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Abstracts and Case Studies From the College of American Pathologists 2007 Annual Meeting (CAP '07)

Posted on: Thursday, 13 September 2007, 09:00 CDT

By Anonymous

Abstract and case study poster sessions will be conducted during the College of American Pathologists' Annual Meeting (CAP '07), which is scheduled for September 30 to October 3, 2007. The meeting will occur at the Sheraton Chicago Hotel & Towers, Chicago, Ill. The poster sessions will occur in the Connection Cafe and Exhibit Hall. Specific dates and times for each poster session are listed below. Also shown below each poster session listing are the subject areas that will be presented during each session. POSTER SESSION 100: SUNDAY, SEPTEMBER 30, 2007, 10:00 AM-12:30 PM

Informatics; Hematopathology

Synoptic Reporting of Cancer Resection Specimens Using a Synoptic Tool: A 3-Year Experience With More Than 7500 Specimens

(Poster No. 1)

Anil V. Parwani, MD, PhD1 (parwaniav@upmc.edu); Ronald Angeles, MD1; Anthony Piccoli, BS1; Sharon Winters, MS2; Samuel Yousem, MD1; Michael Becich, MD, PhD.3 Departments of 1Pathology and 2Cancer Registry, University of PittsburghMedical Center, Pittsburgh, Pa; 3Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pa.

Context: Cancer checklists comprising standardized data elements are valuable tools that clinicians use to guide them in managing patients. We describe our experience with the use of Synoptic Worksheet entry tool for multiple malignant resections and also describe the use of synoptics in providing reports in our clinical environment of multiple academic and community centers.

Design: We used a synoptic reporting tool as part of existing laboratory information system, CoPathPlus, from Cerner DHT Corp. We modified the College of American Pathologists checklists into worksheets for select organ systems and malignancies. The synoptics have been in use for 40 months in our laboratory information system. The data were present as discrete data elements. A data element, that is, tumor type, is in the value dictionary under the value of tumor type, allowing users to search for cases that have that value point populated.

Results: A total of 7626 specimens in our network had synoptic report completed. Breast (1534), prostate (1373), colorectum and appendix (673), lung (606), and melanoma (533) were the most used templates in the system. Rarer malignancies including parathyroid and adrenal cortical carcinoma, penile tumor, and gallbladder tumors had fewer synoptic templates in the system (Table).

Conclusions: Use of the new synoptic report minimizes transcription errors, enables quicker access to information, and improves communication for cancer management. Such uniformity lends itself to ease of data viewing and extraction, as demonstrated by rapid production of standardized, high-quality data from these malignant resection specimens.

This work is partially supported by College of American Pathologists Foundation Rippey Grant for Quality Assurance.

Analysis of a Standardized Colorectal Cancer Resection Reporting Process in a Subspecialized Academic Pathology Department

(Poster No. 2)

Chad R. Rund, DO (rundcr@upmc.edu); Sharon B.Winters, MS, RHIA, CTR; Anthony L. Piccoli, BS; Anil V. Parwani, MD, PhD. Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pa.

Context: University of Pittsburgh Medical Center (UPMC) use (Cerner's CoPathPlus) of reporting College of American Pathologists (CAP) colorectal resection synoptic defined clinical elements was studied. Specific aims included (1) does UPMC synoptic use reflect the CAP requirements, (2) are CAP checklists more accurate and complete than traditional reports, and (3) will pathologists routinely use the checklists.

Design: Fifty random colorectal synoptics were chosen and evaluated for accuracy with respect to the 15 CAP scientifically validated elements (2005). Synoptics were compared with final text diagnoses and comments and codes were assigned according to completeness and accuracy. Textbased and synoptic values were assessed for the same cases but not at the individual pathologist level.

Code 0: synoptic value completed but not matching final text diagnosis

Code 1: . . . completed and matches

Code 2: . . . completed and matches comment only

Code 3: . . . completed but not in final diagnosis or comment

Code 4: . . . not completed but available in final diagnosis

Code 5: . . . not completed but available in comment only

Code 6: . . . not completed or available in final diagnosis or comment

Results: UPMC synoptic use exceeded CAP required recommendations by adding the 8 optional data elements. Absence of nearest surgical margin documentation (code 6), text based to synoptic final diagnosis discrepancy (code 0), and optimal TNM staging (code 1) was identified in 76%, 22%, and 100% of the cases, respectively. A 95% compliance rate was recorded.

Conclusions: Based on this limited study, UPMC synoptic use is effective at capturing CAP required elements and standardizing reports.

Multispectral Imaging of Urine Cytology: Comparison of 2 Available Tools

(Poster No. 3)

Ibrahim Mansoor, MD1 (ibm979@gmail.com); Carola Zalles, MD1; Farhan Zahid, BS2; David L. Rimm, MD, PhD.1 Departments of 1Cytopathology and 2Pathology, Yale University, School of Medicine, New Haven, Conn.

Context: Multispectral imaging is an emerging tool that uses both spatial and spectral image information to classify benign versus malignant cells. Two such tools include GENIE, which is a hybrid genetic algorithmbased artificial intelligence system (AIS), and MIDAS, which is a neural network-based AIS. Both of these tools classify images using automatically learned spatial-spectral features. The aim of this study was to compare the ability of these 2 tools in differentiating benign versus malignant urothelial cells (UCs) in urine cytology, with the ultimate goal of reproducibly distinguishing low-grade urothelial carcinoma from benign and reactive changes.

Design: A random training set (4 negative, 5 positive) and a testing set (5 negative, 5 positive) of urine cytology were selected. GENIE was limited in number of pixels that could be trained. All cases in both sets had a follow-up biopsy to confirm the cytologic interpretation. Both tools were trained on random well- preserved cells (77 normal UCs and 77 malignant UCs) from the training set. Solution was developed from both tools and was tested on a testing set. The testing set was composed of 191 normal UCs from 5 negative cases and 223 malignant UCs from 5 malignant cases. Cells were categorized as positive or negativewhenmore than 80% of the pixels delineating the cell were classified by the solution.

Results: Results generated by testing the solutions from GENIE and MIDAS on the testing set are summarized below (Tables 1 and 2).

Conclusions: Both tools showed similar sensitivity; however, MIDAS showed a statistically significant increase in specificity (75.39%) as compared with GENIE (60.2%) among the negative training set (P = .02). We aim to conduct further studies to optimize and develop MIDAS-based multispectral imaging to differentiate various equivocal urothelial lesions.

Anatomic Pathology Reporting System for the 21st Century

(Poster No. 4)

Stephen K. Lau, MD1 (slau@emory.edu); Theresa Gillespie, PhD2; Joseph Lipscomb, PhD2; Kenneth Gerlach, MPH3; Patricia Jamison, MPH3; Vijay Varma, MD.1 Departments of 1Pathology and 2Research and Development, Atlanta VA Medical Center and Emory University, Decatur, Ga; 3Department of Informatics, Centers for Disease Control and Prevention, Atlanta, Ga.

Context: Surgical pathology reports provide critical information for patient care. They are also the source of data for clinical and translational research. Increasing work load and the complexity of information required on each diagnostic report has made the traditional narrative reports dif- ficult to produce and difficult to use. We report on an electronic system that we are developing, which produces reports that meet the College of American Pathologists (CAP) standards, facilitates SNOMED CT coding, and at the same time creates a searchable data repository.

Design: The custom software application consists of interactive forms driven by a relational database. Service Oriented Architecture was used to facilitate interoperability. The forms have drop-down menus with logical dependencies that prompt the user to include all the necessary data. Each menu field is populated with a dictionary of standardized terminology from the CAP checklists. Each of these terms is associated with appropriate SNOMED CT numerical code. Permissions enable stratified access for laboratory staff, residents, and attending physicians to enter data, edit, revise, and finalize reports.

