1
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Miller S, Vandergriff T, Woodworth Goff H, Xu J, Oliver D. Comparison of 2 T-Cell Receptor-γ Clonality Assays on Skin Biopsies Suspicious for Mycosis Fungoides. Am J Dermatopathol 2024:00000372-990000000-00301. [PMID: 38457687 DOI: 10.1097/dad.0000000000002654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
ABSTRACT PCR-based fragment analysis of the T-cell receptor (TCR) gene is used extensively in diagnostic labs to assess clonality in T-cell populations in multiple tissue sites. Of the numerous TCR assays that have been reported, studies assessing use on biopsies suspicious for mycosis fungoides specifically are lacking. We compared clonality findings from a previously run 2-tube/2-fluorochrome dye assay to a redesigned 1-tube/1-fluorochrome dye assay on formalin-fixed skin biopsies. Overall, the accuracy of the 2-tube assay was marginally better (75.7% vs. 71.4%), when using clinical history combined with histologic diagnosis as the gold standard. The 2-tube assay had better sensitivity (73.7% vs. 65.8%), while the 1-tube assay had superior specificity (93.8% vs. 87.5%). Clonality results were easier to interpret with the 1-tube assay. In nearly 19% of cases, a change of assays on the same biopsy resulted in a change of clonality interpretation. For laboratories that change TCR-γ clonality assays, follow-up biopsies for mycosis fungoides assessment may result in a change of diagnosis.
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Affiliation(s)
- Stan Miller
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX; and
| | - Travis Vandergriff
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX; and
- Department of Dermatology, UT Southwestern Medical Center, Dallas, TX
| | | | - Jing Xu
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX; and
| | - Dwight Oliver
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX; and
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2
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Nguyen PC, Nguyen T, Wilson C, Tiong IS, Baldwin K, Nguyen V, Came N, Blombery P, Westerman DA. Evaluation of T-cell clonality by anti-TRBC1 antibody-based flow cytometry and correlation with T-cell receptor sequencing. Br J Haematol 2024; 204:910-920. [PMID: 38098188 DOI: 10.1111/bjh.19252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/08/2023] [Accepted: 11/28/2023] [Indexed: 03/14/2024]
Abstract
Flow cytometry (FC) incorporating the T-cell receptor β constant chain-1 (TRBC1) has been recently proposed as a new standard in T-cell clonality assessment. While early studies demonstrated high sensitivity in samples with conspicuous tumour burden, performance in real-world samples, including those with low tumour burden and correlation with molecular methods has been limited. We evaluated TRBC1-FC performance and correlated the results with high-throughput TRB sequencing and a targeted next-generation sequencing gene panel. Our cohort consisted of 90 evaluable samples from 57 patients. TRBC1-FC confirmed T-cell clonality in 37 out of 38 samples (97%) that were involved in a mature T-cell neoplasm (MTCN). T-cell clonality was also identified in nine samples from patients lacking a current or prior diagnosis of MTCN, consistent with the emerging entity T-cell clonality of uncertain significance. TRBC-FC was polyclonal in all samples and negative for disease involvement by standard pathology assessment. However, correlation with TRB sequencing in 17 of these samples identified two cases that harboured the known clonal sequence from index testing, indicating the presence of measurable residual disease not otherwise detected. Our study provides real-world correlative validation of TRBC1-FC, highlighting the strengths and limitations pertinent to its increasing implementation by general diagnostic laboratories.
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Affiliation(s)
- Phillip C Nguyen
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tamia Nguyen
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Clarissa Wilson
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ing Soo Tiong
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Kylie Baldwin
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Vuong Nguyen
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Neil Came
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Piers Blombery
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David A Westerman
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
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3
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Yuan CT, Wang JT, Sheng WH, Cheng PY, Kao CJ, Wang JY, Chen CY, Liau JY, Tsai JH, Lin YJ, Chen CC, Chen YC, Chang SC, Wu UI. Lymphadenopathy Associated With Neutralizing Anti-interferon-gamma Autoantibodies Could Have Monoclonal T-cell Proliferation Indistinguishable From Malignant Lymphoma and Treatable by Antibiotics: A Clinicopathologic Study. Am J Surg Pathol 2021; 45:1138-1150. [PMID: 34010155 DOI: 10.1097/pas.0000000000001731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Early recognition of adult-onset immunodeficiency associated with neutralizing anti-interferon gamma autoantibodies (anti-IFNγ Abs) remains difficult, and misdiagnoses have been reported. Although febrile lymphadenopathy is among the most common initial manifestations of this disorder, no comprehensive clinicopathologic analysis of lymphadenopathy in patients with anti-IFNγ Abs has been reported. Here, we describe 26 lymph node biopsy specimens from 16 patients. All patients exhibited concurrent disseminated nontuberculous mycobacterial infections, and 31% received a tentative diagnosis of lymphoma at initial presentation. We found 3 distinct histomorphologic patterns: well-formed granuloma (46%), suppurative inflammation or loose histiocytic aggregates (31%), and lymphoproliferative disorder (LPD, 23%). The latter shared some of the features of malignant T-cell lymphoma, IgG4-related disease, and multicentric Castleman disease. Half of the specimens with LPD had monoclonal T cells, and 33.3% were indistinguishable from angioimmunoblastic T-cell lymphoma as per current diagnostic criteria. All lymphadenopathy with LPD features regressed with antibiotics without administration of cytotoxic chemotherapy or immunotherapy. The median follow-up time was 4.3 years. Our study highlights the substantial challenge of distinguishing between lymphoma and other benign lymphadenopathy in the setting of neutralizing anti-IFNγ Abs. Increased vigilance and multidisciplinary discussion among clinicians and pathologists are required to achieve the most appropriate diagnosis and management.
