Evaluation of the Correlation of Immunohistochemical Findings with Flow Cytometric Findings in Newly Diagnosed Pediatric Acute Lymphoblastic Leukemia Patients

Abstract

Background and objectives: The development of new therapeutic options to treat leukemia (therapies targeting chimeric antigen receptor [CAR] T cells) down-regulates markers expressed on the cell surface. Therefore, conventional immunophenotyping panels no longer make these antigens unreliable for identifying a B cell immunophenotype. In our study, we methodically compared multiparametric flow cytometry (FC) in bone marrow aspiration and immunohistochemical (IHC) analysis in bone marrow biopsy in childhood acute lymphoblastic leukemia (ALL). We sought to answer whether these two methods could be alternatives to each other in the diagnosis of leukemia. Material-Method: Twenty-eight patients diagnosed with ALL were included in the study. A Kappa test was performed between the expression rates of the antibodies studied in simultaneous FC and IHC studies in bone marrow aspiration and biopsy samples performed at the initial diagnosis. Results: Twenty-three of the patients were precursor B-ALL (BCP-ALL) and 5 were T-ALL. In the immunophenotyping of patients with BCP-ALL using FC and IHC, MPO, CD79A, CD14, CD3 expressions were the same, while CD19, CD7, CD117, CD33, CD 56, CD34 expressions were very good, good concordance for CD20 expressions and moderate for CD10 expressions. In immunophenotyping of patients diagnosed with T-ALL using FC and IHC, CD20, CD19, CD14, CD79a, MPO, CD22 expressions were the same and excellent agreement was found in terms of CD2, CD10, CD34 expressions. Conclusion: In cases where there are treatments that affect immunophenotyping, costly methods such as FC are not available, or bone marrow aspiration cannot be taken adequately, immunophenotyping with IHC can be safely performed in the diagnosis of pediatric ALL in bone marrow biopsy.

Keywords

• Acute Lymphoblastic Leukemia
• immunohistochemical
• flow cytometry
• immunophenotyping

Yeni Tanı Pediatrik Akut Lenfoblastik Lösemide, Kemik İliği Biyopsisinde İmmünohistokimyasal Bulguların Akım Sitometrik Bulgular ile İlişkisinin Değerlendirilmesi

Abstract

Amaç: Lösemiyi tedavi etmek için yeni terapötik seçeneklerin geliştirilmesi (kimerik antijen reseptörü [CAR] T hücrelerini hedefleyen tedaviler), hücre yüzeyinde eksprese edilen belirteçlerin down regülasyonuna neden olmaktadır. Bu nedenle, geleneksel immünofenotipleme panelleri artık bu antijenleri bir B hücresi immünofenotipinin tanımlanması için güvenilmez hale getirmektedir. Çalışmamızda, çocukluk çağı akut lenfoblastik lösemisinde (ALL) kemik iliği aspirasyonunda multiparametrik akım sitometrisi (AS) ile kemik iliği biyopsisinde immünohistokimyasal (İHK) analizi metodolojik olarak karşılaştırdık. Lösemi tanısında bu iki yöntemin birbirine alternatif olup olamayacağını yanıtlamaya çalıştık. Gereç-Yöntem: ALL tanısı alan 28 hasta çalışmaya dahil edildi. İlk tanı sırasında yapılan kemik iliği aspirasyonu ve biyopsi örneklerinde eş zamanlı AS ve İHK çalışmalarında kullanılan antikorların ekspresyonları arasındaki uyum için Kappa testi yapıldı. Bulgular: Hastaların 23'ü pre-B ALL (BCP-ALL) ve 5'i T-ALL idi. BCP-ALL'li hastaların AS ve İHK'da kullanılan MPO, CD79A, CD14, CD3 antikorlarında ekspresyonlar aynı iken, CD19, CD7, CD117, CD33, CD 56, CD34 antikor ekspresyonları arasında çok iyi, CD20 antikor ekspresyonunda iyi ve CD10 ekspresyonunda ise orta düzeyde uyum mevcuttu. T-ALL tanılı hastaların AS ve İHK'da kullanılan CD20, CD19, CD14, CD79a, MPO, CD22 antikorlarının ekspresyonları aynıydı, CD2, CD10, CD34 antikorlarının ekspresyonları açısından çok iyi uyum mevcuttu. Tartışma: İmmünfenotiplemeyi etkileyen tedavilerin olduğu, AS gibi maliyetli yöntemlerin bulunmadığı veya kemik iliği aspirasyonunun yeterince alınamadığı durumlarda, kemik iliği biyopsisinde pediatrik ALL tanısında İHK ile immünfenotipleme güvenle yapılabilir.