Results: The electronic templates are user-friendly but with powerful interactive features. The reports have a clear and consistent format and include all the data elements, and the captured data can be easily searched with predefined or custom queries. Data sharing with tumor registry and billing departments improves efficiency and accuracy.

Conclusions: An anatomic pathology reporting application built on a database system and interactive electronic forms is a user- friendly system that enhances the quality of the diagnostic reports, creates a searchable database, and enables controlled access to this critical data.

Interactive Pathology Atlas

(Poster No. 5)

Vijay Varma, MD (vvarma@emory.edu); Stephen K. Lau, MD; Christine Norton, MD; Stephen B. Hunter, MD. Department of Pathology, Emory University, Atlanta, Ga. Context: When faced with difficult cases, to arrive at a specific diagnosis, pathologists consult books on clinical and morphologic features of lesions and consider differential diagnoses. Books are now supplemented by CDs and Web sites. We report on a database-driven Web site that produces dynamic pages on demand that provide a rich interactive teaching and reference resource.

Design: The software application consists of a relational database back end and an HTML front end with PERL, java script, and AJAX in the middle layer. An authoring tool consisting of electronic forms and an image manager is integrated into the application. Permissions allowselective access to various functions of editors, authors, and users.

Results: Clicking on any of the entities in the table of contents launches the main page that provides clinical, radiologic, and pathologic features of that lesion in an outline format. Tables and detailed explanations are embedded in a deeper layer that can be accessed with a click. Links to search for up-to-date literature on each topic are provided. High-resolution images are linked to thumbnails on the outline page. The differential diagnosis of each lesion can be viewed on a page with side-by-side comparisons of images as well as key features. This page can be customized to add and remove images as well as lesions. The authoring tool provides a way to edit the text and tables online.

Conclusions: A database-supported Web site provides a powerful, rich, and up-to-date resource for teaching and consultation.

Dr Varma has a financial interest in Contexta, Inc, and is also a consultant for Elsevier, Inc.

Quantitative Analysis of Flow Cytometry Immunophenotypic Data in the Diagnosis of Myelodysplastic Syndromes

(Poster No. 6)

Ha Nishino, MD1 (nishino@bcm.edu); April Ewton, MD2; Youli Zu, MD, PhD2; Audrey Ponce De Leon, MT2; Chung-Che Chang, MD, PhD.2 1Department of Pathology, Baylor College of Medicine, Houston, Tex; 2Department of Pathology, The Methodist Hospital, Houston, Tex.

Context: Recent studies using qualitative analysis of flow cytometry data have demonstrated various immunophenotypic abnormalities associated with myelodysplastic syndromes (MDSs). However, there are limited reports assessing the ability of quantitative immunophenotypic analysis to discriminate MDS from other cytopenic conditions.

Design: Using flow cytometry, we studied 37 bone marrow specimens from 23 patients with MDS and 14 cytopenic patients with nonclonal hematologic disorders (age-matched with MDS patients). Samples were analyzed quantitatively for percentages of T cells, B cells, natural killer cells, granulocytes, monocytes, blasts, erythroid precursors, and plasma cells; CD4/CD8 ratio; percent granulocyte subsets; percent CD56+ monocytes; and % erythroid precursor subsets.

Results: Quantitative analysis of immunophenotypic data in MDS patients compared with controls showed decreased total granulocytes (P = .04) and maturer subsets of CD11b+CD16bright granulocytes (P = .005) and CD10+ granulocytes (P = .02). MDS patients also showed a trending increase in subset percentage of CD56+ monocytes (P = .06). Using receiver operating characteristic analysis, cut-off values for these parameters favoring a diagnosis of MDS were identified as follows: total granulocytes less than 60%, CD11b+CD16bright granulocytic subset less than 40%, CD10+ granulocytic subset less than 40%, and CD56+ monocytic subset more than 10%. Subsequently, a scoring system was proposed whereby a score of 1 was assigned for the presence of each quantitative abnormality. Using this system, the presence of at least 2 abnormalities (score >/=2) revealed optimal sensitivity (69.6%) and specificity (71.4%) for a diagnosis of MDS.

Conclusions: These findings suggest that quantitative analysis of immunophenotypic data complements qualitative interpretation and is useful for distinguishing MDS from nonclonal cytopenic disorders.

Detecting Hematopoietic Malignancies With a4=1 Flow Cytometry Assay

(Poster No. 7)

Abstract Withdrawn

Bone Marrow Involvement by Nephrogenic Systemic Fibrosis (Nephrogenic Fibrosing Dermopathy)

(Poster No. 8)

William D. Payne, MD (William.D.Payne@uth.tmc.edu); Dollett T. White, MD; Nghia Nguyen, MD. Department of Pathology and Laboratory Medicine, University of Texas Health Science Center, Houston.

Context: Nephrogenic systemic fibrosis, also known as nephrogenic fi- brosing dermopathy, is a recently recognized rare disease usually occurring in patients with renal failure and, until recently, considered limited to the skin. The characteristic cutaneous findings include symmetrical skin thickenings on the extremities with accumulation of collagen and fibrous tissue and often positivity for CD34, CD68, and factor XIIIa. Although there have been recent reports of systemic involvement, bone marrow findings have not been reported to our knowledge.

Design: A bone marrow biopsy with aspiration was performed on a male patient with nephrogenic fibrosing dermopathy. Reticulin, trichrome, and immunoperoxidase stains for CD34, CD68, and factor XIIIa stains were performed. Peripheral blood was sent for immunophenotyping by flow cytometry.

Results: The peripheral blood showed pancytopenia but otherwise had no significant abnormalities, with unremarkable flow cytometry panel results. The bone marrow biopsy showed only rare dysplastic erythroid forms. Diffuse reticulin fibrosis was present, with CD34 showing rare (<2% of nucleated cells) positivity. CD68 showed scattered positivity. Factor XIIIa and trichrome were negative.

Conclusions: Diffuse reticulin fibrosis was found in the bone marrow of this patient with nephrogenic systemic fibrosis. Other etiologies for bone marrow reticulin fibrosis (such as myeloproliferative disorders, hairy cell leukemia, and human immunodeficiency virus infection) were excluded. The possibility of bone marrow involvement by nephrogenic systemic fibrosis leading to pancytopenia holds important diagnostic and treatment implications.

Multidrug Resistance-Associated Protein: A Useful Hodgkin Cell Immunostaining Marker

(Poster No. 9)

Hussam A. Abu-Farsakh, MD1 (f1lab@yahoo.com); Maher Sughayer, MD.2 1Department of Pathology, First Medical Lab, Amman, Jordan; 2Department of Pathology, King Hussein Cancer Center, Amman, Jordan.

Context: Multidrug resistance-associated protein (MRP) molecule is an integral membrane glycophosphoprotein. It is believed that the main function of MRP in drug resistance is that of a plasma membrane drug efflux pump. The value of this study is to see the expression of this marker in Hodgkin cells and compare it with other large mononuclear cell origins.

Design: The staining was performed by immunohistochemical techniques using clone MRPr1 on all classical Hodgkin lymphomas diagnosed during the years 2004 to 2005. There were 36 cases. We used the following controls: 10 cases of large cell immunoblastic lymphomas, 7 cases of reactive germinal centers, 2 cases of large T- cell lymphoma, and 3 cases of nasopharyngeal carcinomas. All these cases were studied to see the large cell staining pattern.

Results: Immunostainings showed positive staining on all Hodgkin lymphoma cases in the Hodgkin cells (36/36) in membranous and Golgi pattern. The staining in the control specimens were as follows: in 4 of 10 immunoblastic lymphoma in membranous pattern without Golgi pattern; no staining was seen in large T-cell lymphoma, in carcinoma cells, in nasopharyngeal carcinoma, or in immunoblasts in reactive germinal center cases.