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Affiliation(s)
- Chang-Tsu Yuan
- Graduate Institute of Clinical Medicine
- Departments of Pathology
- Departments of Pathology
| | - Jann-Tay Wang
- Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
| | - Wang-Huei Sheng
- Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
| | - Pei-Yuan Cheng
- Graduate Institute of Pathology, National Taiwan University
| | | | - Jann-Yuan Wang
- Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
| | - Chien-Yuan Chen
- Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
| | - Jau-Yu Liau
- Graduate Institute of Pathology, National Taiwan University
- Departments of Pathology
| | - Jia-Huei Tsai
- Graduate Institute of Pathology, National Taiwan University
- Departments of Pathology
| | | | | | - Yee-Chun Chen
- Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
- Center of Infection Control, National Taiwan University Hospital, Taipei, Taiwan
| | - Shan-Chwen Chang
- Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
| | - Un-In Wu
- Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine
- Medicine, National Taiwan University Cancer Center
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4
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Ho CC, Tung JK, Zehnder JL, Zhang BM. Validation of a Next-Generation Sequencing-Based T-Cell Receptor Gamma Gene Rearrangement Diagnostic Assay: Transitioning from Capillary Electrophoresis to Next-Generation Sequencing. J Mol Diagn 2021; 23:805-815. [PMID: 33892183 DOI: 10.1016/j.jmoldx.2021.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 03/15/2021] [Accepted: 03/25/2021] [Indexed: 01/23/2023] Open
Abstract
Assessment of T-cell receptor γ gene (TRG) rearrangements is an importants consideration in the diagnostic workup of lymphoproliferative diseases. Although fragment analysis by PCR and capillary electrophoresis (CE) is the current standard of such assessment in clinical molecular diagnostic laboratories, it does not provide sequence information and is only semi-quantitative. Next-generation sequencing (NGS)-based assays are an attractive alternative to the conventional fragment size-based methods, given that they generate results with specific clonotype sequence information and allow for more accurate quantitation. The present study evaluated various test parameters and performance characteristics of a commercially available NGS-based TRG gene-rearrangement assay by testing 101 clinical samples previously characterized by fragment analysis. The NGS TRG assay showed an overall accuracy of 83% and an analytical specificity of 100%. The concordance rates were 88% to 95% in the Vγ1-8, Vγ10, and Vγ11 gene families, but lower in the Vγ9 gene family. This difference was mostly attributed to the incomplete polyclonal symmetry resulting from the two-tube CE assay versus the one-tube design of the NGS assay. The NGS assay also demonstrated strengths in distinguishing clonotypes of the same fragment size. This clinical validation demonstrated robust performance of the NGS-based TRG assay and identified potential pitfalls associated with CE assay design that are important for understanding the observed discrepancies with the CE-based assay.
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Affiliation(s)
- Chandler C Ho
- Molecular Pathology Laboratory, Stanford Health Care, Stanford, California
| | - Jack K Tung
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - James L Zehnder
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Bing M Zhang
- Department of Pathology, Stanford University School of Medicine, Stanford, California.
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5
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Keppens C, Boone E, Gameiro P, Tack V, Moreau E, Hodges E, Evans P, Brüggemann M, Carter I, Lenze D, Sarasquete ME, Möbs M, Liu H, Dequeker EMC, Groenen PJTA. Evaluation of a worldwide EQA scheme for complex clonality analysis of clinical lymphoproliferative cases demonstrates a learning effect. Virchows Arch 2021; 479:365-376. [PMID: 33686511 PMCID: PMC8364525 DOI: 10.1007/s00428-021-03046-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/18/2020] [Accepted: 01/28/2021] [Indexed: 11/26/2022]
Abstract
Clonality analysis of immunoglobulin (IG) or T-cell receptor (TR) gene rearrangements is routine practice to assist diagnosis of lymphoid malignancies. Participation in external quality assessment (EQA) aids laboratories in identifying systematic shortcomings. The aim of this study was to evaluate laboratories' improvement in IG/TR analysis and interpretation during five EQA rounds between 2014 and 2018. Each year, participants received a total of five cases for IG and five cases for TR testing. Paper-based cases were included for analysis of the final molecular conclusion that should be interpreted based on the integration of the individual PCR results. Wet cases were distributed for analysis of their routine protocol as well as evaluation of the final molecular conclusion. In total, 94.9% (506/533) of wet tests and 97.9% (829/847) of paper tests were correctly analyzed for IG, and 96.8% (507/524) wet tests and 93.2% (765/821) paper tests were correctly analyzed for TR. Analysis scores significantly improved when laboratories participated to more EQA rounds (p=0.001). Overall performance was significantly lower (p=0.008) for non-EuroClonality laboratories (95% for IG and 93% for TR) compared to EuroClonality laboratories (99% for IG and 97% for TR). The difference was not related to the EQA scheme year, anatomic origin of the sample, or final clinical diagnosis. This evaluation showed that repeated EQA participation helps to reduce performance differences between laboratories (EuroClonality versus non-EuroClonality) and between sample types (paper versus wet). The difficulties in interpreting oligoclonal cases highlighted the need for continued education by meetings and EQA schemes.
