The urgency of Burkitt lymphoma diagnosis in fluid cytology-A tertiary care experience

BACKGROUND

Burkitt lymphoma (BL) is an aggressive high-grade B-cell non-Hodgkin lymphoma commonly diagnosed in young age and is known to involve extra nodal sites. But the involvement of body fluids by BL is an uncommon presentation. Rapid diagnosis of BL is vital to prevent complications like tumour lysis syndrome. Cytological examination of body fluids continues to be an indispensable tool for rapid diagnosis of BL.

OBJECTIVES

In this study, we aim to study the clinical, cytomorphological and immunophenotypic characteristics of BL involving serous effusions and other fluids.

MATERIALS AND METHODS

In this retrospective study, 17 cases reported as BL in fluid cytology from 2016 to 2022 were collected and reviewed. We performed a comprehensive analysis of the clinical data, cytomorphological features, immunophenotyping data along with the haematological workup of these cases. We have also compared with the histopathological diagnosis for those cases where biopsy was available.

RESULTS

BL more commonly involved ascitic fluid (52%), followed by pleural fluid (4 cases) and cerebrospinal fluid (CSF; 4 cases). Primary diagnosis of BL in fluid was done in 88% of the cases. Bone marrow involvement was noted in two cases. Cytological smears showed discrete monomorphous population of medium-sized atypical lymphoid cells with frequent apoptotic bodies. Classic cytoplasmic punched out vacuoles were observed in 88% of the cases. Immunophenotyping data was available for 12 cases in which tumour cells showed positivity for CD20 (100%), CD10 (4 of 7 cases), BCL6 (3 of 5 cases) and cMYC (7 of 7 cases-100%) and were negative for Terminal deoxynucleotidyl transferase (TdT) (11 of 11 cases). Mean Ki67 labelling index was 95%. Histopathological diagnosis was available for 9 cases, and there was 100% agreement between cytological and histopathological diagnosis in 7 cases.

CONCLUSION

Precise diagnosis of BL can be rendered in body fluids by identification of classic cytomorphological features and by performing supportive ancillary tests in fluids for immunophenotyping.

Blastoid Variant of Mantle Cell Lymphoma with Extranodal Presentation and Aberrant CD10 Expression

Mantle cell lymphoma (MCL) constitutes 3%-10% of non-Hodgkin lymphoma and is characterized by t (11:14)(q13;q32). The common presentation is generalized lymphadenopathy with weight loss, infrequently night sweats, and fever. Among histological subtypes of MCL, the blastoid variant of MCL constitutes 10%-15% of all the cases. It is challenging to diagnose the blastoid variant of MCL based on its morphology alone as it mimics large B-cell lymphoma. Hence, the immunophenotyping and molecular studies aid in its correct diagnosis. We report an elderly man diagnosed with blastoid variant MCL. He presented with disseminated soft-tissue and subcutaneous nodules, and showed aberrant CD10 expression. Presentation of the extranodal site and aberrant CD10 expressions carries an overall poor prognosis. CD10-positive MCL can be mistaken for large B-cell lymphoma.

Quality assessment of platelet concentrates prepared by platelet-rich plasma, buffy-coat, and apheresis methods in a tertiary care hospital in South India: A cross-sectional study

INTRODUCTION

In blood banking and transfusion medicine, it is of paramount importance to improve transfusion safety and provide a higher quality of product to maximize the therapeutic outcomes and minimize the risk of developing transfusion-associated complications for patients receiving a blood transfusion.

MATERIALS AND METHODS

This was a cross-sectional study conducted at the department of transfusion medicine in a tertiary care hospital of South India from February 2019 to December 2020. The primary objective of the study was to assess the quality of platelet concentrates (PC) prepared by platelet-rich plasma (PRP), buffy-coat (BC), and apheresis method. A total of 760 PCs were subjected to quality assessment, among which 124 were PRP-PC, 176 were BC-PC, and 460 were single donor platelet (SDP).

RESULTS

The total percentage of platelets meeting all the six quality control parameters in PRP, BC and SDP was 78.23%, 81.81%, and 89.96%, respectively. Apheresis PCs showed a significantly higher platelet concentration per µL on comparison with whole-blood-derived platelets. BC-PCs were found to be better than PRP-PC with regard to lower white blood cell (WBC) contamination (P < 0.05) and red blood cell (RBC) contamination (P < 0.01). No statistically significant difference was found with regard to platelet yield, volume, swirling, and pH.

CONCLUSION

Ex vivo quality of PCs prepared by BC-PC, PRP-PC, and apheresis-PC fulfilled the desired quality control parameters. BC-PC was better than PRP-PC in terms of lesser WBC and RBC contamination and comparable in terms of volume, platelet yield, swirling, and pH. Apheresis PCs showed a higher platelet concentration per microliter on comparison with whole-blood-derived platelets; hence in a blood center where facilities for collection of apheresis product are available, SDPs should be the choice of platelet transfusion.

Does the Inclusion of CD34+ B-cell Progenitors (Hematogones) in Stem Cell Enumeration of Apheresis Product Using ISHAGE Protocol Affect the Final Harvest dose Adequacy and the Outcome of Transplantation? A Single Institution Experience from Southern India

Purpose

Hematogones have similar antigenic and light scatter properties when compared to CD34+ hematopoietic stem cells (HSC) but they form a separate cluster with dimmer CD45 expression. These should be excluded while enumerating HSC, as their inclusion can overestimate and hence affect the final dose of HSC. However, their exact impact on the outcome of HSC transplant (HSCT) is not entirely known and hence this study was undertaken to address these issues, if any.

Methods

This was a retrospective study in which patients undergoing HSCT were included, and flow cytometric enumeration was done on the apheresis product using single platform ISHAGE protocol. The gating of all plots was reviewed and carefully studied for hematogone population which would have otherwise been included in the original gating.

Results

Totally 78 patients underwent HSCT during the study period. On re-analysis, it was found that 10/78 (12.8%) cases had a separate hematogone population which was included in the HSC in the original analysis. Out of these 10 cases, 7/51 and 3/27 were in autologous and allogenic subgroup respectively. However, all the ten cases ultimately had adequate final stem cell dose and had successful engraftment.