Conclusions: MRP is an excellent marker for identifying Hodgkin cells, in addition to CD15 and CD30. The typical staining pattern is membranous and Golgi pattern. We strongly recommend performing this staining as an adjuvant and as an important marker for confirmation of classical Hodgkin lymphoma.

Flow Immunophenotypic Properties of the Hodgkin Lymphoma Inflammatory Infiltrate

(Poster No. 10)

Eve M. Betancourt, MD (evsanson@utmb.edu); Jyoti Patel, MTIII (ASCP); S. D. Hudnall, MD. Department of Pathology, University of Texas Medical Branch, Galveston.

Context: Hodgkin lymphoma (HL) is characterized by few malignant Reed-Sternberg cells admixed with numerous reactive T cells. We performed a detailed retrospective comparison of the flow immunophenotype of HL and reactive lymphoid hyperplasia (RLH) to identify HLspecific immunophenotypic features.

Design: Single-cell suspensions from 60 lymph nodes involved by HL (at initial diagnosis) and 38 lymph nodes involved by RLH were subjected to a battery of fluorochrome-conjugated monoclonal antibodies to lymphocyte subsets. Cells were analyzed on a FACSCalibur flow cytometer with CellQuest software (Becton Dickinson, San Jose, Calif).

Results: CD3^sup +^ T cells were increased, and CD19^sup +^ B cells decreased, in HL versus RLH. In terms of HL subtypes, the CD3/ CD20 ratio difference, when compared with RLH, was only significant in nodular sclerosis HL (NSHL). The CD4/CD8 ratio was increased in NSHL, while decreased in mixed-cellularity HL (MCHL), in comparison with RLH. Natural killer- like T cells were slightly increased in HL, especially in MCHL. No differences in CD8^sup +^ T-cell content were detected in any group. More CD7^sup -^ T cells were detected in nodular lymphocyte-predominant HL and RLH than in NSHL and lymphocyte-depleted HL. CD4^sup +^CD25^sup +^ T cells were significantly increased in HL. Although no significant difference was detected in Epstein-Barr virus-positive versus Epstein-Barr virus-negative NSHL, a trend toward increased CD3/CD20 ratio, increased natural killer cells, and decreased CD4^sup +^CD25^sup +^ T cells in Epstein-Barr virus-positive HL was noted.

Conclusions: The cellular composition of the lymphocytic infiltrate in HL differs significantly from that seen in RLH. It is characterized by increased T cells (excluding MCHL), decreased B cells (excluding MCHL and lymphocyte-rich HL), increased CD4/CD8 ratio (NSHL only), and increased CD4^sup +^CD25^sup +^ T regulatory cells. Bone Marrow Talc Granulomatosis

(Poster No. 11)

Suzanne H. Martin, MD (smartin@usouthal.edu); Andrea G. Kahn, MD; J. Allan Tucker, MD; Zhuang Zuo, MD, PhD; Jacek M. Polski, MD. Department of Pathology and Laboratory Medicine, University of South Alabama, Mobile.

Context: Intravenous drug abuse sometimes involves injecting adulterated drugs with insoluble filler substances such as talc. Granulomatous reaction ensues as a result of these practices. Talc granulomata are usually located in lungs but can sometimes be disseminated as documented by a few case reports. We recently encountered a bone marrow aspiration with multiple small and poorly formed granulomata composed of foamy macrophages with refractile crystals. Scanning electron microscopy and energy dispersive x-ray microanalysis (EDXA) of clot sections revealed that the particles were composed of magnesium and silicon, consistent in ratio with talc. A retrospective study of bone marrow aspiration and biopsy was undertaken to study the frequency of talc granulomatosis in archival cases of bone marrow granulomata at our institution including study with EDXA.

Design: Thirty-nine additional cases of bone marrow granulomata of all etiologies were retrieved from our laboratory information system. The hematoxylin-eosin-stained and periodic acid-Schiff- stained sectionswere examined with polarizing light filters for refractile material. Cases with polarizable crystals were examined using EDXA.

Results: Of the 39 additional cases of bone marrow granulomata reviewed, 1 case showed polarizable crystals within the granulomata. The crystals were morphologically consistent with talc crystals. However, EDXA was unsuccessful because B5 precipitates preclude identification of the crystals.

Conclusions: This study documents that bone marrow talc granulomatosis is a rare condition (in our study, 5% of bone marrow granulomata). However, the possibility of talc granulomatosis should be considered in cases of bone marrow granulomata and can be evaluated with EDXA.

Role of Peripheral Blood Flow Cytometry in the Evaluation of Patients With Myelodysplasia

(Poster No. 12)

Hooman H. Rashidi, MD1 (hooman.rashidi@yale.edu); Nelofar Shafi, MD2; Brian R. Smith, MD1; Michal G. Rose, MD.1 1Department of Pathology and Laboratory Medicine, Yale School of Medicine, New Haven, Conn; 2Department of Pathology and Laboratory Medicine, Yale School of Medicine/ VA Connecticut Health Care System, New Haven/ West Haven.

Context: Myelodysplastic syndromes (MDSs) comprise a heterogeneous group of hematopoietic disorders with a variable clinical course. Diagnosis is made by morphology of bone marrow specimens and cytogenetics. Flow cytometry (FC) of the bone marrow (BM) specimen is used to determine percent blasts and may suggest abnormal myeloid maturation. There are little data on the use of FC evaluation of peripheral blood myeloid cells in patients with MDS. Here, we evaluate the utility of peripheral blood FC immunophenotypic abnormalities in predicting MDS in patients with cytopenias.

Design: FC evaluation of patients with BM-proven high-risk (n = 14) and low-risk (n = 15) MDS (based on World Health Organization guidelines) was compared with 16 controls. The ratio of mean marker fluorescence to mean control autofluorescence was calculated.

Results: The mean granulocyte CD10-control fluorescence ratio (+- SD) was 3.67 +- 0.65 for the control group (n = 16), 3.65 +- 0.9 for the lowgrade MDS group (n = 15), and 2.2 +- 0.7 for the high-grade MDS group (n = 14), P < .001. The sensitivity and specificity of granulocyte CD10 expression ratio less than 3 in predicting BM involvement by high-risk MDS was 52% and 88%, respectively. Positive and negative predictive values of the CD10 expression ratio less than 3 were 88.2% and 87.5%, respectively.

Conclusions: Our preliminary data suggests that peripheral blood FC for granulocyte CD10 expression may help rule-out high-risk MDS in patients with cytopenias, without the need to perform an invasive BM evaluation. This approach may be particularly valuable in the majority of MDS patients who are elderly with multiple comorbidities.

Marginal Zone Variant of Mantle Cell Lymphoma: A CD5-Negative Cyclin D1-Positive Variant

(Poster No. 13)

Natalia Golardi, MD1 (nagolard@utmb.edu); Mario R. Velasco, MD2; M. Tarek Elghetany, MD.1 1Department of Pathology, University of Texas Medical Branch, Galveston; 2Department of Pathology, Cancer Care Specialists of Central Illinois, Decatur.

An 83-year-old white man presented with pneumonia, persistent cough, and 30-lb weight loss for the past 15 months. Blood count was significant for neutrophilia and mild anemia. Computed tomography scan showed extensive necrotic mediastinal, celiac, and retroperitoneal lymphadenopathy; a large right hilar mass encasing the right upper lobe bronchus; bilateral pleural effusions; and a soft tissue mass near the gastroesophageal junction. A right upper lobe lung biopsy and a right axillary lymph node showed involvement by predominantly small cleaved lymphocytes with a small proportion of large cells. No epithelial invasionwas seen in the lung biopsy. On initial frozen sections, small cell lung carcinoma was considered. However, the cells were positive for CD20 and CD45 and negative for CD3, neuron-specific enolase, and chromogranin. A morphologic diagnosis of follicular lymphoma, grade 2 of 3, was rendered. Flow cytometry on the lymph node showed the B lymphocytes to be negative for CD5 and CD10. Morphologic reassessment showed the small lymphocytes to have monocytoid appearance and prominent cell borders surrounding naked germinal centers. Cyclin D1 unequivocally stained the nuclei of 40% to 50% of cells. Bone marrow examination revealed extensive involvement by cells with similar morphologic and immunophenotypic characteristics. Moreover, cytogenetic analysis on the marrow showed a clone with the following karyotype: -3,-6,- 11,t(11; 14)(q13;q32) consistent with mantle cell lymphoma. Because of the aggressive clinical behavior, the patient received multiagent lymphoma chemotherapy. Marginal zone variant of mantle cell lymphoma is a challenging diagnosis that needs to be recognized because of its aggressive clinical behavior.