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Affiliation(s)
- Cleo Keppens
- Department of Public Health and Primary Care, Biomedical Quality Assurance Research Unit, University of Leuven, Kapucijnenvoer 35 block d, 1st floor, box 7001, 3000 Leuven, Belgium
| | - Elke Boone
- AZ Delta vzw - Laboratorium Moleculaire Diagnostiek, Deltalaan 1, 8800 Roeselare, Belgium
| | - Paula Gameiro
- Laboratory of Hemato-Oncology, Portuguese Institute of Oncology of Lisbon, Rua Prof Lima Basto, 1099-023 Lisboa, Portugal
| | - Véronique Tack
- Department of Public Health and Primary Care, Biomedical Quality Assurance Research Unit, University of Leuven, Kapucijnenvoer 35 block d, 1st floor, box 7001, 3000 Leuven, Belgium
| | - Elisabeth Moreau
- AZ Delta vzw - Laboratorium Moleculaire Diagnostiek, Deltalaan 1, 8800 Roeselare, Belgium
| | - Elizabeth Hodges
- Precision Medicine Centre, Queen’s University Belfast, Health Science Building, 97 Lisburn Road, Belfast, BT9 7AE UK
| | - Paul Evans
- HMDS, Leeds Institute of Oncology, St. James University Hospital, Level 3 Bexley Wing Leeds, Leeds, LS9 7TF UK
| | - Monika Brüggemann
- Department of Hematology, University Hospital Schleswig-Holstein, Langer Segen 8-10, 24105 Kiel, Germany
| | - Ian Carter
- Molecular Diagnostics, Histopathology, Nottingham University Hospitals NHS Trust, City Campus, Hucknall Rd., Nottingham, NG5 1PB UK
| | - Dido Lenze
- Institut für Pathologie, Molekularpathologie, Charité –Universitätsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Maria Eugenia Sarasquete
- Laboratorio Biología Molecular, Servicio de Hematología, Hospital Universitario de Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Markus Möbs
- Institut für Pathologie, Molekularpathologie, Charité –Universitätsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany
| | - Hongxiang Liu
- Molecular Malignancy Laboratory, Haematopathology and Oncology Diagnostic Service (HODS), Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Box 234, Hills Road, Cambridge, CB2 0QQ UK
| | - Elisabeth M. C. Dequeker
- Department of Public Health and Primary Care, Biomedical Quality Assurance Research Unit, University of Leuven, Kapucijnenvoer 35 block d, 1st floor, box 7001, 3000 Leuven, Belgium
| | - Patricia J. T. A. Groenen
- Department of Pathology, Radboud University Medical Centre Nijmegen, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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6
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Marsilio S, Ackermann MR, Lidbury JA, Suchodolski JS, Steiner JM. Results of histopathology, immunohistochemistry, and molecular clonality testing of small intestinal biopsy specimens from clinically healthy client-owned cats. J Vet Intern Med 2019; 33:551-558. [PMID: 30820999 PMCID: PMC6430868 DOI: 10.1111/jvim.15455] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 02/05/2019] [Indexed: 01/25/2023] Open
Abstract
Background Histopathology, immunohistochemistry, and molecular clonality testing are metrics frequently used to diagnose chronic enteropathy (CE) in cats. However, normal values for these metrics have been based mainly on samples from cats that were relatively young, specific pathogen‐free, or both. Objectives To describe results of histopathology, immunohistochemistry, and clonality testing of endoscopically‐derived biopsy specimens of the upper small intestinal tract from a cohort of clinically healthy client‐owned cats. Animals Twenty clinically healthy client‐owned cats ≥3 years of age. Methods Tissue specimens were collected from the stomach and duodenum and evaluated single blinded by a board‐certified pathologist. In addition, samples were evaluated by routine immunohistochemistry and clonality testing. Cats were followed after the procedure for signs of CE. Results Integrated results from histopathology, immunohistochemistry, and clonality testing were interpreted as consistent with small cell lymphoma (SCL; n = 12), emerging SCL (n = 1), lymphocytic enteritis (n = 6), and pseudoclonality (n = 1). On follow‐up, 3 cats eventually developed clinical signs of CE, of which 2 were euthanized 295 and 654 days post‐endoscopy. The remaining 17 cats did not show clinical signs of CE after a median of 709 days (range, 219‐869 days). Conclusions and Clinical Importance Intestinal biopsy specimens from clinically healthy client‐owned cats commonly had abnormal findings on histopathology, immunohistochemistry, clonality testing, or some combination of these without apparent clinical relevance. Current diagnostic metrics for diagnosing CE in cats may need modification to be applicable to the general population of cats.
