Development of B-lymphoblastic leukemia in patients treated for multiple myeloma – A case series of 14 patients

Development of B-lymphoblastic leukemia/lymphoma (BALL) is uncommon in patients with plasma cell neoplasm (PCN). Currently, little is known about risk factors for and characteristics of BALL arising in patients who have undergone treatment for PCN. We reviewed the clinicopathologic features of 14 patients with PCN who developed subsequent BALL and assessed the clonal relationship between these two neoplasms in 5 of the 14 patients. Clinical and laboratory data were extracted from the electronic medical record in accordance with an institutional review board-approved protocol. For the IgH clonality studies DNA was extracted from formalin fixed paraffin embedded tissue and analyzed utilizing the LymphoTrack® IGH FR2/3 Assay -- S5/PGM™ reagents from Invivoscribe Technologies. Next-generation sequencing of libraries was performed on a ThermoFisher Scientific Ion Torrent S5™ sequencer. The LymphoTrack® Software - S5/PGM™ Version 2.4.5 was used to analyze the IGH rearrangement sequences and relative proportion of the sequences was determined as a percentage of total sequencing reads. All PCN patients in our cohort received an autologous stem cell transplant (auto-SCT) with subsequent lenalidomide maintenance therapy. The mean time from the start of lenalidomide treatment after auto-SCT to BALL development was 62 months. None of the BALL cases were Philadelphia chromosome-positive. There was increased incidence of TP53 mutations and deletions (36%). IgH clones were identified in all but one sample. Comparison of the IgH clones from the original PCN and subsequent BALL revealed distinct clones in all 5 patients tested. In 2 of the 5 patients, the original PCN clone was also identified along with the distinct BALL clone. Our study reveals that BALL cases arising in patients with treated PCN are not clonally related to the original disease, and may represent therapy-related malignancy associated to prior treatment including lenalidomide maintenance therapy. More studies are needed to establish the incidence and understand the pathogenesis of this possible therapy-related complication.

Evaluation of PCR cycle threshold values by patient population with the quidel lyra SARS-CoV-2 assay

The Lyra SARS-CoV-2 assay was the primary method for molecular testing performed at Barnes-Jewish Healthcare System in St. Louis, Missouri during the initial COVID-19 surge from mid-March to late-April 2020. We performed a retrospective analysis of 1,043 positive Lyra SARS-CoV-2 results during these 36 days to investigate associations between cycle threshold (C_T)  value and patient characteristics. Total RNA were extracted from NP or OP swabs using either the EasyMag or KingFisher automated extraction systems and quantified with RotorGene Q (Qiagen) or Applied Biosystems 7500 Fast Dx thermocyclers respectively. Notably, we found lower a significant median lower C_T for samples tested on the KingFisher-ABI 7500 fastDX (KF/ABI) system compared to the EasyMag/RotorGene (EM/RGQ) platform. Since 77.5% of our tests were ran on the EM/RGQ pipeline we then perform additional analysis on these values and found that C _T values in outpatient care settings compared to samples obtained in the emergency department or inpatient had significantly lower C _T values. These collective findings suggests a difference in viral load amongst various patient populations.

Establishing a Nucleated Count Reflex Trigger for Performing Cell Differential on Cerebrospinal Fluid in Pediatric Patients

Introduction

Analysis of cerebrospinal fluid (CSF) assists in the diagnosis of several disease processes affecting the central nervous system (CNS). Nucleated cell (NC) count and cell differential are two important components of laboratory testing performed to analyze CSF samples. These tests can help diagnose conditions such as infection, inflammation, and malignancy involving the CNS; however, the cell differential, performed manually on a cytospin, is labor-intensive and may divert laboratory resources. Currently, the laboratory at our tertiary care pediatric hospital performs both NC count and cell differential on all specimens submitted for CSF cell count analysis. We hypothesized that when the NC count is low (<10/mcl), performing manual cell differential does not provide clinically meaningful information and leads to unnecessary testing, increasing the turnaround time and decreasing precision. In this study, we investigated the utility of performing a manual differential on CSF when the NC count is ≤10/mcl and the need to establish reflex criteria for performing a cell differential.