Epstein-Barr Virus Is Exceptionally Rare in Nodular Lymphocyte- Predominant Hodgkin Lymphoma Cases From North America

(Poster No. 14)

Miriam D. Post, MD (mdpost@partners.org); Lawrence R. Zukerberg, MD; Robert P. Hasserjian, MD. Department of Pathology, Massachusetts General Hospital, Boston.

Context: Both histologic features and clinical behavior distinguish nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) from classical Hodgkin lymphoma (cHL). Epstein-Barr virus (EBV) is strongly associated with cHL and is present in up to 90% of cases in developing countries. The relationship between EBV and NLPHL is less clear, as few cases have been studied in a limited geographic distribution.

Design: We searched one institution's database to identify cases of NLPHL originating in North America and evaluated EBV early RNA expression by in situ hybridization. Cases were considered positive if any of the large neoplastic cells demonstrated staining. We compared our results to those reported for NLPHL globally.

Results: Only 1 of 29 North American NLPHL cases showed positive EBV staining by EBV early RNA expression in situ hybridization. This case was from the cervical lymph node of a 44-year-old man with stage IA disease. The large neoplastic cells stained positively for PAX5 and were variably positive for CD20; a subset weakly expressed CD30 but were negative for CD15. Overall, this case showed features intermediate between NLPHL and lymphocyte-rich cHL.

Conclusions: Compared with previous studies demonstrating EBV in NLPHL cases from Europe (5/26 cases; 19%) and developing countries (9/14 cases; 64%), we found EBV in only 1 (3%) of 29 North American NLPHL cases. Our findings demonstrate that EBV expression in NLHPL is exceptionally rare in North America and that this feature may help distinguish it from lymphocyte-rich cHL. Additionally, the geographic differences in EBV expression in NLPHL seem to parallel those observed in cHL.

Lymphoma-Specific S-Phase Fractions in 2 Subtypes of Diffuse Large B-Cell Lymphomas

(Poster No. 15)

David D. Grier, MD (grierdd@gmail.com); Samer Z. Al-Quran, MD; William Clapp, MD; Ying Li, MD, PhD; Raul C. Braylan,MD. Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville.

Context: Recent studies of diffuse large B-cell lymphomas (DLBCL) using cDNA microarray techniques have shown that DLBCL can be divided into prognostically significant subgroups such as the germinal center B-cell-like (GC-DLBCL) and activated B-cell-like (ABC-DLBCL) types. The GC-DLBCL subgroup has a significantly better survival rate than the ABC-DLBCL subgroup. However, it is unknown if these 2 DLBCL subtypes have different cell cycle kinetic properties (ie, DNA S-phase fraction [SPF]).

Design: DLBCL cases with SPF data were identified. SPF was measured using DRAQ5 (a dye that binds supravitally to DNA in intact cells), with simultaneous labeling of 2 B-cell surface antigens. This approach allowed the SPF to be measured specifically in the lymphoma cells. The cases of DLBCL were classified based on the results of immunohistochemistry using 3 antibodies (CD10, Bcl-6, and MUM1). Two pathologists reviewed the immunohistochemistry and staining greater than 30% of the lymphoma cells was considered positive.

Results: Fourteen DLBCL were identified (8 GC-DLBCL and 6 ABCDLBCL). SPF ranged from 5% to 22% (mean, 11.1%) in GC-DLBCL and 6% to 20% (mean, 12%) in ABC-DLBCL. There was no statistical difference in SPF between the 2 DLBCL subtypes. Conclusions: In this preliminary study, we observed ample variability and no significant differences in lymphoma-specific SPF between GCDLBCL and ABC-DLBCL. If confirmed by a larger number of samples, these data do not support the notion that the differences in prognosis observed between patients with GC-DLBCL and ABC-DLBCL are related to differences in tumor growth kinetics.

Development of an In Vitro Human Erythroid Cell Expansion Model Correlating the Morphology With the Immunophenotypic Markers

(Poster No. 16)

Archana M. Agarwal, MD1 (archana.agarwal@hsc.utah.edu); Donghoon Yoon, PhD2; Hana Bruchova, PhD2; Josef T. Prchal, MD2; Jaroslav F. Prchal, MD.3 1Department of Pathology and 2Division of Hematology,University of Utah School of Medicine, Salt Lake City; 3Department of Oncology, McGill University, Montreal, Quebec, Canada.

Context: In vitro erythroid expansion model (using cytokine support) is used widely to study red cells at their different stages of development. In these models, specific erythroid stage is currently estimated by using differential expression of CD71 (transferrin receptor) and CD235a (glycophorin A). However, the expression of these immunophenotypic markers has never been correlated with morphology in expanded human erythroid progenitor cells.

Design: We used peripheral blood mononuclear cells (PB-MNCs) from healthy donors as well as patients with polycythemia vera (PV) and expanded them along erythroid lineage in 3-week culture (erythropoietin given second week onward). Through the culture, we took samples at 8 time points (days 1, 7, 9, 11, 14, 16, 19, and 21) to evaluate differentiation patterns. We generated 5 different regions using CD71 and CD235a and characterized these regions by standard morphologic analysis. This protocol allowed differentiation of PB-MNCs to all erythroid stages ending with late normoblast, reticulocyte, and mature erythrocytes.

Results: First week: no difference in proliferation between PV and normal groups; however, differentiation progressed more rapidly in PV compared with normal (likely reflecting erythropoietin independence). Second and third week: markedly increased proliferation in PV group; however, differentiation pattern was the same in both. This in vitro expansionmethod allowed expansion of PB- MNCs along erythroid lineage with 60% to 80% stage homogeneity as to the stage of differentiation in both PV and normal groups.

Conclusions: To our knowledge, this is the first report of an in vitro human erythroid cell expansion model correlating the morphology with the expression of immunophenotypic markers.

Cord Blood and Acute Chorioamnionitis: A Guide for Treating Neonatal Sepsis?

(Poster No. 17)

John C. Lee, MD1 (jlee800@yahoo.com); Fernando Chaves, MD1; Thomas Ahern, MPH2; Karen Quillen, MD.1 1Department of Pathology, Boston Medical Center, Boston, Mass; 2Department of Epidemiology, Boston University School of Public Health, Boston, Mass.

Context: Acute chorioamnionitis (ACA) is associated with neonatal sepsis. Unlike in adults, white blood cell parameters are less reliable in neonates for an infection workup. Our objective was to determine if cord blood (CB) can be used for a complete blood count with differential in correlating with pathologically confirmed ACA in comparison with peripheral blood (PB).

Design: CB was retrieved from consecutively submitted placentas. The complete blood count with differential parameters for CB and cliniciandrawn PB includes the white blood cell count, absolute neutrophil count, neutrophil percent, band percent, immature neutrophil percent, mean neutrophil volume, neutrophil distribution width, hemoglobin, and hematocrit. Statistical analysis was run using Statistical Analysis System software.

Results: Of the 64 cases, 14 had ACA. The absolute neutrophil count was a significant CB predictor for ACA (Table). CB white blood cell count and neutrophil percent were borderline predictors for ACA. From the smaller PB subset (29 cases), band percent and immature neutrophil percent were significant predictors for ACA (Table).When comparing CB and PB hematologic parameters, hemoglobin, hematocrit, and white blood cell count were strongly correlated. Absolute neutrophil count had moderate correlation. Neutrophil percent, band percent, and immature neutrophil percent had weak correlation. Lastly, increasing gestational age correlated with increasing neutrophil distribution width (t test: P = .008).