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Affiliation(s)
- Sina Marsilio
- Gastrointestinal Laboratory, Texas A&M University, College Station, Texas
| | - Mark R Ackermann
- Gastrointestinal Laboratory, Texas A&M University, College Station, Texas.,Oregon Veterinary Diagnostic Laboratory, Carlson College of Veterinary Medicine, Oregon State University, Corvallis, Oregon
| | - Jonathan A Lidbury
- Gastrointestinal Laboratory, Texas A&M University, College Station, Texas
| | - Jan S Suchodolski
- Gastrointestinal Laboratory, Texas A&M University, College Station, Texas
| | - Jörg M Steiner
- Gastrointestinal Laboratory, Texas A&M University, College Station, Texas
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7
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Xia D, Morgan EA, Berger D, Pinkus GS, Ferry JA, Zukerberg LR. NK-Cell Enteropathy and Similar Indolent Lymphoproliferative Disorders: A Case Series With Literature Review. Am J Clin Pathol 2019; 151:75-85. [PMID: 30212873 DOI: 10.1093/ajcp/aqy108] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objectives We report four new cases of natural killer-cell enteropathy (NKCE) and similar lymphoproliferative disorders (LPDs), as well as review the literature concerning indolent natural killer (NK)-cell LPDs of the gastrointestinal tract. Methods Pathologic and clinical data were obtained from institutional/referral records. Results Patient 1 (45-year-old man) had anemia; a small intestinal lesion was endoscopically biopsied. Patient 2 (65-year-old woman) had biliary colic, treated with cholecystectomy. Patient 3 (62-year-old man) had a small colonic polyp, biopsied on routine colonoscopy. Patient 4 (68-year-old man) had presumed Crohn disease; multiple biopsies were performed over more than 10 years. Diagnostic specimens showed atypical infiltrates of Epstein-Barr virus-negative lymphocytes with immunophenotypes suggestive of NK cells. In all cases, there was distortion of glandular architecture but no marked intraepithelial lymphocytosis or necrosis. The patients did not receive therapy for lymphoma and were well on follow-up. Conclusions These cases support the indolent nature of NKCE and similar LPDs, and they indicate that involvement outside the alimentary canal may occur.
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Affiliation(s)
- Daniel Xia
- The James Homer Wright Pathology Laboratories of the Massachusetts General Hospital, Boston
- Department of Pathology, University Health Network, Toronto, Canada
| | | | - David Berger
- Division of General Surgery, Massachusetts General Hospital, Boston
| | | | - Judith A Ferry
- The James Homer Wright Pathology Laboratories of the Massachusetts General Hospital, Boston
| | - Lawrence R Zukerberg
- The James Homer Wright Pathology Laboratories of the Massachusetts General Hospital, Boston
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8
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Wang HW, Raffeld M. Molecular assessment of clonality in lymphoid neoplasms. Semin Hematol 2018; 56:37-45. [PMID: 30573043 DOI: 10.1053/j.seminhematol.2018.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 05/08/2018] [Indexed: 02/03/2023]
Abstract
Molecular clonality assays in B- and T-cell lymphoproliferative disorders often provide critical information in establishing a diagnosis of a lymphoproliferative disorder. These assays rely on the unique genetic structures that serve as assay targets, created in the process of generating immunoglobulin and T-cell receptors during B- and T-cell development. Molecular clonality assays are generally used when flow cytometry or immunohistochemistry has not sufficiently clarified the benign or malignant nature of a lymphoid proliferation. Additionally, since molecular clonality assays are tumor specific, they allow the clinician to distinguish recurrences from second tumors, and have the sensitivity to monitor minimal residual disease. In this review, we discuss the principles underlying these tests, the current approaches to clonality testing, some of the pitfalls in their interpretation, and the future applications of next generation sequencing technology to clonality testing.
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Affiliation(s)
- Hao-Wei Wang
- Hematopathology Section, Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Mark Raffeld
- Molecular Diagnostics Section, Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD.
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9
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Sholl LM, Longtine J, Kuo FC. Molecular Analysis of Genetic Markers for Non-Hodgkin Lymphomas. CURRENT PROTOCOLS IN HUMAN GENETICS 2017; 93:10.14.1-10.14.29. [PMID: 28384399 DOI: 10.1002/cphg.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Molecular analysis complements the clinical and histopathologic tools used to diagnose and subclassify hematologic malignancies. The presence of clonal antigen-receptor gene rearrangements can help to confirm the diagnosis of a B or T cell lymphoma and can serve as a fingerprint of that neoplasm to be used in identifying concurrent disease at disparate sites or recurrence at future time points. Certain lymphoid malignancies harbor a characteristic chromosomal translocation, a finding that may have significant implications for an individual's prognosis or response to therapy. The polymerase chain reaction (PCR) is typically used to detect antigen-receptor gene rearrangements as well as specific translocations that can be supplemented by fluorescence in situ hybridization (FISH) and karyotype analysis. © 2017 by John Wiley & Sons, Inc.