Conclusion

The inclusion of hematogones in CD34+ HSC enumeration of apheresis products did not yield any impact on neither the final dose nor the outcome of transplant in this study. However, it is recommended to exclude them from the final count when they are > 10% of the final HSC lest it overestimate the final harvest dose and outcome of HSCT.

CD157 Can Replace CD24 and CD14 in a Single-Tube Flow-Cytometric Assay to Detect Paroxysmal Nocturnal Hemoglobinuria (PNH) Clones on Both Neutrophils and Monocytes: A Prospective Study From North India

Introduction

As per current guidelines, detection of paroxysmal nocturnal hematuria (PNH) clones on leucocytes requires the demonstration of the loss of at least two glycosyl-phosphatidyl-inositol (GPI)-linked molecules on both neutrophils and monocytes by flow cytometry. CD24 and CD14 are GPI-linked molecules expressed on neutrophils and monocytes respectively, whereas another GPI-linked molecule, CD157, is expressed on both neutrophils and monocytes. This prospective study evaluated the ability of CD157 to replace both CD24 and CD14 in a single-tube flow-cytometric assay to detect PNH clones on both neutrophils and monocytes.

Materials and methods

PNH clones were newly detected in 52 patients by an existing “standard” single-tube six-color flow-cytometric method, which was routinely performed in our laboratory at the time of undertaking this study. Six antibodies (CD45/CD15/CD64/CD24/CD14/FLAER) were used in this "standard" technique. Subjects were divided into two groups: (i) PNH disease (n=10), and (ii) aplastic anemia/myelodysplastic syndrome (AA/MDS) (n=42). Diagnosis of PNH disease and AA/MDS were made as per standard literature and guidelines. Results were compared with a single-tube five-color “test” assay using the antibodies CD45/CD15/CD64/CD157/FLAER by flow cytometry. Samples from 20 healthy control subjects were used to calculate cut-off values for the “test” assay.

Results

By the "test" method, cut-off values for detecting PNH clones obtained from receiver operating-characteristic curve analysis were >0.4% for neutrophils (sensitivity=96.15%, specificity=95%), and >0.9% for monocytes (sensitivity=98.08%, specificity=95%). There was significant correlation between PNH clone sizes measured by both the “standard” and “test” assays in neutrophils (PNH disease: r=0.976, p<0.001; AA/MDS: r=0.980, p<0.001) as well as monocytes (PNH disease: r=0.806, p=0.005; AA/MDS: r=0.915, p<0.001). Bland-Altman analysis showed agreement between both assays in all the 52 patients and in individuals with AA/MDS. The cost of the test to the patients was about 15% less in the “test” method than the ”standard” technique, with improved technical efficiency.

Conclusion

CD157 can replace both CD24 and CD14 in a single-tube flow-cytometric assay to detect PNH clones on both neutrophils and monocytes, with reduced cost to the patients and improved technical efficiency.

How FNAC and flowcytometry helped in diagnosing a high-grade B cell lymphoma masquerading as leukemia

High-grade B cell lymphoma (HGBL) has been recently introduced in the category of aggressive, mature B cell lymphomas. They are biologically different from diffuse large B cell lymphoma and Burkitt Lymphoma and have an aggressive course. Leukemic presentation though is known in various types of mature B cell and mature T cell lymphomas, it is rare in high-grade B cell lymphoma. We report one such case of a high-grade B cell lymphoma which was masquerading as acute leukemia with a soft tissue infiltration with added emphasis on the role of fine-needle aspiration cytology and flow cytometry in the diagnosis and its therapeutic significance.

Extramedullary early T-cell lymphoblastic crisis in a young pregnant chronic myeloid leukemia patient: Diagnosis with fine-needle aspiration cytology and flow cytometry

Chronic myeloid leukemia (CML) most commonly presents in chronic phase. Blast crisis in CML is usually of myeloid phenotype, whereas among lymphoid lineage, B-cell lymphoblastic crisis is common. T lymphoblastic crisis is rare with near early T-cell precursor (ETP) immunophenotype being exceedingly rare and very little is known about its characteristics, treatment, and prognosis. Blast crisis can occur in extramedullary sites with lymph node being the most common site. CML is also less investigated and studied in pregnancy as it is considered a disease of older adults. We report a rare case of CML presenting in extramedullary site (lymph node) as extramedullary T-cell lymphoblastic crisis of near ETP immunophenotype in a young pregnant female, which was diagnosed on fine-needle aspiration cytology in combination with flow cytometry.

Concomitant Diagnosis of Plasmablastic Lymphoma and Chronic Lymphocytic Leukemia: A Rare Phenomenon

Plasmablastic lymphoma (PBL) is a rare, aggressive non-Hodgkin lymphoma which shows blastic morphology and an immunophenotype of plasma cell differentiation while chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma is an indolent B-cell lymphoma and has a variable clinical course. A CLL transforming into a PBL and the coexistence of CLL with PBL are both extremely rare findings. We report an unusual case of a 72-year-old HIV-negative male who presented with a gingival swelling which was diagnosed as PBL with simultaneous CLL in the blood and bone marrow. Further, in this case, the PBL spontaneously regressed postbiopsy adding to the peculiarity and rarity of this case. This could be due to immune system modulation and can open up a new window to the treatment strategies of PBL in the future.

Indian Society of Hematology and Blood Transfusion (ISHBT) Consensus Document on Hematological Practice During COVID-19 Pandemic

The SARS-CoV-2 (COVID-19) pandemic is a worldwide public health emergency with widespread impact on health care delivery. Unforeseen challenges have been noted during administration of usual haematology care in these unusual COVID-19 times. Medical services have been overstretched and frontline health workers have borne the brunt of COVID-19 pandemic. Movement restrictions during lockdown prevented large sections of population from accessing health care, blood banks from holding blood drives, and disrupted delivery of diagnostic hematology services. The disruption in hematology care due to COVID-19 pandemic in India has been disproportionately higher compared to other subspecialities as hematology practice in India remains restricted to major cities. In this review we chronicle the challenges encountered in caring for hematology patients during the COVID-19 pandemic in India and put forth recommendations for minimizing their impact on provision of hematology care with special emphasis on hematology practice in lower and middle income countries (LMICs).