Methods

Data were extracted from our electronic medical record database. We searched for all CSF samples that were submitted to our pediatric hospital’s laboratory for cell count analysis from September 2019 to January 2020. NC count, red blood cell (RBC) count, and number of cells available for differential (€œcells diffed) on cytospin, to a maximum of 100 cells per specimen, were obtained for each sample.

Results

A total of 577 CSF samples from 332 patients were submitted and analyzed for cell counts, of which 471 (82%) had NC count ≤10/mcl. There was a significant moderate positive correlation between NC count and cells diffed (Pearson correlation coefficient, 0.45, P-value <0.001). Of these 471 samples, 24 (5%) showed evidence of peripheral blood contamination (>500/mcl RBCs in samples with NC = 0/mcl, >500 x (NC count)/mcl RBCs in samples with NC > 0/mcl). A total of 4 cases from two patients with NC ≤10/mcl (0.8%) showed blasts on manual differential. Both patients had B-lymphoblastic leukemia/lymphoma and were being evaluated for CNS involvement with concurrent cytology. One patient was diagnosed as negative for CNS involvement by cytology. The sample for manual differential was contaminated by peripheral blood, hence the presence of blasts did not represent CNS disease. The second patient had the remaining 3 positive samples and was diagnosed with CNS involvement by cytology on multiple follow-ups.

Conclusion

Performing CSF manual differential when NC < 10/mcl does not provide additional clinically actionable information and is associated with a lower cell yield on the cytospin. Establishing a NC count cutoff for performing manual differential will prevent unnecessary testing, decrease turnaround time, and increase precision. Exceptions may be necessary for oncology patients at high risk for CNS involvement.

Lenalidomide demonstrates clinical activity in anaplastic lymphoma kinase-positive large B-cell lymphoma

Anaplastic lymphoma kinase-positive large B-cell lymphoma (ALK+ LBCL) is known to be a rare and aggressive form of lymphoma that relapses quickly after both conventional chemotherapy and more targeted therapy. Lenalidomide is an immunomodulator that has shown safety and efficacy in multiple myeloma and is also approved for use in several types of lymphoma. In the case described here, the patient had a significant partial response to lenalidomide, which has not previously been described in this type of lymphoma. Given how aggressive and difficult to treat ALK+ LBCL is, further research is warranted to more completely elucidate the mechanism of action of lenalidomide in ALK+ LBCL and its role in treatment.

Napsin A is a highly sensitive marker for nephrogenic adenoma: an immunohistochemical study with a specificity test in genitourinary tumors

Nephrogenic adenomas are uncommon benign lesions that are typically cytologically bland, but degenerative and reactive changes may make it difficult to distinguish these lesions from malignant entities, such as urothelial carcinoma and prostatic adenocarcinoma. In this study, we explored whether napsin A, a sensitive marker for lung adenocarcinoma, may also have a role in distinguishing nephrogenic adenoma from other genitourinary lesions. Immunohistochemically, napsin A was expressed in all 43 nephrogenic adenomas (bladder: 38, prostatic urethra: 4, and ureter: 1; mean positive tumor cells: 72%, median: 80%, range: 15-100%) and showed regional variability in its expression pattern with a bias toward surface architectures (flat, papillary) compared with stromal architectures (tubular/glandular, microcystic). We also compared napsin A with other markers including PAX8, GATA3, p63, and 34BE12. Although napsin A matched PAX8 in terms of its sensitivity for nephrogenic adenoma (100%), napsin A stained a lower percentage of tumor cells than PAX8 (72% vs 99%, respectively, P = 1.0 × 10^-5). P63 was negative in all nephrogenic adenomas, whereas GATA3 showed variable staining in 25 cases (58%). All 43 nephrogenic adenomas showed variable 34BE12 staining. Finally, we profiled napsin A expression among 401 genitourinary tumors on tissue microarrays (n = 308) and full tissue blocks (N = 93) and observed napsin A positivity in 37 tumors (9%), which included urothelial carcinomas with the glandular/microcystic component differentiation (in the glandular/microcystic component in 4/6), bladder adenocarcinomas (primary: 4/4 and metastatic: 3/3), urinary tract clear-cell carcinomas (primary: 8/9, metastatic uterine primary: 1/1), and some renal tumors (17/174). All 81 pure urothelial carcinomas and 53 prostatic acinar adenocarcinomas were negative for napsin A. Our study indicates that napsin A is a highly sensitive marker for nephrogenic adenoma and can serve as a useful addition in immunohistochemical panels seeking to distinguish it from pure urothelial carcinoma and prostatic acinar adenocarcinoma but not clear-cell carcinoma or urothelial carcinoma with glandular differentiation.