Conclusions: The absolute neutrophil count in CB was a significant predictor of ACA. CB has advantages in that it is faster, easier, and safer to obtain than PB. CB may be an alternative to PB as a source for complete blood count with differential in the early neonatal sepsis workup.

The Transcription Factor Yin Yang 1 Is Widely Expressed in Lymphoma Tissue

(Poster No. 18)

Rodney R. Miles, MD, PhD1 (rodneymi@umich.edu); Sheryl R. Tripp, MT(ASCP)2; George Z. Rassidakis, MD, PhD3; L. J. Medeiros, MD3;Megan S. Lim, MD, PhD1; Kojo S. Elenitoba-Johnson, MD.1 1Department of Pathology, University of Michigan, Ann Arbor; 2Institute for Research and Development, ARUP Laboratories, Salt Lake City, Utah; 3Department of Hematopathology, The University of Texas M. D. Anderson Cancer Center, Houston.

Context: We identified the transcription factor yin yang 1 (YY1) in a mass spectrometry-based screen of follicular lymphoma (FL)- derived cells. YY1 can inhibit apoptosis in lymphoma cells, and increased YY1 mRNA has recently been associated with worse outcome in FL and diffuse large B-cell lymphoma (DLBCL) patients.

Design: We performed an immunohistochemical study of YY1 expression in arrays of reactive lymphoid tissue, 37 hematopoietic cell lines, and Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) tissues. We also evaluated YY1 expression in 11 hematopoietic cell lines using Western blotting.

Results: YY1 expression in tonsillar tissue was strongest in the small lymphocytes of mantle and marginal zones and was weak in centrocytes and centroblasts of the germinal centers. Strong YY1 expression was seen in 37 of 37 human myeloid, B-cell, and T-cell lines. YY1 was expressed in DLBCLs (42/42); FLs (10/10); and small lymphocytic (2/2), splenic marginal zone (2/2), and mantle cell lymphomas (1/1). Most DLBCLs (79%) and FLs (70%) showed weak expression as did 8 of 8 HLs. Twenty-four of 27 anaplastic large cell lymphomas expressed YY1. The expression was weak in 13 cases and did not correlate with anaplastic lymphoma kinase expression. By Western blotting, YY1 was expressed in 4 of 5 B-cell and 5 of 6 T- cell NHL cell lines.

Conclusions: YY1 was expressed in nearly all reactive lymphoid tissues, hematopoietic cell lines, and HL and NHL tissue samples tested. Weak staining was noted in DLBCL, FL, HL, and anaplastic large cell lymphoma. Further studies are warranted to determine the basis of weak to absent expression of YY1 in a subset of lymphomas.

Utility of Ki-67 Proliferation Index Marker in Assessing Clinical Aggressiveness of Follicular Lymphoma: Retrospective Study and Clinicopathologic Correlation

(Poster No. 19)

Nahid M. Nanaji, MD, MPH (nanaji@uic.edu); Robert J. Cabay, MD, DDS; Sujata Gaitonde, MD. Department of Pathology, University of Illinois, Chicago.

Context: Although follicular lymphoma (FL) is usually an indolent disease, some patients experience a more aggressive clinical course. The proliferation index (PI) of FL generally correlates with histologic grade. However, in cases of discordance (low-grade and high PI or high-grade and low PI), histologic grade or PI may not correlate with clinical aggressiveness. In this study, we evaluate the utility of Ki-67 proliferation index marker in assessing the clinical aggressiveness of FL.

Design: Formalin-fixed, paraffin-embedded tissues from 23 FL cases at the time of initial diagnosis were analyzed. PI was determined via Ki-67 immunostaining and automated image analysis and recorded as an average percentage of proliferating cells within 10 randomly selected microscopic high-power fields (low PI < 20%, high PI >/= 20%). The correlations of PI with histologic grade and clinical aggressiveness (transformation to diffuse large B-cell lymphoma) were evaluated.

Results: The correlations of PI with histologic grade (r = 0.34, P = .11) and clinical aggressiveness (r = 0.01, P = .97) were weak and not statistically significant. Discordance between histologic grade and PI was present in 4 cases (3 grade 1 with high PI, 1 grade 3 with low PI). There was no clinical follow-up in 3 discordant cases; the other case (grade 1 with high PI) had persistent disease without transformation.

Conclusions: Our study did not provide evidence that Ki-67 immunostaining is a better predictor of the clinical aggressiveness of FL than simple and less expensive histologic grading. The low number of discordant cases with clinical follow-up prevented an assessment of the predictive value of Ki-67 immunostaining therein.

Cytogenetic Abnormality Correlation With Megakaryocyte Dysplasia in Myelodysplastic Syndromes

(Poster No. 20)

Douglas J. Hartman, MD1 (douglas.hartman@uhhs.com); Philip E. Bomeisl, DO1; Chrisine Curtis, PhD2; Howard J. Meyerson, MD.1 1Department of Pathology and 2Center for Cytogenetics, University Hospitals Case Medical Center, Cleveland, Ohio.

Context: Cytogenetic abnormalities of chromosomes 5 and 7 are associated with myelodysplastic syndrome (MDS) and specifically dysplasia in megakaryocytes. Megakaryocyte dysplasia was evaluated in a subset of MDS patients to determine frequency and association of this and other cytogenetic abnormalities.

Design: Morphologic and clinical features of 50 MDS patients with concurrent cytogenetic samples seen at University Hospitals of CaseMedical Center from 1995 to 2006 were retrospectively reviewed. A bone marrow dysplasia score was assigned to each hematopoietic lineage as follows: no dysplasia, 0; 1% to 20% or less of cells within 1 lineage exhibiting dysplasia, 1+ (mild dysplasia); 21% to 50% or less, 2+ (moderate dysplasia); and 51% to 100%, 3+ (severe dysplasia). Results: Significant (moderate to severe) megakaryocytic dysplasiawas found in 62% (31/50) of the cases evaluated.Megakaryocyte abnormalities were seen in 93% (14/15) of complex cytogenetic abnormalities (>3). In addition, megakaryocytic dysplasia was observed in 83% (10/12) of patients with chromosome 7, 79% (11/14) with chromosome 5, 78% (7/9) with chromosome 17, 60% (3/ 5) with chromosome 8 abnormalities, and all 5 cases with chromosome 20 abnormalities. Although megakaryocytic dysplasia was commonly observed, severe megakaryocyte dysplasia was significantly more common in abnormalities of chromosome 5, chromosome 7, or both (P = .01) compared with other cytogenetic findings. Chromosomal 5 and 7 structural defects accounted for 48% of the cases with dysplastic megakaryocytes.

Conclusions: Abnormalities of chromosomes 5 and 7 are associated with dysplastic megakaryocytes. However, these cytogenetic abnormalities cannot explain the significant megakaryocyte dysplasia in many cases of MDS.

Posttransplant Lymphoproliferative Disorder Hodgkin Lymphoma

(Poster No. 21)

Bhavna Khandpur, MD (avneet=kochar@hotmail.com); Jeffrey West, MD. Department of Pathology, Danbury Hospital, Danbury, Conn.