The utility of fine needle aspiration cytology in orbital haematolymphoid neoplasms

BACKGROUND

Orbital hematolymphoid lesions are rare and usually encountered in elderly patients. Orbital lesions are not easy to biopsy: hence fine needle aspiration cytology (FNAC) can be a very good diagnostic modality for these lesions.

MATERIALS AND METHODS

Cases of orbital masses subjected to FNAC dating from 2013 to 2020 were retrieved from our archives. A total of 16 cases with biopsy confirmation were included. All clinical details, the type of procedure, details of the immunocytochemistry (ICC) performed on smear, follow-up biopsy, and their haematological work-up were analysed in detail.

RESULTS

Sixteen biopsy-confirmed cases had been diagnosed as orbital haematolymphoid lesions on cytomorphology and further categorised with ancillary studies including ICC. In twelve instances, the cytology impression was congruent with the histopathological diagnosis and eight of the sixteen cases (50%) proved to be primary orbital lymphoma. Four were secondary orbital lymphomas and the remaining four included one case each of plasmacytoma, myeloid sarcoma, Rosai-Dorfman disease and angiolymphoid hyperplasia with eosinophilia.

CONCLUSION

FNAC is a minimally invasive procedure for diagnosing most of the haematolymphoid orbital lesions and it has a rapid turnaround time. The accuracy of cytomorphology combined with ICC on smears/cell blocks can be as good as a biopsy for exact categorisation. Additionally, aspirate smears are preferred samples for cytogenetics compared to formalin-fixed tissue blocks, as molecular cytogenetics techniques are frequently employed for diagnostic, prognostic, and therapeutic purposes.

FLAER Based Assay According to Newer Guidelines Increases Sensitivity of PNH Clone Detection

Flow cytometry has become 'gold standard' for detecting abnormal clones in paroxysmal nocturnal hemoglobinuria (PNH), aplastic anemia (AA) and myelodysplastic syndrome (MDS). This pilot study was conducted in 2015 with a primary aim to evaluate the utility of single tube fluorescent aerolysin (FLAER) based testing and its comparison with two tubes non-FLAER based testing (CD55, CD59, CD24 and CD66b) in detecting abnormal PNH clones in these newly diagnosed cases. The secondary aim was an attempt to distinguish PNH from AA/MDS cases associated with PNH clones based on clinical, laboratory features and clone size at diagnosis. In this study, the abnormal PNH clones were detected using a single tube FLAER based testing and two tubes non-FLAER based testing in all cases of PNH (n = 12), healthy subjects (n = 18) and AA/MDS with PNH clone (n = 9) and compared with clinical and laboratory features at diagnosis. The receiver operator curve (ROC) analysis defined the optimal cut-offs for FLAER in granulocytes (> 0.7%) and monocytes (> 0.9%). There was significant positive correlation between FLAER and non-FLAER based testing in these cells (r > 0.3 and p < 0.05). FLAER based testing helped us in picking up smaller clones which were missed by latter technique in four patients thereby increasing its sensitivity and also technically proved to be cost-effective (Rs. 1800 vs. Rs. 2100). Even in PNH patients, the clone size was slightly higher by using FLAER when compared to non-FLAER based antibodies panel. The clone size of monocytes was always higher than granulocytes in both PNH and AA/MDS groups. Bone marrow cellularity and mean size of granulocytes and monocytes clone at diagnosis showed a striking statistically significant 'p' value of < 0.0001 between these groups. In this pilot study, a single tube FLAER based PNH testing had improved clone detection in all cases of PNH, AA/MDS with PNH clones. The clone size was > 30% in majority of PNH cases whereas in AA/MDS, it was usually < 10% at diagnosis. Hence this newer technique not only increased the sensitivity of PNH clone detection but also proved to be cost-effective.

Utility of Lupus Anticoagulant Assays (APTT-LA, KCT, DPT and DRVVT) in Detection of Antiphospholipid Syndrome (APS) in High Risk Pregnancy Cases

Routine investigation for recurrent pregnancy loss includes measurement of antiphospholipid antibodies. The lupus anticoagulant has long been associated with increased risks for thrombosis and adverse obstetric outcomes. But there are some disadvantages with lupus anticoagulant (LAC) tests which includes varied sensitivity of different clot based assays. ISTH recommends only 2 assays (preferably DRVVT and APTT-LA) for the identification of lupus anticoagulant but there are some studies which don't support this contention. Our study analyzed 526 samples from high risk pregnancy cases for APLA by all four LAC tests from tertiary centre of northern India. Among all the cases studies 65 cases were positive for lupus anticoagulant 25 of this became negative after 12 weeks. Among the 40 repeated positive assays, dRVVT could able to diagnose 36 cases followed by APTT-LA which could able to diagnose 28 cases, while KCT could able to diagnose 23 cases and dPT could able to diagnose only 14 cases. There were 12 cases in whom all lupus assays were positive. Our study thus concluded that DRVVT was the most sensitive followed by APPT-LA, KCT, dPT. The combination of dRVVT with APTT-LA or KCT appeared to be superior to other combinations. No individual test per se is 100% sensitive for the diagnosis of APLA in high risk pregnancy cases. Further results confirmed that repeated LAC result is required even in a high-risk setting. Positive LAC assay in majority were not associated with exclusively recurrent pregnancy loss but were associated with sporadic stillbirth and thrombosis.

Utility of 5-Methylcytosine Immunohistochemical Staining to Assess Global DNA Methylation and Its Prognostic Impact in MDS Patients

Background:

DNA methylation plays a vital role in the pathogenesis of the myelodysplastic syndrome (MDS), a heterogeneous group of clonal hematopoietic stem cell (HSC) disorders. It is reported to be an independent prognostic factor affecting overall survival (OS). Our aim was to analyze the role of global DNA methylation using an anti-5-methylcytosine (5-MC) antibody by immunohistochemistry (IHC) of bone marrow biopsy (BM Bx) specimens in MDS patients, assessing correlations with various clinical and biological prognostic factors.

Material and methods:

A total of 59 MDS cases, classified as per the World Health Organization (WHO) 2008 guidelines, were evaluated over a period of 4 years. Clinical data were retrieved from departmental case records and anti-5-MC expression was analyzed with formalin fixed paraffin embedded sections of BM Bx specimens of MDS patients and controls.