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Affiliation(s)
| | | | - Frank C Kuo
- Brigham and Women's Hospital, Boston, Massachusetts
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10
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Abstract
The accurate distinction of reactive and neoplastic lymphoid proliferations can present challenges. Given the different prognoses and treatment strategies, a correct diagnosis is crucial. Molecular clonality assays assess rearranged lymphocyte antigen receptor gene diversity and can help differentiate reactive from neoplastic lymphoid proliferations. Molecular clonality assays are commonly used to assess atypical, mixed, or mature lymphoid proliferations; small tissue fragments that lack architecture; and fluid samples. In addition, clonality testing can be utilized to track neoplastic clones over time or across anatomic sites. Molecular clonality assays are not stand-alone tests but useful adjuncts that follow clinical, morphologic, and immunophenotypic assessment. Even though clonality testing provides valuable information in a variety of situations, the complexities and pitfalls of this method, as well as its dependency on the experience of the interpreter, are often understated. In addition, a lack of standardized terminology, laboratory practices, and interpretational guidelines hinders the reproducibility of clonality testing across laboratories in veterinary medicine. The objectives of this review are twofold. First, the review is intended to familiarize the diagnostic pathologist or interested clinician with the concepts, potential pitfalls, and limitations of clonality testing. Second, the review strives to provide a basis for future harmonization of clonality testing in veterinary medicine by providing diagnostic guidelines.
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Affiliation(s)
- S. M. Keller
- Department of Pathobiology, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - W. Vernau
- Department of Pathology, Microbiology and Immunology, University of California, Davis, CA, USA
| | - P. F. Moore
- Department of Pathology, Microbiology and Immunology, University of California, Davis, CA, USA
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11
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Park IJ, Bena J, Cotta CV, Hsi ED, Jegalian AG, Rogers HJ, Tubbs RR, Wang L, Cook JR. Frequency, interobserver reproducibility and clinical significance of equivocal peaks in PCR clonality testing using Euroclonality/BIOMED-2 primers. J Clin Pathol 2014; 67:1093-8. [PMID: 25244911 DOI: 10.1136/jclinpath-2014-202454] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS PCR studies for lymphoid clonality are now widely employed, especially using Euroclonality/BIOMED-2 primers. Criteria for interpretation as a clonal result, however, have proven controversial. This study examines the frequency and clinical significance of equivocal amplification patterns and measures the interobserver reproducibility of clonality interpretations. METHODS At our institution, results of each primer set are first classified as clonal, non-clonal or abnormal (equivocal peak on polyclonal background). Final results for all primer sets are then collectively reported as positive (≥1 clonal result), negative (non-clonal results) or indeterminate (≥1 abnormal result) for a clonal population. Results of 274 consecutive clonality cases were reviewed, and the interobserver reproducibility of individual primer set reactions and final results was determined in a subset of 30 cases. RESULTS 44/161 (27%) B-cell and 50/163 (31%) T-cell cases contained at least one abnormal peak. Of these, 29 (64%) and 31 (62%), respectively, showed clonal results in another primer set. Interobserver reproducibility was excellent for most primer sets and for final interpretations, but only fair to good for IGK V-J and TCRB D-J1+2 primer sets. A definitive diagnosis of lymphoma was rendered in 93%, 20% and 6% of B-cell cases and 90%, 42%, and 14% of T-cell cases positive, indeterminate or negative for a clonal population, respectively. CONCLUSIONS Using a subjective approach, abnormal (equivocal) peaks are frequently observed in routine practice. However, most cases with abnormal peaks contain clonal rearrangements in other primer sets, facilitating overall interpretation of final results with excellent interobserver reproducibility.