Keywords

• Akut lenfoblastik lösemi
• İmmünohistokimya
• Akım sitometri
• İmmünofenatiplendirme

References

1. 1. Nordlund J, Syvänen AC. Epigenetics in pediatric acute lymphoblastic leukemia. Semin Cancer Biol. 2018;51:129-38.
2. 2. Steliarova-Foucher E, Colombet M, Ries LAG, et al. International incidence of childhood cancer, 2001-10: a population-based registry study. Lancet Oncol. 2017;18(6):719-31.
3. 3. Howlader N, Noone A-M, Krapcho M, et al. SEER cancer statistics review, 1975–2010. National Cancer Institute. 2014.
4. 4. Hunger SP, Mullighan CG. Acute Lymphoblastic Leukemia in Children. N Engl J Med. 2015;373(16):1541-52.
5. 5. Iacobucci I, Mullighan CG. Genetic Basis of Acute Lymphoblastic Leukemia. J Clin Oncol. 2017; 35(9): 975-83.
6. 6. Inaba H, Mullighan CG. Pediatric acute lymphoblastic leukemia. Haematologica. 2020;105(11):2524-39.
7. 7. Jastaniah W, Essa MF, Ballourah W, et al. Incidence trends of childhood acute lymphoblastic leukemia in Saudi Arabia: Increasing incidence or competing risks? Cancer Epidemiol. 2020;67:101764.
8. 8. Loghavi S, Kutok JL, Jorgensen JL. B-acute lymphoblastic leukemia/lymphoblastic lymphoma. Am J Clin Pathol. 2015;144(3):393-410.