Results:

The median age at diagnosis was 52 years (15-85years). Patients were categorized into low risk (59%) and high risk (41%) according to International Prognostic Scoring System (IPSS). The median follow-up time was 10 months (1 to 37 months). We generated a methylation score (M-score) using anti-5-MC and with the derived cut-off of 30.5 from the receiver operator curve (ROC), there was a significant difference between the two groups in the percentage of BM blasts (p=0.01), WHO sub-type (p=0.01), IPSS (p=0.004), progression to AML (p=0.04) on univariate analysis. Interestingly, patients showing a high M-score (M-score ≥ 30.5) demonstrated a significantly shorter OS and progression to AML. However, on multivariate analysis, only BM blasts (p=0.01) and IPSS (p=0.02) remained independent variables for progression to AML and OS respectively.

Conclusion:

Immunostaining with anti-5-MC antibody with BM Bx samples is a simple and cost effective technique to detect global methylation, a powerful tool to predict overall survival in patients with MDS.

Flow cytometric analysis of patients with hereditary spherocytosis - an Indian scenario

OBJECTIVES

Flow cytometry osmotic fragility test (FC-OFT) was a recently introduced screening test for hereditary spherocytosis (HS). This study was conducted to evaluate the utility of FC-OFT in all newly diagnosed cases of HS, to compare its diagnostic value with conventional OFT and to correlate with clinical disease severity.

METHODS

In this study, the percentage of residual red cells (%RRC) was measured using flow cytometer after creating a red cell suspension. Subsequently, this was spiked with deionized water for FC-OFT in all cases of HS (n = 40), healthy subjects (n = 40) and beta-thalassemia traits (BTT) (n = 20).

RESULTS

The receiver operator curve analysis defined the optimal cut-offs for FC-OFT-derived indices, such as %RRC value (≤16.29%) and %RRC ratio (>1.72), for HS cases when compared with healthy subjects and BTT (p < 0.05). The FC-OFT (96%) achieved higher test efficiency than the conventional OF test (68.9%). A significant positive and a negative correlation were found between number of spherocytes/hpf and %RRC ratio (p = 0.001) and %RRC values (p = 0.0486). No significant correlation was observed between %RRC value (p = 0.8934), %RRC ratio (p = 0.6348) and HS disease severity score.

CONCLUSION

Our results suggest that FC-OFT could be the better screening test for HS cases in developing countries if flow cytometer is available.

Diagnosis of Paroxysmal Nocturnal Hemoglobinuria: Recent Advances

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal hematopoietic stem cell disorder with its protean clinical manifestations. This is due to partial or complete absence of 'glycophosphatidyl-inositol-anchor proteins' (GPI-AP). The main aim of this review is to highlight various diagnostic modalities available, basic principle of each test and recent advances in the diagnosis of PNH. Recently among various tests available, the flow cytometry has become 'the gold standard' for PNH testing. In order to overcome the difficulties encountered by the testing and research laboratories throughout the world, International Clinical Cytometry Society has come up with guidelines regarding the indications for testing, protocol for sample collection, processing, panel of antibodies as well as gating strategies to be used, how to interpret the test and reporting format to be used. It is essential to test at least two GPI-linked markers on at least two different lineages particularly on red cells and granulocytes/monocytes. The fluorescent aerolysin combined with other monoclonal antibodies in multicolour flow cytometry offered an improved assay not only for diagnosis but also for monitoring of PNH clones. It is equally important to diagnose this rare entity with high index of suspicion.

Assessment of physico-chemical characteristics of water in Tamilnadu

Water is an important component to human life. The major aims of the present work are to assess the quality of the ground water and its impact in Villupuram District of Tamilnadu. The present study focus to bring an awareness among the people about the quality of ground water by taking water samples from various locations for Physico - Chemical analysis of the ground water. This analysis result was compared with the WHO, ICMR, USPH and European standards of drinking water quality parameters with the following water quality parameters namely pH, Electrical conductivity, Cl, , Na, K, Ca , Mg, Total dissolved solids, Total hardness, Dissolved oxygen, Fluoride etc. Various chemical methods have been employed to investigate the extent level of pollution in ground water.

The Impact of Age on Visual Search Performance

Visual search is an important component of many real world tasks such as industrial inspection and driving. Several studies have shown that age has an impact on visual search performance. In general older people demonstrate poorer performance on such tasks as compared to younger people. However, there is controversy regarding the source of the age-performance effect. The objective of this study was to examine the relationship between component abilities and visual search performance, in order to identify the locus of age-related performance differences. Six abilities including reaction time, working memory, selective attention and spatial localization were identified as important components of visual search performance. Thirty-two subjects ranging in age from 18 - 84 years, categorized in three different age groups (young, middle, and older) participated in the study. Their component abilities were measured and they performed a visual search task. The visual search task varied in complexity in terms of type of targets detected. Significant relationships were found between some of the component skills and search performance. Significant age effects were also observed. A model was developed using hierarchical multiple linear regression to explain the variance in search performance. Results indicated that reaction time, selective attention, and age were important predictors of search performance with reaction time and selective attention accounting for most of the variance.

The Relationship of Age and Cognitive Characteristics of Drivers to Performance of Driving Tasks on an Interactive Driving Simulator

Older adults depend highly on the automobile to satisfy their mobility needs. They use the private car for the majority of their trips. However, driving is not without risks for older drivers and those who share the road with them. Drivers 65 and older contribute to more accidents per mile driven than younger drivers except those 18-24 years old. Furthermore, they are more likely to be injured or die as a result of such accidents than their younger counterparts. Current thinking suggests that the cognitive abilities of older drivers may be the best explanation for these accidents. This study investigated the contribution of age and specific cognitive, psychomotor, and perceptual dimensions upon the performance of driving tasks on an interactive simulator. The results suggest that age as such does not explain performance of driving tasks. Rather, age-sensitive cognitive characteristics of drivers provide a better understanding of performance of specific driving tasks.

Transfusion-acquired Hemoglobinopathies: A Report of Two Cases

Transfusion-acquired hemoglobinopathy occurs when a carrier of hemoglobinopathy with no significant abnormalities donates blood, and the blood is transfused to a recipient. This process can lead to spurious results in the recipient without any clinical abnormality or infrequently can result in disastrous situations. The incidental finding of such posttransfusion related abnormal peaks in hemoglobin high-performance liquid chromatography (Hb HPLC) may cause diagnostic dilemmas and result in unnecessary laboratory testing. Here, we report two such cases of transfusion-acquired hemoglobinopathies, which were subsequently resolved by the abnormally low percentage of the Hb variants, transient nature of the peaks, and parental Hb HPLC.