Hodgkin lymphoma disease (HD) posttransplantation is rare. Posttransplant lymphoproliferative disorders (PTLDs) comprise a spectrum, ranging from early Epstein-Barr virus (EBV)-driven polyclonal proliferations resembling infectious mononucleosis to EBV- positive or EBV-negative lymphomas of predominantly B-cell or less often T-cell type. Even though non-Hodgkin lymphoma in brain has been reported, to our knowledge ours is the first case of HD in the brain. A 46-year-old man presented with an onset of right focal upper extremity seizure. His medical and surgical history was significant for vision problems because of diabetes following kidney transplant 15 years ago and cadaveric pancreatic transplant 5 years ago. He was on immunosuppressive therapy for the past 15 years. We received 2 frozen fragments of grey-brown tissue measuring 1.1 and 2.5 cm in greatest dimension. Microscopy revealed brain parenchyma with large areas of chronic and granulomatous inflammation in a slightly nodular pattern. The inflammatory infiltrate included lymphocytes, histiocytes, plasma cells, and rare eosinophils. Scattered throughout this background were large atypical cells with large nuclei and prominent nucleoli. The atypical cells were positive for CD30, and rare cells showed CD15 positivity (Figure 1). The frequency of HD after transplantation needs to be defined to explain the discrepancy with the frequency of Bcell neoplasms, although both are associated with EBV. More clinical data are needed to establish therapeutic protocol in patients with secondary immune deficiency. Immunohistologic and molecular biologic analysis of EBV in tumors will help in understanding development of HD in transplant patients, in whom immunosuppression could be a part of a multistep process.

When Should a Differential Count Be Done on Cerebrospinal Fluid?

(Poster No. 22)

Eugene S. Pearlman, MD (czaroflabs@aol.com); Melissa Haygood, MT(ASCP); Kelli Dalton, MT(ASCP); Stanley Sprei, MD. Department of Pathology, Lourdes Hospital, Paducah, Ky.

Context: Historically, the Lourdes Hospital Laboratory has attempted a differential count on any diagnostic cerebrospinal fluid (D-CSF) specimen when the total cell count was 1 or more white blood cells (WBCs) per microliter. We were interested in determining whether the policy in respect to D-CSF was necessary. Also we felt the data would help to define review criteria when new instrumentation automating body fluid cell counting was acquired.

Design: We reviewed results on 566 CSF cell counts performed during a 2-year period. Of these, 308 were myelogram-derived CSFs. The 0 to 97.5 percentiles of the latter group defined the reference interval for WBC count (0-8/[mu]L).

Results: Of the 258 D-CSFs, 115 specimens from 104 patients had 1 or more WBCs per microliter. The electronic medical records with regard to these 115 specimens were reviewed. Sixty specimens (51 patients) had more than 8 WBCs/[mu]L. Of these, 27 (53%) patients had a discharge diagnosis of meningitis (all types), encephalitis, or cerebral abscess. The median count among these 27 patients was 171 WBCs/[mu]L (range, 28- 5000). Of the 55 specimens (53 patients) with 8 or fewer WBCs per microliter, 53 specimens had 2 or fewer polymorphonuclear leukocytes per microliter and only 1 patient (human immunodeficiency virus-positive) had a discharge diagnosis of ''likely aseptic meningitis'' with a cell count of 5 WBCs/[mu]L.

Conclusions: On the basis of this data, a reference interval for CSF cell count was defined as 0 to 8 WBCs/[mu]L, and differential counts on specimens with total cell counts within the reference interval were discontinued unless specifically requested by the attending clinician.

Blastic Transformation of Follicular Lymphoma

(Poster No. 23)

Archana M. Agarwal, MD1 (archana.agarwal@hsc.utah.edu); Neeraj Agarwal, MD2; A. F. Tryka, MD3; JohnH. Ward,MD2; Megan S. Lim, MD.4 Departments of 1Pathology and 2Medicine, University of Utah, Salt Lake City; 3Department of Pathology, St John's Medical Center, Jackson, Wyo; 4Department of Pathology, University of Michigan, Ann Arbor.

Context: Follicular lymphomas (FLs) can undergo transformation to high-grade lymphomas/leukemias with blastic morphology. There is little literature available on this entity.

Design: We evaluated the clinical and pathologic features of 2 cases of FL with blastic morphology.

Results: Case 1: A 72-year-old woman, with prior history of stage IV low-grade FL 5 years ago, presented with cervical lymphadenopathy. The peripheral blood and bone marrow showed a large population of monoclonal lymphoblasts that were evaluated by flow cytometry to be positive for CD10, CD19, CD22, and partial CD20 without TdT. Karyotyping revealed multiple cytogenetic abnormalities. A diagnosis of blastic transformation of FL was made. She had short-lasting partial response to salvage chemotherapy and died 4 months after presentation because of refractory disease. Case 2: A 71-year-old man presented with abdominal lymphadenopathy. Lymph node biopsy revealed complete effacement of nodal architecture by a dense atypical lymphoid infiltrate with blastic morphology and expressed monoclonal light chains, Bcl-6, Bcl-2, and CD10 but not Bcl-1, CD5, or TdT. Bone marrow and peripheral blood were negative. A diagnosis of blastic variant of FL was made. The patient achieved complete remission after treatment with 6 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone.

Conclusions: A subset of FL undergo blastic transformation. Recognition of blastic transformation of FL can be challenging, and its morphologic features may simulate lymphoblastic lymphoma/ leukemia, acute myeloid leukemia, or the blastic variant of mantle cell lymphoma. We present a review of the literature of FL associated with blastic morphology.

DRAQ5 Cell Cycle Analysis and CD71 Expression Differences in Diffuse Large B-Cell Lymphoma and Low-Grade B-Cell Non-Hodgkin Lymphoma

(Poster No. 24)

Todd M. LeLeux, MD1 (leleux@bcm.edu); April Ewton, MD2; Randall J. Olsen, MD, PhD2; Audrey Ponce de Leon, MT2; Youli Zu, MD, PhD2; Chung-Che Chang, MD, PhD.2 1Department of Pathology and Laboratory Medicine, Baylor College of Medicine, Houston, Tex; 2Department of Pathology and Laboratory Medicine, The Methodist Hospital and The Methodist Hospital Research Institute, Houston, Tex.

Context: Cell cycle analysis using DNA-binding dye has been used to grade lymphomas. CD71, the transferrin receptor, is typically up- regulated in cells entering the cell cycle because iron is needed for DNA synthesis. DRAQ5, a cell-permeable anthraquinone DNA- binding dye, penetrates intact live cells while preserving light scatter and surface antigenicity. This allows simultaneous measurement of cell cycle kinetics and antigenic pro- files.

Design: Cell cycle analysis and surface antigen expression data were obtained via multiparametric flow cytometry using DRAQ5 DNA- binding dye and fluorochrome conjugated antibodies. CD19 was used for selective cell cycle analysis of neoplastic B cells, which limited contamination by reactive T cells. Cases were then assigned to either diffuse large B-cell lymphoma (DLBCL; n = 10) or low- grade B-cell non-Hodgkin lymphoma (n = 28) (follicular lymphoma, small lymphocytic lymphoma/chronic lymphocytic leukemia, marginal zone lymphoma, lymphoplasmacytic lymphoma) for comparison.

Results: DLBCL had significantly higher S-phase (25.4 +- 15.0 vs 13.6 +- 12.1, P = .02, Student t test) and G2M+S-phase (27.9 +- 15.9 vs 16.6 +- 11.9, P = .02, Student t test) fractions versus low- grade B-cell non-Hodgkin lymphoma. Likewise, CD71 expression was significantly higher in the DLBCL cases (54.7 +- 27.8 vs 20.2 +- 17.4, P < .001, Student t test).

Conclusions: CD19 subset selection and simultaneous measurements for DRAQ5 and CD71 shows that DLBCL has increased S-phase fraction, G2M+S-phase fraction, and CD71 expression compared with low-grade B- cell non-Hodgkin lymphoma. We did not observe direct correlation between cell cycle S-phase fraction and CD71 expression in either group. This suggests that neoplastic lymphocytes may have more diverse mechanisms for iron transport to meet DNA synthesis requirements.