Tumor mutation burden and checkpoint immunotherapy markers in primary and metastatic synovial sarcoma

Synovial sarcoma (SS) is a soft-tissue malignancy that most often affects patients aged between 15 and 40 years, and the prognosis for patients with metastatic disease is generally poor. This study was performed to evaluate checkpoint blockade immunotherapy markers in SS, including tumor mutational burden (TMB), DNA mismatch repair (MMR) status, and PDL-1 (programmed cell death ligand 1), PD1 (programmed cell death 1), and CD8 expression by normal-tumor paired whole-exome sequencing (WES) and immunohistochemistry (IHC). Outcomes evaluated included event-free and overall survival. Twenty one (21) FISH (Fluorescence In Situ Hybridization)-confirmed SS cases (11 F, 10 M) were studied, with age ranging from 8 to 89 years at diagnosis and follow-up ranging from 1 to 16 years. TMB (n = 16) ranged from 0.83 to 212/Mb (median, 1.7). Only one case showed a high TMB of 212/Mb and missense variants of MMR genes in the primary tumor, while the other 15 cases had a low TMB of less than 5/Mb. IHC was performed on all 21 tumor samples for PD-L1, PD1, CD8, and MMR proteins. PD-L1 membranous staining was detected in 3 of 21 cases (14.3%), ranging from 1 to 5% for tumor proportion score and 1-10 for combined positive score. PD1 was detected in 15 of 21 cases (71.4%), ranging from 1 to 25/HPF (high power field) (median, 2). CD8 stain was seen in all cases, ranging from 2 to 60/HPF (median, 5). PD1 staining results correlated with CD8 staining results (P < 0.0001). No correlation of TMB or IHC markers was found with survival. No fixed pattern of TMB or IHCs between primary and metastatic tumors was observed; there was no correlation between TMB or IHCs and age, location, or diagnosis subtype. All of the cases tested showed retained expression of MMR proteins. The results show that for SS, a tumor with strong driver translocation, most cases have a low TMB, but occasionally a high TMB may be present, as observed in 1 of the 16 (6.25%) cases. The demonstration of a subgroup of SS cases with high TMB might explain the 10% response rate to checkpoint immunotherapy observed in clinical trials in patients with SS.

Clinical and Pathological Features of a Newborn With Compound Heterozygous ANKS6 Variants

We report a term female infant born to nonconsanguineous parents who presented with renal failure at birth, hypothyroidism, cholestasis, and progressive cardiac dysfunction. Multigene next-generation sequencing panels for cholestasis, cardiomyopathy, and cystic renal disease did not reveal a unifying diagnosis. Whole exome sequencing revealed compound heterozygous pathogenic variants in ANKS6 (Ankyrin Repeat and Sterile Alpha Motif Domain Containing 6), which encodes a protein that interacts with other proteins of the Inv compartment of cilium (NEK8, NPHP2/INVS, and NPHP3). ANKS6 has been shown to be important for early renal development and cardiac looping in animal models. Autopsy revealed cystic renal dysplasia and cardiomyocyte hypertrophy, disarray, and focal necrosis. Liver histology revealed cholestasis and centrilobular necrosis, which was likely a result of progressive cardiac failure. This is the first report of compound heterozygous variants in ANKS6 leading to a nephronopthisis-related ciliopathy-like phenotype. We conclude that pathogenic variants in ANKS6 may present early in life with severe renal and cardiac failure, similar to subjects with variants in genes encoding other proteins in the Inv compartment of the cilium.