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

Objectives Myeloperoxidase (MPO) detection either by enzyme cytochemistry (cMPO) or flow cytometry (fMPO) plays a major role in acute leukaemia (AL) diagnosis as per World Health Organization (WHO) 2008 classification. Although 3% cMPO was recommended as positivity, no specific cut-off had been mentioned by WHO for fMPO. Various authors recommend different cut-offs ranging from 3 to 28% for fMPO. The aim of this study was to analyse fMPO cut-offs ranging from 3 to 10% in classifying AL and to assess whether a new cut-off could be suggested. Methods Totally, 216 cases of AL were retrospectively analysed for fMPO ranging from 3 to 10% and compared with gold standard. Presence of cMPO (≥3%) and/or expression of two or more pan-myeloid markers (CD13, CD33, and CD117) in the absence of CD19 and CD3 were kept as gold standard for diagnosis of acute myeloid leukaemia (AML). Results Sensitivities for classifying AL as AML/mixed phenotypic acute leukaemia (MPAL) at 3, 5.4, and 10% were 98.3, 98.3, and 96.6%, respectively, whereas specificities at this cut-off were 22.2, 91, and 71%, respectively. Discussion Only few studies have been done in this aspect to define a consistent cut-off for fMPO for proper classification of acute leukaemias. This was one of the largest and few studies available till date in this regard. Conclusion The newer cut-off for fMPO (5.4%) emerged out from our study with best sensitivity and specificity for accurately classifying AL cases into acute lymphoblastic leukaemia, AML, and MPAL.

Hairy cell leukemia: A decade long experience of North Indian Hematology Center

INTRODUCTION

Hairy cell leukemia is a rare chronic B-cell disorder that follows an indolent but progressive course. This disorder is characterized by pancytopenia, splenomegaly, bone marrow fibrosis and the presence of atypical lymphoid cells with hairy projections in peripheral blood, bone marrow and spleen. Treatment is mainly with nucleoside analog cladribine, which induces complete remission in up to 85% cases.

MATERIALS AND METHODS

This is a retrospective analysis of Hairy cell Leukemia cases diagnosed and treated in the Department of Hematology, All India Institute of Medical Sciences, New Delhi between 2002 and 2013. Various parameters such as clinical features, laboratory parameters including complete blood cell count, bone marrow findings, cytochemistry, immunophenotyping by flowcytometry or immunohistochemistry, treatment protocol and complications secondary to treatment and relapse were reviewed.

RESULTS

A total of 35 cases were diagnosed during this period of 12 years of which 27 received cladribine and went in to remission. Median follow-up duration was 26 months. 5 (18%) cases had a relapse and all relapsed cases achieved second remission with cladribine; however, there was no case of second malignancy in our cohort.

CONCLUSION

Cladribine has emerged as the treatment of choice for hairy cell leukemia given that the overwhelming majority of patients achieve long-lasting complete remissions. Upon relapse, these patients could be successfully salvaged with cladribine retreatment.

Unusual presentation of hairy cell leukemia: a case series of four clinically unsuspected cases

Hairy cell leukemia (HCL) is characterized by pancytopenia and usually associated with massive splenomegaly, however the same may not be true in the clinical settings. Here we report four cases of HCL and all of them were without the classical clinical feature of splenomegaly. This is an observational study conducted between January 2013 to March 2014 where we could diagnose ten cases of HCL in Department of Hematology, All India Institute of Medical Sciences, New Delhi. Of these, four cases attracted attention because of absence of classical clinical features of HCL. Of the four cases, three presented with weakness/fatigability while fourth patient presented with recurrent respiratory tract infection. Surprising finding in these cases was absence of splenomegaly, both clinically and on imaging which demerit the suspicion of HCL clinically. All four had bi/pancytopenia and bone marrow examination coupled with immunophenotypic analysis confirmed the diagnosis of HCL. Three patients received chemotherapy with cladribine and achieved complete hematological remission. One patient did not receive chemotherapy due to poor general condition and was subsequently lost to follow up. To conclude, HCL can and do present without splenomegaly and this should not restrain one from suspecting HCL based on histomorphology which needs to be further confirmed by ancillary techniques. This finding in our series could be because these cases were picked early in their natural course of the disease. A high index of suspicion is essential for diagnosing and appropriately managing such cases.

A systematic approach to assess the strengths and limitations of cytomorphology in the diagnosis of the follicular variant of papillary thyroid carcinoma

OBJECTIVE

To identify the most useful cytomorphological features of follicular variant of papillary thyroid carcinoma (FVPTC).

METHODS

Fine needle aspiration cytological features of seven histologically proven FVPTCs were systematically evaluated in a blinded manner for various architectural, nuclear, cytoplasmic and background features with special reference to nuclear morphology.

RESULTS

Most smears were moderate to highly cellular with clustered and/or repetitive microfollicles, rare macrofollicles and minimal thick gummy colloid. Six of seven cases showed significant nuclear crowding/overlapping. Fairly uniform nucleomegaly (mostly three to five times the size of a mature lymphocyte) of intact neoplastic cells and enlarged naked nuclei were prominent features in all seven cases, whereas enlarged ovoid nuclei were seen in two cases. Chromatin was fine to coarsely granular and evenly distributed. Occasional nuclear grooves (NGs) and intranuclear cytoplasmic inclusions (INCIs) were seen in five and three cases, respectively. This refined approach led to a precise diagnosis of FVPTC in six cases, which were earlier interpreted as various follicular lesions. Follicular hyperplasia was excluded by the absence of significant amounts of colloid and atretic naked nuclei, whilst the possibility of follicular adenoma or follicular carcinoma was excluded by the presence of one or more features suggestive of papillary thyroid carcinoma.

CONCLUSIONS

Our study showed a high cell yield, microfollicular pattern, nuclear overcrowding/overlapping, scanty gummy colloid and enlarged naked nuclei as the most consistent features of FVPTC. Although inconsistent, features such as enlarged ovoid nuclei and syncytial clusters were complementary to the diagnosis in the absence of NGs and INCIs.