Flow Cytometric Determination of Clonotypic B-Lymphocyte Phenotype in Multiple Myeloma: Implications for Prognosis and Therapy

(Poster No. 25)

Earl J. Conway, MD (liquid=oz@yahoo.com); Jianguo Wen, PhD; Albert Mo, BS; Yongdong Feng, MD, PhD; David H. Vesole, MD; Chung- Che Chang, MD, PhD. Department of Pathology and Laboratory Medicine, The Methodist Hospital and The Methodist Hospital Research Institute, Houston, Tex. Context: Despite intensive chemotherapy supported by autologous peripheral blood stem cell transplantation, virtually all multiple myeloma patients relapse with expression of the original clonal light chain. Relapse in these patients may be the result of persistent or residual clonotypic B lymphocytes (CBLs, also known as myeloma precursor cells or myeloma stem cells), which are resistant to the chemotherapeutic agents used and provide a reservoir for recurrent disease.

Design: Flow cytometry was used to identify a phenotypic surface profile for CBLs from peripheral blood stem cell harvest samples of 20 multiple myeloma patients. Polymerase chain reaction for complementarity determining regions 3 was performed to confirm that the isolated cells are CBLs.

Results: Light chain-restricted CBLs had the following surface phenotypic marker expression profile: CD34^sup +^, CD44^sup +^, HLA- DR^sup +^, CD31 (weak to negative), CD38 (moderate to negative), CD184 (weak to negative), CD45RO (weak to negative), CD50^sup +^, CD10^sup -^, CD11b^sup -^, CD14^sup -^, CD19^sup -^, CD20^sup -^, CD44^sup -^, CD45RO, CD49d^sup -^, CD54^sup -^, CD56^sup -^, CD62L^sup -^, CD117^sup -^, CD126^sup -^, CD130^sup -^, CD138^sup - ^. This profile was expressed in both the putative neoplastic CBLs and, in lesser amounts, in normal plasma cell precursors. Cells sorted using CD34 and cytoplasmic light chain were determined to posses rearranged complementary determining regions 3 similar to the patients' respective myeloma cells.

Conclusions: Neoplastic CBLs and normal plasma cell precursors have a similar phenotype. Persistent or reinfused CBLs could explain high myeloma relapse after autologous stem cell transplant. The CD34^sup +^CD117^sup -^ phenotype of the CBLs suggests that purification of stem cell harvest using CD117 instead of the currently commonly used CD34 may avoid the contamination of CD34^sup +^ CBLs.

Clinical Experience of Capillary Zone Electrophoresis to Traditional (Non-High-Performance Liquid Chromatography) Methods for the Evaluation of Hemoglobinopathies

(Poster No. 26)

Joo Y. Song, MD1 (joosong@gwu.edu); Sheereen Brown, MT2; Ghislaine Gautier, MT2; Edward C. Wong, MD.2 1Department of Pathology, The George Washington University, Washington, DC; 2Division of Laboratory Medicine, Children's National Medical Center, Washington, DC.

Context: Traditional methods have been reliably used to evaluate hemoglobinopathies but are labor intensive and time consuming. Capillary zone electrophoresis for automated quantitation and elucidation of hemoglobin (Hb) variants has the potential for improving hemoglobinopathy diagnosis.

Design: Parallel studies were performed using traditionalmethods and Hb program on the CAPILLARYS 2 (Sebia, France). Traditional methods included Hb electrophoresis and densitometry (Paragon kit, Beckman Instruments, Brea, Calif), isoelectric focusing (Resolve Hb kit, Perkin Elmer- Wallac, Akron, Ohio), HbA^sub 2^ quantitation performed by Sickle-Thal Quick Column method (Helena Laboratories, Beaumont, Tex), and HbF quantitation by alkali denaturation method. Interpretive patient studies, precision, stability, and timing studies were performed.

Results: CAPILLARYS intra-assay precision demonstrated coefficients of variation (CVs) ranging from 0.1% to 3.4% depending on Hb variant and percentage. Interassay CVs using frozen and thawed controls (n = 7-10, 2-month period) ranged from 0.07% to 5.04%. Stability studies during a 9-day period using refrigerated samples demonstrated good to excellent stability with maximal absolute difference of 3.2%, 3.2%, 2.1%, and 0.1% for HbA, HbF, HbS, and HbA^sub 2^, respectively. Linear regression analysis demonstrated R^sup 2^ = 0.84 (HbA^sub 2^, n = 48), R^sup 2^ = 0.92 (HbF, n = 92, alkali denaturation), and R^sup 2^ >/= 0.97 (HbA, HbS, or HbF, n = 80, densitometry). Analysis of Hb variants for 8 samples could be performed in 20 to 30 minutes, whereas manual methods required batching and took up to 1 week. Interpretive studies showed excellent correlation between CAPILLARYS and traditional methods.

Conclusions: Automated capillary zone electrophoresis provides an alternative, rapid method of hemoglobinopathy determination in comparison with traditional (non-high-performance liquid chromatography) methods.

Peripheral T-Cell Lymphoma Associated With Anti-Tumor Necrosis Factor + Antibody Therapy for Ulcerative Colitis

(Poster No. 27)

Lindsay A. Schmidt, MD (lindschm@med.umich.edu); Megan S. Lim, MD, PhD. Department of Pathology, University of Michigan, Ann Arbor.

The risk of development of lymphoproliferative disorders in patients with inflammatory bowel disease has been attributed to immunosuppressive and immunomodulatory therapies. Infliximab is a chimeric monoclonal IgG1 antibody directed against tumor necrosis factor (TNF- ) that was approved by the US Food and Drug Administration (FDA) in 1998 as an effective agent against inflammatory bowel disease. We analyzed the histologic, immunophenotypic, and molecular features of a Tcell lymphoproliferative disorder involving the axillary lymph node of a 33-year-old man following infliximab treatment for ulcerative colitis. The lymph node was effaced by a proliferation of small to intermediate-sized atypical T lymphocytes that expressed CD2, CD3, CD5, CD4, CD8, and CD30 but not TIA-1 or CD56. In situ hybridization studies were negative for Epstein-Barr virus RNA (EBER-1). Although the effacement of architecture and cytologic atypia were suspicious for a peripheral T-cell lymphoma, molecular studies for T-cell receptor gene rearrangement demonstrated a polyclonal T-cell population. Lymphomas of both B- and Tcell lineage have been described in patients treated with TNF- blockade. To date 8 cases of T-cell lymphoproliferative disorders associated with infliximab have been reported to the FDA's Adverse Event Reporting System, all of which have been subclassified as hepatosplenic T-cell lymphomas with aggressive clinical outcomes. These lymphomas, along with the peripheral T-cell lymphoma described in this case report, have been negative for Epstein-Barr virus RNA suggesting that lymphoproliferative disorders following infliximab treatment for inflammatory bowel disease may involve Epstein-Barr virus- independent immune dysregulation. The spectrum of lymphoproliferative disorders associated with infliximab and the potential mechanisms by which they occur are discussed.

Langerhans Cell Histiocytosis With Coexisting Classical Hodgkin Lymphoma

(Poster No. 28)

Kressida T. Cain, MD1 (kcain@usouthal.edu); Jacek Polski, MD1; Richard R. Gacek, MD2; Tommy Boudreau, MD.3 1Department of Pathology, University of South Alabama, Mobile; 2Department of Otolaryngology, University of Massachusetts Medical Center, Worcester; 3Department of Pathology, Mobile Infirmary Medical Center, Mobile, Ala.