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Affiliation(s)
- Il Joong Park
- Department of Laboratory Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - James Bena
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Claudiu V Cotta
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric D Hsi
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Armin G Jegalian
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Heesun J Rogers
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raymond R Tubbs
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - James R Cook
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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12
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Gazzola A, Mannu C, Rossi M, Laginestra MA, Sapienza MR, Fuligni F, Etebari M, Melle F, Sabattini E, Agostinelli C, Bacci F, Sagramoso Sacchetti CA, Pileri SA, Piccaluga PP. The evolution of clonality testing in the diagnosis and monitoring of hematological malignancies. Ther Adv Hematol 2014; 5:35-47. [PMID: 24688753 PMCID: PMC3949299 DOI: 10.1177/2040620713519729] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Currently, distinguishing between benign and malignant lymphoid proliferations is based on a combination of clinical characteristics, cyto/histomorphology, immunophenotype and the identification of well-defined chromosomal aberrations. However, such diagnoses remain challenging in 10-15% of cases of lymphoproliferative disorders, and clonality assessments are often required to confirm diagnostic suspicions. In recent years, the development of new techniques for clonality detection has allowed researchers to better characterize, classify and monitor hematological neoplasms. In the past, clonality was primarily studied by performing Southern blotting analyses to characterize rearrangements in segments of the IG and TCR genes. Currently, the most commonly used method in the clinical molecular diagnostic laboratory is polymerase chain reaction (PCR), which is an extremely sensitive technique for detecting nucleic acids. This technique is rapid, accurate, specific, and sensitive, and it can be used to analyze small biopsies as well as formalin-fixed paraffin-embedded samples. These advantages make PCR-based approaches the current gold standard for IG/TCR clonality testing. Since the completion of the first human genome sequence, there has been a rapid development of technologies to facilitate high-throughput sequencing of DNA. These techniques have been applied to the deep characterization and classification of various diseases, patient stratification, and the monitoring of minimal residual disease. Furthermore, these novel approaches have the potential to significantly improve the sensitivity and cost of clonality assays and post-treatment monitoring of B- and T-cell malignancies. However, more studies will be required to demonstrate the utility, sensitivity, and benefits of these methods in order to warrant their adoption into clinical practice. In this review, recent developments in clonality testing are examined with an emphasis on highly sensitive systems for improving diagnostic workups and minimal residual disease assessments.
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Affiliation(s)
- Anna Gazzola
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Claudia Mannu
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Maura Rossi
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Maria Antonella Laginestra
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Maria Rosaria Sapienza
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Fabio Fuligni
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Maryam Etebari
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Federica Melle
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Elena Sabattini
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Claudio Agostinelli
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Francesco Bacci
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Carlo Alberto Sagramoso Sacchetti
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Stefano Aldo Pileri
- Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - Pier Paolo Piccaluga
- Molecular Pathology Laboratory, Department of Experimental, Diagnostic, and Specialty Medicine, Bologna University Medical School, Unit of Hematopathology, S. Orsola Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
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Greiner TC. Clinical use of next-generation sequencing of TRG gene rearrangements has arrived. Am J Clin Pathol 2014; 141:302-4. [PMID: 24515756 DOI: 10.1309/ajcp5ym3aalkqbii] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Timothy C. Greiner
- Department of Pathology & Microbiology, University of Nebraska Medical Center, Omaha
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Abstract
T-cell neoplasms include both mature T-cell leukemias and lymphomas and immature proliferations of precursor T cells. Molecular laboratories routinely assay suspected T-cell proliferations for evidence of clonality. In addition, some T-cell neoplasms are characterized by recurrent structural abnormalities that can be readily identified by such techniques as fluorescence in situ hybridization. New massively parallel sequencing technologies have led to the identification of numerous recurrent gene mutations in T-cell neoplasms. These findings are reviewed. As new technologies become implemented in molecular diagnostic laboratories and as targeted therapies are developed, it is anticipated that more extensive genomic characterization of T-cell neoplasms will be routinely performed in the future.
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Fan H, Robetorye RS. Detection of clonal T-cell receptor beta and gamma chain gene rearrangement by polymerase chain reaction and capillary gel electrophoresis. Methods Mol Biol 2014; 999:169-88. [PMID: 23666697 DOI: 10.1007/978-1-62703-357-2_11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Although established diagnostic criteria exist for mature T-cell neoplasms, a definitive diagnosis of a T-cell lymphoproliferative disorder cannot always be obtained using more conventional techniques such as flow cytometric immunophenotyping, conventional cytogenetics, fluorescence in situ hybridization, or immunohistochemistry. However, because T-cell malignancies contain identically rearranged T-cell receptor gamma (TCRG) and/or beta (TCRB) genes, the polymerase chain reaction (PCR) can be a fast, convenient, and dependable option to identify clonal T-cell processes. This chapter describes the use of PCR and capillary electrophoresis to identify clonal TCRB and TCRG gene rearrangements (TCRB and TCRG PCR) using a commercially available method employing multiple multiplex PCR tubes that was originally developed as the result of a large European BIOMED-2 collaborative study (Invivoscribe Technologies). The core protocol for the TCRB assay involves the use of three separate multiplex master mix tubes. Tubes A and B target the framework regions within the variable and joining regions of the TCRB gene, and Tube C targets the diversity and joining regions of the TCRB gene. The core protocol for the TCRG assay utilizes two multiplex master mix tubes (Tubes A and B) that target the variable and joining regions of the TCRG gene. Use of the five BIOMED-2 TCRB and TCRG PCR multiplex tubes in parallel can detect approximately 94% of clonal TCR gene rearrangements.