Role of pro-angiogenic marker galectin-3 in follicular neoplasms of thyroid

The role of pro-angiogenic marker galectin-3 (GAL-3) was examined in differential diagnosis of follicular neoplasms of thyroid into histological subsets of follicular adenoma (FA), follicular carcinoma (FC) and follicular variant of papillary thyroid carcinoma (FVPTC). The study included 22 cases from January 2006 to June 2011 comprising of FA (n = 12), FC (n = 3) and FVPTC (n = 7). Immunohistochemical evaluation of GAL-3 was performed on representative histologic sections from the resected thyroid specimens. The proportion of stained cells and intensity of staining in tumor blood vessels were evaluated. GAL-3 expression showed that angiogenesis was prominent in malignancy (FC and FVPTC) and negative in non-neoplastic thyroid parenchyma and benign condition (FA). GAL-3 expression was found to differentiate benign from malignant follicular neoplasms. Focal and diffuse positivity for GAL-3 was found to be associated with FC and FVPTC respectively, thus GAL-3 can be used as a immunohistochemical marker in the differential diagnosis of follicular neoplasms of thyroid based on the type of expression. Limitation of this study was relatively less number of cases studied; however, this data need to be corroborated in larger cohort.

Down syndrome with different hematological manifestations: a short series of 3 cases with review of literature

Children with Down syndrome (DS) present with a spectrum of hematolymphoid malignancies ranging from transient myeloproliferative disorder (TMD) which regress spontaneously to frank acute leukemia of both myeloid and lymphoid lineage. Here we present a series of three cases with different manifestation in DS. Three cases of DS presented with TMD, acute myeloid leukemia (AML-M2) and acute megakaryoblastic leukemia (AMKL), respectively. This case series displays the spectrum of hematological manifestations in children with DS. Although TMD and AMKL are strongly associated with DS, other AML subtypes can also be seen in such patients.

Understanding water deficit stress-induced changes in the basic metabolism of higher plants - biotechnologically and sustainably improving agriculture and the ecoenvironment in arid regions of the globe

Water is vital for plant growth, development and productivity. Permanent or temporary water deficit stress limits the growth and distribution of natural and artificial vegetation and the performance of cultivated plants (crops) more than any other environmental factor. Productive and sustainable agriculture necessitates growing plants (crops) in arid and semiarid regions with less input of precious resources such as fresh water. For a better understanding and rapid improvement of soil-water stress tolerance in these regions, especially in the water-wind eroded crossing region, it is very important to link physiological and biochemical studies to molecular work in genetically tractable model plants and important native plants, and further extending them to practical ecological restoration and efficient crop production. Although basic studies and practices aimed at improving soil water stress resistance and plant water use efficiency have been carried out for many years, the mechanisms involved at different scales are still not clear. Further understanding and manipulating soil-plant water relationships and soil-water stress tolerance at the scales of ecology, physiology and molecular biology can significantly improve plant productivity and environmental quality. Currently, post-genomics and metabolomics are very important in exploring anti-drought gene resources in various life forms, but modern agriculturally sustainable development must be combined with plant physiological measures in the field, on the basis of which post-genomics and metabolomics have further practical prospects. In this review, we discuss physiological and molecular insights and effects in basic plant metabolism, drought tolerance strategies under drought conditions in higher plants for sustainable agriculture and ecoenvironments in arid and semiarid areas of the world. We conclude that biological measures are the bases for the solutions to the issues relating to the different types of sustainable development.

Comparative effects of different triazole compounds on antioxidant metabolism of Solenostemon rotundifolius

The effect of different triazole compounds, viz., triadimefon (TDM) and hexaconazole (HEX) treatments on the antioxidant metabolism of Solenostemon rotundifolius Poir., Morton plants was investigated in the present study under pot culture. Plants were treated with TDM at 15 mg l(-1) and HEX at 10 mg l(-1) separately by soil drenching on 80, 110 and 140 days after planting (DAP). The plants were harvested randomly on 90, 120 and 150 DAP for determining the effect of both the triazoles on non-enzymatic antioxidant contents like ascorbic acid (AA), reduced glutathione (GSH) and alpha-tocopherol (alpha-toc), activities of antioxidant enzymes like superoxide dismutase (SOD) and ascorbate peroxidase (APX). All the analyses were made in leaf, stem and tubers of both control and treated plants. It was found that both these triazole compounds have profound effects on the antioxidant metabolism and caused an enhancement in both non-enzymatic and enzymatic antioxidant potentials under treatments. These results suggest that, the application of triazoles may be a useful tool to increase the antioxidant production in S. rotundifolius and thereby make it an economical food crop.

Antioxidant potential and indole alkaloid profile variations with water deficits along different parts of two varieties of Catharanthus roseus

The variations in antioxidant potentials and indole alkaloid content were studied in the present investigation, in two varieties (rosea and alba) of Catharanthus roseus, an important herb used in traditional as well as modern medicine, exposed to water deficit stress. The antioxidant and alkaloid profiles were estimated from root, stem, leaf, flowers and pods. The antioxidant potentials were examined in terms of non-enzymatic antioxidant molecules and activities of antioxidant enzymes. The non-enzymatic antioxidant molecules studied were ascorbic acid (AA), alpha-tocopherol (alpha-toc) and reduced glutathione (GSH). The estimated antioxidant enzymes were superoxide dismutase (SOD), ascorbate peroxidase (APX), catalase (CAT), peroxidase (POX) and polyphenol oxidase (PPO). The antioxidant concentrations and activities of antioxidant enzymes were high under water deficit stress in all parts of the plants. Indole alkaloid content was high in the roots of rosea variety in response to stress when compared to alba variety.

Effect of paclobutrazol on water stress amelioration through antioxidants and free radical scavenging enzymes in Arachis hypogaea L

An investigation was carried out to find out the extent of changes occurred in groundnut (Arachis hypogaea L.) cultivars in response to paclobutrazol (PBZ) treatment under water deficit stress. Two groundnut cultivars namely ICG 221 and ICG 476 were used for the study. Individual treatment with PBZ and drought stress showed an increase in ascorbic acid, alpha-tocopherol and reduced glutathione, superoxide dismutase (SOD), ascorbate peroxidase (APX) and catalase (CAT) activities. PBZ with drought stressed plants maintained higher levels of antioxidant and scavenging enzymes. Significant differences were observed between cultivars and treatments. These results suggests that the adverse effects of water stress can be minimized by the application of PBZ by increasing the antioxidant levels and activities of scavenging enzymes such as SOD, APX and CAT. The Cv. ICG 221 appears to be more tolerant to water stress than the ICG 476.