Proliferation of Langerhans cells in one or multiple organ systems de- fines Langerhans cell histiocytosis (LCH). A number of cases have been reported demonstrating the coexistence of LCH with a variety of other malignancies. LCH has been described preceding, following, or existing with other tumors, including lymphoma and leukemia. We describe 2 cases in which lymph nodes with classical Hodgkin lymphoma contained large aggregates of Langerhans cells and eosinophils consistent with LCH. The patients were a 52-year-old man and a 38-year-old woman presenting with cervical and inguinal lymphadenopathy, respectively. Excisional biopsy of the cervical lymph nodes in the first case revealed extensive involvement by lymphohistiocytic infiltrate containing scattered Reed-Sternberg cells and Hodgkin cell variants. The inguinal mass in the second case revealed multiple lymph nodes with subtotal effacement by a nodular proliferation of small lymphocytes, epithelioid histiocytes, and eosinophils with scattered Reed-Sternberg cells and Hodgkin cell variants. In addition, both cases contained focal, sinusoidal aggregates of Langerhans cells, eosinophils, and necrosis. Reed- Sternberg cells and Hodgkin cells were positive for CD15 and CD30. The Langerhans cells were positive for S100 and CD1a. There was no clinical evidence of systemic LCH at the time of diagnosis. These cases illustrate association of LCH with Hodgkin lymphoma. The nature of this association is uncertain. Some studies suggest that it may represent a reactive proliferation of Langerhans cells rather than neoplastic and potentially aggressive disease.

Characterization of Immature Reticulocytes Fraction and Absolute Neutrophil Count Following Engraftment in a Tandem Cord Blood Transplant Patient

(Poster No. 29)

Gretchen Johns, MD1; Guilan Chen, MD1 (ggchen=2000@yahoo.com); John Richart, MD2; Stephanie Becker-Koepke, MD2; Dana Oliver, MPH, MT(ASCP)3; Alan L. Lipe, BA, I(ASCP)1; Michael Creer, MD.1 Departments of 1Pathology and 2Hematology and 3Cancer Center, St Louis University, St Louis, Mo.

Context: Donor engraftment following hematopoietic stem cell transplantation is conventionally determined by measuring absolute neutrophil count (ANC) with engraftment defined as the first of 3 consecutive days when ANC exceeds 500/[mu]L in peripheral blood.

Design: In this study, we monitored peripheral blood ANC, immature reticulocyte fraction (IRF), and other parameters readily measurable by the Sysmex XE-2100 weekly in a chronic myelocytic leukemia patient recovering from tandem cord blood transplants directly into the bone marrow. We compared the trends of ANC, IRF, and other parameters to variable number of tandem repeats data from the bone marrow.

Results: IRF increased simultaneously as the cord blood engrafted and decreased as the engraftment was lost, as compared with the pattern of variable number of tandem repeats. ANC had a delayed but otherwise similar pattern response following engraftment. IRF was superior to ANC in that it not only simultaneously reflected engraftment (several days before the ANC) but also remained low with relapse of the chronic myelocytic leukemia, whereas the ANC increased with relapse. Conclusions: IRF appears to predict engraftment earlier as compared with ANC. ANC also was slightly later to decline with loss of engraftment and increased with relapse of chronic myelocytic leukemia, whereas IRF declined up to 1 week sooner with engraftment loss and remained low during relapse.

Hodgkin Lymphoma Presenting as Paraneoplastic Encephalitis

(Poster No. 30)

Renuka Agrawal, MD (reagrawal@llu.edu); Craig Zuppan, MD; Jun Wang, MD. Department of Pathology, Loma Linda University Medical Center, Loma Linda, Calif.

Hodgkin lymphoma is a common hematologic malignancy, generally presenting as lymphadenopathy, with or without systemic ''B'' symptoms. We report a case of Hodgkin lymphoma with an unusual presentation, mimicking encephalitis. A 23-year-old man with fever, headache, and neck stiffness for 1 month developed progressive vision and hearing loss, dysphagia, slurred speech, and unsteady gait. No lymphadenopathy was evident on physical examination. A presumptive diagnosis of viral meningitis was made. His symptoms initially improved but then worsened again; at which time, neurologic evaluation demonstrated depressed mood, normal pupillary reaction, bilateral positive Babinski sign, a weak gag reflex, and a wide-based unstable gait. A complete blood count and metabolic panel were normal. Spinal fluid showed a mild to moderately elevated cell count with high protein content and a negative bacterial culture. Computed tomography scan of the head was normal, but magnetic resonance imaging showed changes suggestive of autoimmune encephalitis. A chest radiograph revealed a widened superior mediastinum, which computed tomography scan demonstrated to be the result of extensive lymphadenopathy. A mediastinal lymph node biopsy showed classical Hodgkin lymphoma, nodular sclerosing type. Following chemotherapy, the patient had a full neurologic recovery. Paraneoplastic syndromes are an uncommon presentation of Hodgkin lymphoma and, in the absence of clinical lymphadenopathy, may result in misdiagnosis as a neurologic condition. After excluding infection, Hodgkin lymphoma should be considered among the causes of neurologic paraneoplastic syndromes (Figure 2: Reed-Sternberg cell).

Primary Bone Marrow Lymphoma With Unusual Presentation

(Poster No. 31)

Dollett T. White, MD (Dollett.T.White@uth.tmc.edu);William D. Payne, MD; Wei Feng, MD; Anthony Padula, MD; Marylee Kott, MD; Margaret Uthman, MD. Department of Pathology and Laboratory Medicine, University of Texas Medical School, Houston.

Primary extranodal involvement occurs as an initial presentation of diffuse large B-cell lymphoma in up to 40% of cases, with the gastrointestinal tract, testis, soft tissue, and salivary glands being common sites of involvement. The bone marrow and peripheral blood are among the rarest sites of initial presentation. We report a case of primary bone marrow lymphoma. A 27-year-old man presented complaining of intermittent fever, fatigue, and bone pain during a 3- week period. He also had renal failure. He was noted to have hypercalcemia, decreased parathyroid hormone, and normal parathyroid- related peptide. Computed tomography scan for renal stones showed multiple lytic bone lesions. Lymphadenopathy was not present. A monoclonal band was detected neither on serum nor on urine protein electrophoresis. Bone marrow biopsy and fine-needle aspiration of the lytic lesions showed a population of medium- to large-sized cells with basophilic cytoplasm and cytoplasmic vacuolization. Flow cytometry identified a B-cell population with surface restriction positive for CD45, CD19, CD20, CD10, CD22, CD38, and HLA-DR. Immunohistochemistry showed Bcl-6 negativity, Bcl-2 positivity, and a Ki-67 proliferation index of 70% to 90%, consistent with a high- grade diffuse large B-cell lymphoma. The patient received 1 cycle of hyper-CVAD chemotherapy during hospitalization and was discharged to go home. This case illustrates a rare process of primary bone marrow diffuse large B-cell lymphoma with an unusual presentation of multiple lytic bone lesions. The Ki-67 proliferation index, along with the presentation, is instrumental in deciding the appropriate therapy.

Cytogenetic Findings in Primary Cutaneous Anaplastic Large Cell Lymphoma

(Poster No. 32)

Jolie R. Rodriguez, MD1 (jrodriguez@usouthal.edu); Beth Rutland, MD1; Cathy M. Tuck-Muller, PhD2; Christine J. Kusyk, PhD2; Allen K. Lee, MS2; John J. Lazarchick, MD3; Jacek M. Polski, MD.1 Departments of 1Pathology and 2Medical Genetics, University of South Alabama,Mobile; 3Department of Pathology, Mobile Infirmary Medical Center, Mobile, Ala.

Primary cutaneous anaplastic large cell lymphoma (CALCL) is a T- cell lymphoproliferative disorder clinically and morphologically distinct from systemic anaplastic large cell lymphoma. Rearrangements of anaplastic large cell lymphoma kinase are characteristic of anaplastic large cell lymphoma but not of CALCL. In fact, few reports characterizing the chromosomal abnormalities in CALCL have been published. We report the case of a 24-year-old woman with a history of multiple ulcerated skin lesions on her arms and legs that had increased in size compared with the previous year; at presentation, the lesions measured up to 13.0 cm. Multiple skin biopsies revealed a dense dermal i

Source: Archives of Pathology & Laboratory Medicine

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