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Affiliation(s)
- Hongxin Fan
- Department of Pathology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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The role of molecular pathology in the diagnosis of cutaneous lymphomas. PATHOLOGY RESEARCH INTERNATIONAL 2012; 2012:913523. [PMID: 23213624 PMCID: PMC3506916 DOI: 10.1155/2012/913523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 10/18/2012] [Indexed: 01/17/2023]
Abstract
Primary cutaneous lymphomas can be difficult to be distinguished from reactive mimics, even when integrating histologic, immunophenotypic, and clinical findings. Molecular studies, especially PCR-based antigen receptor gene rearrangement (ARGR) analysis, are frequently useful ancillary studies in the evaluation of cutaneous lymphoproliferations. The biologic basis of ARGR studies is discussed, as well as a comparison of various current protocols. The pitfalls and limitations of ARGR analysis are also highlighted. Recent advances in the understanding of the molecular pathogenesis of various cutaneous lymphomas are discussed. Some of these nascent discoveries may lead to the development of diagnostically useful molecular assays.
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EuroClonality/BIOMED-2 guidelines for interpretation and reporting of Ig/TCR clonality testing in suspected lymphoproliferations. Leukemia 2012; 26:2159-71. [PMID: 22918122 PMCID: PMC3469789 DOI: 10.1038/leu.2012.246] [Citation(s) in RCA: 336] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PCR-based immunoglobulin (Ig)/T-cell receptor (TCR) clonality testing in suspected lymphoproliferations has largely been standardized and has consequently become technically feasible in a routine diagnostic setting. Standardization of the pre-analytical and post-analytical phases is now essential to prevent misinterpretation and incorrect conclusions derived from clonality data. As clonality testing is not a quantitative assay, but rather concerns recognition of molecular patterns, guidelines for reliable interpretation and reporting are mandatory. Here, the EuroClonality (BIOMED-2) consortium summarizes important pre- and post-analytical aspects of clonality testing, provides guidelines for interpretation of clonality testing results, and presents a uniform way to report the results of the Ig/TCR assays. Starting from an immunobiological concept, two levels to report Ig/TCR profiles are discerned: the technical description of individual (multiplex) PCR reactions and the overall molecular conclusion for B and T cells. Collectively, the EuroClonality (BIOMED-2) guidelines and consensus reporting system should help to improve the general performance level of clonality assessment and interpretation, which will directly impact on routine clinical management (standardized best-practice) in patients with suspected lymphoproliferations.
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Cushman-Vokoun AM, Connealy S, Greiner TC. Assay design affects the interpretation of T-cell receptor gamma gene rearrangements: comparison of the performance of a one-tube assay with the BIOMED-2-based TCRG gene clonality assay. J Mol Diagn 2011; 12:787-96. [PMID: 20959612 DOI: 10.2353/jmoldx.2010.090183] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Interpretation of capillary electrophoresis results derived from multiplexed fluorochrome-labeled primer sets can be complicated by small peaks, which may be incorrectly interpreted as clonal T-cell receptor-γ gene rearrangements. In this report, different assay designs were used to illustrate how design may adversely affect specificity. Ten clinical cases, with subclonal peaks containing one of the two infrequently used joining genes, were identified with a tri-color, one-tube assay. The DNA was amplified with the same NED fluorochrome on all three joining primers, first combined (one-color assay) and then amplified separately using a single NED-labeled joining primer. The single primer assay design shows how insignificant peaks could easily be wrongly interpreted as clonal T-cell receptor-γ gene rearrangements. Next, the performance of the one-tube assay was compared with the two-tube BIOMED-2-based TCRG Gene Clonality Assay in a series of 44 cases. Whereas sensitivity was similar between the two methods (92.9% vs. 96.4%; P = 0.55), specificity was significantly less in the BIOMED-2 assay (87.5% vs. 56.3%; P = 0.049) when a 2× ratio was used to define clonality. Specificity was improved to 81.3% by the use of a 5× peak height ratio (P = 0.626). These findings illustrate how extra caution is needed in interpreting a design with multiple, separate distributions, which is more difficult to interpret than a single distribution assay.