Reactivity with the EpCAM-specific antibodies MOC-31 and Ber-Ep4 in plasma cell neoplasms: a potential diagnostic pitfall in cytology samples

OBJECTIVE

Epithelial cell adhesion molecule (EpCAM) is a protein expressed on surfaces of healthy epithelia, and is overexpressed in dysplasias and carcinomas. Immunohistochemistry (IHC) utilizing antibodies that react with EpCAM, such as MOC-31 and Ber-EP4, distinguish reactive mesothelial cells from carcinomas in serous effusions. IHC is crucial in effusions with singly dispersed atypical cells, a scenario with a broad differential, including hematopoietic malignancies. Plasma cell neoplasms (PCN) are the second most common hematopoietic malignancy, manifesting as multiple myeloma or plasmacytoma, with 6% of cases developing serous cavity involvement. Most PCNs are readily recognizable; however, variants that deviate from the classic cytomorphology risk erroneous diagnosis. This study demonstrates EpCAM expression in a subset of PCNs, highlighting a potential diagnostic pitfall in serous effusion cytology.

METHODS

A 10-year retrospective search for cytology specimens with a diagnosis of PCN was performed. All cases demonstrating CD138/CD38 and monoclonal immunoglobulin expression, and adequately cellular cell block were included. IHC analysis for MOC-31 and Ber-EP4 was performed using Ventana Benchmark Ultra. Scoring was performed as follows: total IHC score equals the positive proportion (0 = no positive tumor cells; 1 = <1%; 2 = 1-10%; 3 =11-33%; 4 = 34-66%; 5 = 67-100%) plus staining intensity (0, no staining; 1, weak; 2, moderate; 3, strong). A score > 4 was considered positive.

RESULTS

2 of 28 (7%) PCNs demonstrated positivity for MOC-31 and Ber-Ep4.

CONCLUSION

A subset of PCNs in cytology samples show positivity for MOC-31 and Ber-EP4 which could result in misinterpretation as carcinoma.

Knowledge and Perception Regarding Autism among Primary School Teachers: A Cross-sectional Survey from Pakistan, South Asia

Background:

Early detection and intervention seem to improve development in autistic children, and teachers form an important part of their early social environment.

Objectives:

The objective of this study was to assess baseline knowledge and misconceptions regarding autism among school teachers and evaluate factors influencing their knowledge.

Materials and Methods:

This is a cross-sectional survey enrolling primary school teachers using a self-administered questionnaire.

Results:

Seventy-three teachers (mean age of 34 years, 66% females) responded. Gaps in awareness and knowledge were found. About 52 (71.2%) teachers identified themselves as having some knowledge about autism, with 23 (44.2%) among this group understanding autism as a neurological/mental disorder. The majority (73.1%) believe that special education is a helpful intervention. The only significant factor that influenced knowledge among teachers was attendance of behavioral classes (P = 0.01).

Conclusion:

Results suggest that teachers have an inadequate understanding of autism due to several misconceptions. This calls for increased education of teachers with regard to autism and other childhood disorders.

Small lymphocytic lymphoma with Reed Sternberg cells: a diagnostic dilemma

Reed Sternberg (RS) cells in the setting of small lymphocytic lymphoma (SLL) can complicate the histopathological diagnosis. We report a case of a man aged 54 years who presented with cervical lymphadenopathy. Resection of the lymph node was performed and sent for histopathological evaluation to a local laboratory. A diagnosis of SLL with Classic Hodgkin's lymphoma (CHL) was made. The medical oncologist who encountered this diagnosis for the first time sent the biopsy blocks to our laboratory for a second opinion. On review of the biopsy and immunohistochemical stains, it showed typical SLL morphology and immunophenotype. Focally, it showed large mononuclear RS type cells; however, no typical background of CHL was seen. The diagnosis was revised to 'SLL with RS like cells with no convincing evidence of CHL'. The patient was subsequently treated as a case of SLL and no progression was observed on a follow-up of 5 years.