Antioxidant potentials and ajmalicine accumulation in Catharanthus roseus after treatment with giberellic acid

Changes in antioxidant potentials and indole alkaloid, ajmalicine, production were studied in Catharanthus roseus (L.) G. Don. plants under treatment with gibberellic acid (GA(3)). The GA(3) treatments were given in two ways, foliar spray and soil drenching methods on 30, 45, 60 and 75 days after planting (DAP). The plants were uprooted randomly on 90 DAP and separated into root, stem and leaves and used for analyses. The antioxidant potential was studied in terms of non-enzymatc antioxidant molecules like ascorbic acid (AA), alpha-tocopherol (alpha-toc) and reduced glutathione (GSH) and activities of antioxidant enzyme, viz., superoxide dismutase (SOD), ascorbate peroxidase (APX) and catalase (CAT). The alkaloid ajmalicine was extracted and estimated from roots of both control and treated plants. It was found that, GA(3) has a profound effect upon the antioxidant potentials and it caused a significant enhancement in the production of ajmalicine when compared to untreated control as well as foliar-sprayed plants. There was no significant enhancement in GSH and ajmalicine content under GA(3) foliar spray in C. roseus. These preliminary results suggest that, the application of GA(3) may be a useful tool to increase the antioxidant potential and alkaloid production in medicinal plants like C. roseus.

Induction of drought stress tolerance by ketoconazole in Catharanthus roseus is mediated by enhanced antioxidant potentials and secondary metabolite accumulation

A pot culture experiment was conducted to estimate the drought stress mitigating effect of ketoconazole (KCZ), a fungicide cum plant growth regulator, in Catharanthus roseus plants. The plants under pot culture were subjected to drought stress and drought stress with KCZ from 30 days after sowing (DAS) and regular irrigation was kept as control. Antioxidant contents and activities of antioxidant enzymes were estimated from root, stem and leaf of both control and treated plants. The alkaloid ajmalicine was extracted and estimated from the roots of control, drought stressed and KCZ treated plants. Individual and combined drought stress and KCZ treatments increased ascorbic acid, alpha-tocopherol contents, superoxide dismutase, ascorbate peroxidase, catalase and polyphenol oxidase activities when compared to control. There was a significant enhancement in ajmalicine production under KCZ treated plants under drought stress when compared to well watered control as well as drought stressed plants. The KCZ treatment resulted in partial mitigation of drought stress by increasing the antioxidant potentials in C. roseus plants.

Comparative effects of different triazole compounds on growth, photosynthetic pigments and carbohydrate metabolism of Solenostemon rotundifolius

The effects of two triazole compounds, triadimefon and hexaconazole, on the growth and carbohydrate metabolism were studied in Solenostemon rotundifolius Poir., Morton plants under pot culture. Plants were treated with triadimefon at 15mg l(-1) and hexaconazole at 10mg l(-1) separately by soil drenching on 80, 110 and 140 days after planting (DAP). The plants were harvested randomly and growth parameters were studied on 90, 120 and 150 DAP for determining the effect of both the triazole on growth and chlorophyll pigments. These triazole compounds increased the chlorophyll pigments. However, both the treatments decreased the fresh and dry weights of shoot and leaf area. Both these triazole resulted in a marginal increase in starch content and decreased the sugar contents. The carbohydrate metabolizing enzymes alpha- and beta-amylase activities were reduced and invertase activity increased in S. rotundifolius under triadimefon and hexaconazole treatments.

Alterations in osmoregulation, antioxidant enzymes and indole alkaloid levels in Catharanthus roseus exposed to water deficit

Catharanthus roseus (L.) G. Don plants were grown in different water regimes in order to study the drought induced osmotic stress and proline (PRO) metabolism, antioxidative enzyme activities and indole alkaloid accumulation. The plants under pot culture were subjected to 10, 15 and 20 days interval drought (DID) stress from 30 days after sowing (DAS) and regular irrigation was kept as control. The plants were uprooted on 41DAS (10DID), 46DAS (15DID) and 51DAS (20DID). The drought stressed plants showed increased aminoacid (AA), glycine betaine (GB) and PRO contents and decreased proline oxidase (PROX) and increased gamma-glutamyl kinase (gamma-GK) activities when compared to control. The antioxidative enzymes like peroxidase (POX) and polyphenol oxidase (PPO) increased to a significant level in drought stressed plants when compared to control. The drought stressed C. roseus plants showed an increase in total indole alkaloid content in shoots and roots when compared to well-watered control plants. Our results suggest that the cultivation of medicinal plants like C. roseus in water deficit areas would increase its PRO metabolism, osmoregulation, defense system and the level of active principles.

Pseudomonas fluorescens enhances biomass yield and ajmalicine production in Catharanthus roseus under water deficit stress

The effect of plant growth promoting rhizobacteria (PGPR) like Pseudomonas fluorescens on growth parameters and the production of ajmalicine were investigated in Catharanthus roseus under drought stress. The plants under pot culture were subjected to 10, 15 and 20 days interval drought (DID) stress and drought stress with Pseudomonas fluorescens at 1mgl(-1) and 1mgl(-1)Pseudomonas fluorescens alone from 30 days after planting (DAP) and regular irrigation was kept as control. The plants were uprooted on 41 DAS (10 DID), 46 DAS (15 DID) and 51 DAS (20 DID). Drought stress decreased the growth parameters and increased the ajmalicine content. But the treatment with Pseudomonas fluorescens enhanced the growth parameters under drought stress and partially ameliorated the drought induced growth inhibition by increasing the fresh and dry weights significantly. The ajmalicine content was again increased due to Pseudomonas fluorescens treatment to the drought stressed plants. From the results of this investigation, it can be concluded that, the seedling treatments of native PGPRs can be used as a good tool in the enhancement of biomass yield and alkaloid contents in medicinal plants, as it provides an eco-friendly approach and can be used as an agent in water deficit stress amelioration.

