We report the atypical onset of T-lineage ALL in a 31-year-old man. The patient was admitted to the emergency room due to lung failure; at that moment, the patient's initial blood count was normal; the chest X-ray radiography showed a massive pleural effusion and a thoracentesis was carried out. Routine investigations performed on the pleural fluid using a new technology system and digitalized cell analysis demonstrated infiltration by immature cells. Therefore, bone marrow aspirate and flow cytometry analyses were performed, leading to the diagnosis of T-lineage ALL. A cord blood transplantation procedure was performed at the first hematological remission following chemotherapy regimens. The patient died of septic shock.

Conclusion: The case we reported underlines the usefulness of using automated instruments to identify abnormal lymphoid cells in body fluids.

No MeSH data available.


Related in: MedlinePlus