9. 9. Rehman A, Abbas N, Saba T, Rahman SIU, Mehmood Z, Kolivand H. Classification of acute lymphoblastic leukemia using deep learning. Microsc Res Tech. 2018;81(11):1310-7.
10. 10. Del Principe MI, De Bellis E, Gurnari C, Buzzati E, Savi A, Consalvo MAI, et al. Applications and efficiency of flow cytometry for leukemia diagnostics. Expert Rev Mol Diagn. 2019;19(12):1089-97.
11. 11. Kremer M, Quintanilla-Martínez L, Nährig J, von Schilling C, Fend F. Immunohistochemistry in bone marrow pathology: a useful adjunct for morphologic diagnosis. Virchows Arch. 2005;447(6):920-37.
12. 12. Cherian S, Soma LA. How I Diagnose Minimal/Measurable Residual Disease in B Lymphoblastic Leukemia/Lymphoma by Flow Cytometry. Am J Clin Pathol. 2021;155(1):38-54.
13. 13. Brestoff JR, Frater JL. Contemporary Challenges in Clinical Flow Cytometry: Small Samples, Big Data, Little Time. J Appl Lab Med. 2022;7(4):931-44.
14. 14. Sitalakshmi S, Srikrishna A, Devi S, Damodar P, Alexander B. The diagnostic utility of bone marrow trephine biopsies. Indian J Pathol Microbiol. 2005;48(2):173-6.
15. 15. Martino M, Alati C, Canale FA, Musuraca G, Martinelli G, Cerchione C. A Review of Clinical Outcomes of CAR T-Cell Therapies for B-Acute Lymphoblastic Leukemia. Int J Mol Sci. 2021;22(4).
16. 16. Tiacci E, Pileri S, Orleth A, et al. PAX5 expression in acute leukemias: higher B-lineage specificity than CD79a and selective association with t(8;21)-acute myelogenous leukemia. Cancer Res. 2004; 64(20): 7399-404.
17. 17. Gupta GK, Sun X, Yuan CM, Stetler-Stevenson M, Kreitman RJ, Maric I. Usefulness of Dual Immunohistochemistry Staining in Detection of Hairy Cell Leukemia in Bone Marrow. Am J Clin Pathol. 2020; 153(3):322-7.
18. 18. Al Gwaiz LA, Bassioni W. Immunophenotyping of acute lymphoblastic leukemia using immunohistochemistry in bone marrow biopsy specimens. Histol Histopathol. 2008;23(10):1223-8.
19. 19. Manivannan P, Puri V, Somasundaram V, et al. Can threshold for MPO by flow cytometry be reduced in classifying acute leukaemia? A comparison of flow cytometric and cytochemical myeloperoxidase using different flow cytometric cut-offs. Hematology. 2015;20(8):455-61.
20. 20. Bain BJ, Barnett D, Linch D, Matutes E, Reilly JT. Revised guideline on immunophenotyping in acute leukaemias and chronic lymphoproliferative disorders. Clin Lab Haematol. 2002;24(1):1-13.
21. 21. Johansson U, Bloxham D, Couzens S, et al. Guidelines on the use of multicolour flow cytometry in the diagnosis of haematological neoplasms. British Committee for Standards in Haematology. Br J Haematol. 2014;165(4):455-88.
22. 22. Alpar C. (2014) Applied statistics and validity and reliability with examples from sports, health and educational sciences. Ankara: Detay Publishing.
23. 23. Wu C, Li W. Genomics and pharmacogenomics of pediatric acute lymphoblastic leukemia. Crit Rev Oncol Hematol. 2018;126:100-11.
24. 24. Schrappe M, Reiter A, Zimmermann M, et al. Long-term results of four consecutive trials in childhood ALL performed by the ALL-BFM study group from 1981 to 1995. Berlin-Frankfurt-Münster. Leukemia. 2000;14(12):2205-22.
25. 25. Noronha EP, Marinho HT, Thomaz EB, Silva CA, Veras GL, Oliveira RA. Immunophenotypic characterization of acute leukemia at a public oncology reference center in Maranhão, northeastern Brazil. Sao Paulo Med J. 2011;129(6):392-401.
26. 26. Tasian SK, Loh ML, Hunger SP. Childhood acute lymphoblastic leukemia: Integrating genomics into therapy. Cancer. 2015;121(20):3577-90.
27. 27. Hsu PC, Pei JS, Chen CC, et al. Association of Matrix Metallopeptidase-2 Promoter Polymorphisms With the Risk of Childhood Leukemia. Anticancer Res. 2019;39(3):1185-90.
28. 28. KÖKER SA, OYMAK Y, VERGİN R, Dilek İ, GENEL F. The Effects of Immunophenotyping with Flow Cytometry on Prognosis in Acute Lymphoblastic Leukemia. Journal of Contemporary Medicine.11(1):22-8.
29. 29. Mhawech P, Buffone GJ, Khan SP, Gresik MV. Cytochemical staining and flow cytometry methods applied to the diagnosis of acute leukemia in the pediatric population: an assessment of relative usefulness. J Pediatr Hematol Oncol. 2001;23(2):89-92.
30. 30. Kheiri SA, MacKerrell T, Bonagura VR, Fuchs A, Billett HH. Flow cytometry with or without cytochemistry for the diagnosis of acute leukemias? Cytometry. 1998;34(2):82-6.
31. 31. Wimalachandra M, Prabashika M, Dissanayake M, de Silva R, Gooneratne L. Immunophenotypic characterization of acute lymphoblastic leukemia in a flowcytometry reference centre in Sri Lanka. Ceylon Med J. 2020;65(1&2):23-7.
32. 32. Onciu M. Acute lymphoblastic leukemia. Hematol Oncol Clin North Am. 2009;23(4):655-74.
33. 33. Bavikatty NR, Ross CW, Finn WG, Schnitzer B, Singleton TP. Anti-CD10 immunoperoxidase staining of paraffin-embedded acute leukemias: comparison with flow cytometric immunophenotyping. Hum Pathol. 2000;31(9):1051-4.
34. 34. Yasmeen S, Rajkumar A, Grossman H, Szallasi A. Terminal Deoxynucleotidyl Transferase (TdT)-negative Lymphoblastic Leukemia in Pediatric Patients: Incidence and Clinical Significance. Pediatr Dev Pathol. 2017;20(6):463-8.
35. 35. Toth B, Wehrmann M, Kaiserling E, Horny HP. Immunophenotyping of acute lymphoblastic leukaemia in routinely processed bone marrow biopsy specimens. J Clin Pathol. 1999;52(9):688-92.
36. 36. Oberley MJ, Li S, Orgel E, Phei Wee C, Hagiya A, O'Gorman MRG. Clinical Significance of Isolated Myeloperoxidase Expression in Pediatric B-Lymphoblastic Leukemia. Am J Clin Pathol. 2017;147(4):374-81.
37. 37. Savaşan S, Buck S, Gadgeel M, Gabali A. Flow cytometric false myeloperoxidase-positive childhood B-lineage acute lymphoblastic leukemia. Cytometry B Clin Cytom. 2018;94(3):477-83.
38. 38. Fawzy MM, Abd El-hafez A, El-Ashwah S, Abouzeid TE, Waheeb MF, Saif M, et al. Isolated Myeloperoxidase Immunohistochemical Expression in Bone Marrow Biopsy Depicts Clinical Outcomes in Adults with Typical B-Acute Lymphoblastic Leukemia. Asian Pac J Cancer Prev. 2021;22(7):2143-52.
39. 39. Seegmiller AC, Kroft SH, Karandikar NJ, McKenna RW. Characterization of immunophenotypic aberrancies in 200 cases of B acute lymphoblastic leukemia. Am J Clin Pathol. 2009;132(6):940-9.
40. 40. Basturk A, Akinci S, Hacibekiroglu T, et al. Prognostic significance of flow cytometry findings in Turkish adult acute leukemia patients. Eur Rev Med Pharmacol Sci. 2015;19(18):3360-6.
41. 41. Rezaei MS, Esfandiari N, Refoua S, Shamaei M. Characterization of Immunophenotypic Aberrancies in Adult and Childhood Acute Lymphoblastic Leukemia: Lessons from Regional Variation. Iran J Pathol. 2020;15(1):1-7.
42. 42. Aref S, Azmy E, El-Bakry K, Ibrahim L, Abdel Aziz S. Prognostic impact of CD200 and CD56 expression in pediatric B-cell acute lymphoblastic leukemia patients. Pediatr Hematol Oncol. 2017;34(5):275-85.
43. 43. Roshal M, Fromm JR, Winter S, Dunsmore K, Wood BL. Immaturity associated antigens are lost during induction for T cell lymphoblastic leukemia: implications for minimal residual disease detection. Cytometry B Clin Cytom. 2010;78(3):139-46