Water deficit stress mitigation by calcium chloride in Catharanthus roseus: Effects on oxidative stress, proline metabolism and indole alkaloid accumulation

The present investigation was conducted to determine whether CaCl(2) increases Catharanthus roseus drought tolerance and if such tolerance is correlated with changes in oxidative stress, osmoregulation and indole alkaloid accumulation. C. roseus plants were grown under water deficit environments with or without CaCl(2). Drought induced oxidative stress was measured in terms of lipid peroxidation (LPO) and H(2)O(2) contents, osmolyte concentration, proline (PRO) metabolizing enzymes and indole alkaloid accumulation. The plants under pot culture were subjected to 10, 15 and 20 days interval drought (DID) stress and drought stress with 5mM CaCl(2) and 5mM CaCl(2) alone from 30 days after planting (DAP) and regular irrigation was kept as control. The plants were uprooted on 41 DAS (10 DID), 46 DAS (15 DID) and 51 DAS (20 DID). Drought stressed plants showed increased LPO, H(2)O(2), glycine betaine (GB) and PRO contents and decreased proline oxidase (PROX) activity and increased gamma-glutamyl kinase (gamma-GK) activity when compared to control. Addition of CaCl(2) to drought stressed plants lowered the PRO concentration by increasing the level of PROX and decreasing the gamma-GK activities. Calcium ions increased the GB contents. CaCl(2) appears to confer greater osmoprotection by the additive role with drought in GB accumulation. The drought with CaCl(2)-treated C. roseus plants showed an increase in total indole alkaloid content in shoots and roots when compared to drought stressed and well-watered plants.

Mineral uptake and biochemical changes in Helianthus annuus under treatment with different sodium salts

Experiments were conducted to study the effects of different sodium salts viz., sodium chloride (NaCl), sodium sulphate (Na(2)SO(4)) and sodium carbonate (Na(2)CO(3)) on growth, dry matter production, mineral contents, biochemical constituent and enzyme activities of sunflower (Helianthus annuus L.). The germinating sunflower seeds were treated with 10, 20 and 50mM NaCl and Na(2)SO(4) and 5, 10 and 15 mM Na(2)CO(3). The seedling growth, minerals, chlorophyll content and biochemicals like protein and free amino acid contents with enzyme activities like ATPase and protease were analysed on 8 DAS. The seedlings were separated into root, stem, leaf and cotyledon on 8 DAS. All the treatments decreased the germination percentage; shoot length, root length, leaf area and dry weight, chlorophyll and protein contents significantly. Potassium, sodium and free amino acid contents; activities of ATPase and protease were increased when compared to control. This effect was very high in the Na(2)CO(3) treated seedlings this was followed by Na(2)SO(4) and NaCl treated seedlings. From the results of this investigation, it is clear that, the sunflower seedlings were affected significantly in the Na(2)CO(3) treatments, and followed by Na(2)SO(4) and NaCl treatments.

Protection of Vigna unguiculata (L.) Walp. plants from salt stress by paclobutrazol

A pot culture experiment was conducted to estimate the stress ameliorating ability of paclobutrazol, a triazole fungicide in Vigna unguiculata (L.) Walp. plants. Treatments were given as 80 mM NaCl, 80 mM NaCl+15 mg l(-1) paclobutrazol and 15 mg l(-1) paclobutrazol alone. The samples were collected on 60 and 80 days after sowing (DAS). NaCl stress inhibited the root and stem length, total leaf area, fresh weight (FW), dry weight (DW) and activities of antioxidant enzymes like superoxide dismutase (SOD), catalase (CAT) and peroxidase (POX). Plants treated with NaCl with paclobutrazol increased these parameters to a larger extent when compared to NaCl stressed plants. The results showed that the paclobutrazol significantly ameliorated the adverse effects of NaCl stress in V. unguiculata plants.

Changes in antioxidant metabolism of Vigna unguiculata (L.) Walp. by propiconazole under water deficit stress

In the present study, a pot culture experiment was conducted to estimate the ameliorating effect of propiconazole (PCZ) on drought stress in cowpea (Vigna unguiculata (L.) Walp.) plants. From 30 days after sowing (DAS), the plants were subjected to 3, 6 and 9 days interval drought (DID) stress and drought stress with PCZ at 15 and 15 mg l(-1) PCZ alone and 1 day interval irrigation was kept as control. The plant samples were collected on 34 DAS (3 DID), 37 DAS (6 DID) and 40 DAS (9 DID). The plants were separated into root, stem and leaf for estimating the antioxidant contents and activities of antioxidant enzymes. Individual and combined drought stress and PCZ treatments increased ascorbic acid (AA), alpha-tocopherol (alpha-toc) contents, superoxide dismutase (SOD), ascorbate peroxidase (APX), catalase (CAT) and polyphenol oxidase (PPO) activities when compared to control. The PCZ treatment mitigated the adverse effects of drought stress by increasing the antioxidant potentials and thereby paved the way for overcoming drought stress in V. unguiculata plants.

Growth, biochemical modifications and proline metabolism in Helianthus annuus L. as induced by drought stress

In the present investigation, two watering treatments, viz., 100% and 60% field capacity (FC) were used to understand the effects of water deficit on early growth, biomass allocation, pigment and biochemical constituents and proline metabolism of five varieties of Sunflower (Helianthus annuus L.) plants. We found that there was a significant difference in early growth, dry matter accumulation, pigment, biochemical constituents and proline metabolism among the five varieties. The root length, shoot length, total leaf area, fresh and dry weight, chlorophyll a, b, total chlorophyll and carotenoid were significantly reduced under water stress treatments. Water stress increased the proline, free amino acid and glycinebetaine contents along with increased activity of gamma-glutamyl kinase but the activity of proline oxidase reduced as a consequence of water stress.

The role of working memory, field dependence, visual search, and reaction time in the left turn performance of older female drivers

Older drivers have difficulties at intersections, especially in their performance of left turns. Older females are especially at risk in intersection maneuvers. Information processing abilities have been most promising in explaining the crash involvement of elderly drivers. This study examines the relationship of field dependence, visual search skills, and working memory to the decision to make a left turn at an intersection as well as to gap choice. Participants included thirty-three women ranging in age from 61 to 84 years. The results show that working memory plays a very important role in left-turn performance. Implications for appropriate interventions are discussed.