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Affiliation(s)
- Allison M Cushman-Vokoun
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198-3135, USA
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TCRγ-Chain Gene Rearrangement by GeneScan: Incidence and Significance of Clonal Heterogeneity in Sézary Syndrome. J Invest Dermatol 2010; 130:2312-9. [DOI: 10.1038/jid.2010.97] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kummalue T, Chuphrom A, Sukpanichanant S, Pongpruttipan T, Sukpanichanant S. Detection of monoclonal immunoglobulin heavy chain gene rearrangement (FR3) in Thai malignant lymphoma by High Resolution Melting curve analysis. Diagn Pathol 2010; 5:31. [PMID: 20482846 PMCID: PMC2886000 DOI: 10.1186/1746-1596-5-31] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Accepted: 05/19/2010] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED Malignant lymphoma, especially non-Hodgkin lymphoma, is one of the most common hematologic malignancies in Thailand. The diagnosis of malignant lymphoma is often problematic, especially in early stages of the disease. Detection of antigen receptor gene rearrangement including T cell receptor (TCR) and immunoglobulin heavy chain (IgH) by polymerase chain reaction followed by heteroduplex has currently become standard whereas fluorescent fragment analysis (GeneScan) has been used for confirmation test. In this study, three techniques had been compared: thermocycler polymerase chain reaction (PCR) followed by heteroduplex and polyacrylamide gel electrophoresis, GeneScan analysis, and real time PCR with High Resolution Melting curve analysis (HRM). The comparison was carried out with DNA extracted from paraffin embedded tissues diagnosed as B- cell non-Hodgkin lymphoma. Specific PCR primers sequences for IgH gene variable region 3, including fluorescence labeled IgH primers were used and results were compared with HRM. In conclusion, the detection IgH gene rearrangement by HRM in the LightCycler System showed potential for distinguishing monoclonality from polyclonality in B-cell non-Hodgkin lymphoma. INTRODUCTION Malignant lymphoma, especially non-Hodgkin lymphoma, is one of the most common hematologic malignancies in Thailand. The incidence rate as reported by Ministry of Public Health is 3.1 per 100,000 population in female whereas the rate in male is 4.5 per 100,000 population 1. At Siriraj Hospital, the new cases diagnosed as malignant lymphoma were 214.6 cases/year 2. The diagnosis of malignant lymphoma is often problematic, especially in early stages of the disease. Therefore, detection of antigen receptor gene rearrangement including T cell receptor (TCR) and immunoglobulin heavy chain (IgH) by polymerase chain reaction (PCR) assay has recently become a standard laboratory test for discrimination of reactive from malignant clonal lymphoproliferation 34. Analyzing DNA extracted from formalin-fixed, paraffin-embedded tissues by multiplex PCR techniques is more rapid, accurate and highly sensitive. Measuring the size of the amplicon from PCR analysis could be used to diagnose malignant lymphoma with monoclonal pattern showing specific and distinct bands detected on acrylamide gel electrophoresis. However, this technique has some limitations and some patients might require a further confirmation test such as GeneScan or fragment analysis 56.GeneScan technique or fragment analysis reflects size and peak of DNA by using capillary gel electrophoresis. This technique is highly sensitive and can detect 0.5-1% of clonal lymphoid cells. It measures the amplicons by using various fluorescently labeled primers at forward or reverse sides and a specific size standard. Using a Genetic Analyzer machine and GeneMapper software (Applied Bioscience, USA), the monoclonal pattern revealed one single, sharp and high peak at the specific size corresponding to acrylamide gel pattern, whereas the polyclonal pattern showed multiple and small peak condensed at the same size standard. This technique is the most sensitive and accurate technique; however, it usually requires high technical experience and is also of high cost 7. Therefore, rapid and more cost effective technique are being sought.LightCycler PCR performs the diagnostic detection of amplicon via melting curve analysis within 2 hours with the use of a specific dye 89. This dye consists of two types: one known as SYBR-Green I which is non specific and the other named as High Resolution Melting analysis (HRM) which is highly sensitive, more accurate and stable. Several reports demonstrated that this new instrument combined with DNA intercalating dyes can be used to discriminate sequence changes in PCR amplicon without manual handling of PCR product 1011. Therefore, current investigations using melting curve analysis are being developed 1213.In this study, three different techniques were compared to evaluate the suitability of LightCycler PCR with HRM as the clonal diagnostic tool for IgH gene rearrangement in B-cell non-Hogdkin lymphoma, i.e. thermocycler PCR followed by heteroduplex analysis and PAGE, GeneScan analysis and LightCycler PCR with HRM.
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Affiliation(s)
- Tanawan Kummalue
- Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital, Bangkok 10700, Thailand.
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Sholl LM, Longtine J. Molecular analysis of genetic markers for non-Hodgkin lymphomas. CURRENT PROTOCOLS IN HUMAN GENETICS 2010; Chapter 10:Unit 10.14.1-25. [PMID: 20373512 DOI: 10.1002/0471142905.hg1014s65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Molecular analysis complements the clinical and histopathologic tools used to diagnose and subclassify hematologic malignancies. The presence of clonal antigen-receptor gene rearrangements can help to confirm the diagnosis of a B or T cell lymphoma and can serve as a fingerprint of that neoplasm to be used in identifying concurrent disease at disparate sites or recurrence at future time points. Certain lymphoid malignancies harbor a characteristic chromosomal translocation, a finding that may have significant implications for an individual's prognosis or response to therapy. The polymerase chain reaction (PCR) is typically used to detect antigen-receptor gene rearrangements as well as specific translocations that can be supplemented by fluorescence in situ hybridization (FISH) and karyotype analysis.
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Goeldel A, Cornillet-Lefebvre P, Durlach A, Birembaut P, Bernard P, Nguyen P, Grange F. T-cell receptor γ gene rearrangement in cutaneous T-cell lymphoma: comparative study of polymerase chain reaction with denaturing gradient gel electrophoresis and GeneScan analysis. Br J Dermatol 2009; 162:822-9. [DOI: 10.1111/j.1365-2133.2009.09575.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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