流式细胞术在诊断APL及其MRD中的作用

1王宏伟王宏伟山西医科大学第二医院山西医科大学第二医院二零一一年五月二零一一年五月FCM在诊断APL及监测其MRD中的应用AmJAmJClinClinPatholPathol..2011Jan;135(1):762011Jan;135(1):76--84.84.FlowFlowcytometrycytometryrapidlyidentifiesallacuterapidlyidentifiesallacutepromyelocyticpromyelocyticleukemiasleukemiaswithhighwithhighspecificityindependentofunderlyingspecificityindependentofunderlyingcytogeneticabnormalities.cytogeneticabnormalities.DongHYDongHY,,KungJXKungJX,,BhardwajBhardwajVV,,McGillJMcGillJ..GenzymeGenzymeGenetics,NewYork,NY10019,USA.Genetics,NewYork,NY10019,USA.Background:TodiagnoseAPLatthefirstsuspicionisveryimportant!„10-15%ofalladultAML„APL：ahighlyaggressivediseasepromptdiagnosisandspecificearlyintervention„earlydeath:majorcontributortotheoverallmortality„decreasemortalityandvastlyimprovesurvivalBackground:conventionalAPL„„TraditionaldiagnosisofAPL:TraditionaldiagnosisofAPL:MorphologyMorphologyCytogeneticsCytogenetics:t(15;17)/otherraretranslocations:t(15;17)/otherraretranslocationsFISHFISHRTRT--PCRPCR„„ComparedwithothertypesofAMLComparedwithothertypesofAMLAPL:highSSCAPL:highSSCabsentorweakCD34absentorweakCD34absentHLAabsentHLA--DRDRconsistentCD117,CD13,CD33,MPOconsistentCD117,CD13,CD33,MPOBackground„„Delayeddiagnosis:Delayeddiagnosis:APLwithNormalAPLwithNormalkaryotypekaryotypeorornegativeFISHresultnegativeFISHresult„„FCM:correctandrapiddiagnosisofAPL?FCM:correctandrapiddiagnosisofAPL?Background:reliablyidentifyingallAPLcasesbyFCMremainsachallenge„InsufficientforseparatingAPLfromotherAMLHLA-DR-:19%to24%ofnon-APLAMLCD34-/HLA-DR-:10%ofnon-APLAMLHLA-DR+:9%ofAPLCD34+:20-41%ofAPL2Background:inexpedientcriteria„„thewidelyusedfindingstodiagnoseAPL:thewidelyusedfindingstodiagnoseAPL:CD34CD34––/HLA/HLA--DRDR––blastsisblastsisinexpedient!inexpedient!FCMfeaturesof149APLcases„„149APLcases:19caseswithvariant149APLcases:19caseswithvarianttranslocationstranslocations76.5%CD117+/CD3476.5%CD117+/CD34––/HLA/HLA--DRDR––71.2%variableexpressionofCD6471.2%variableexpressionofCD64100%CD33+CD13+CD10100%CD33+CD13+CD10--CD16CD16--„„107non107non--APLcasesascontrolAPLcasesascontrolResults1:ImmunophenotypicFeaturesofAPLBACImmunophenotypicfeaturesofAPLbyFCM„„A,TypicalAPLcellspresentasinglepopulationwithA,TypicalAPLcellspresentasinglepopulationwithheterogeneoussidescatterchannels(SSC)spanningawideheterogeneoussidescatterchannels(SSC)spanningawiderange.range.CD34CD34––/HLA/HLA--DRDR––/CD117+87.1%/CD117+87.1%adistinctCD11badistinctCD11b––myeloidpopulationmyeloidpopulation„„B,MimickingregularB,MimickingregularmyeloblastsmyeloblastsCD34+/HLACD34+/HLA--DR+/DR+/--/CD117+6.80%/CD117+6.80%„„C,MimickinggranulocytesexhibithighSSCC,MimickinggranulocytesexhibithighSSC(similarto(similartoneutrophilsneutrophils))CD34CD34--/HLA/HLA--DRDR--/CD117/CD117--6.10%6.10%noticethedistinctCD11bnoticethedistinctCD11b––myeloidpopulationmyeloidpopulation„„CD11bCD11b––myeloidpopulationwasmyeloidpopulationwasindependentofmorphologicvariationandindependentofmorphologicvariationandwhetherthewhethertheimmunophenotypicimmunophenotypicfeaturesfeatureswerewere““blasticblastic””(CD34+/CD117+/HLA(CD34+/CD117+/HLA--DR+DR+andlowSSC;)orandlowSSC;)or““granulocyticgranulocytic””(CD34(CD34––/CD117/CD117––/HLA/HLA--DRDR––andhighSSC)andhighSSC)Results2:CombinationofCD11b-CD11c-HLA-DR-Identifies100%ofAPLs3Results1:ImmunophenotypicFeaturesofAPLBACHLAHLA--DRDR--CDCD11b11b--CD11CD11cc--enableustoidentifytheother2groupswithenableustoidentifytheother2groupswithclassicalimageAclassicalimageA„„InageB:CD34str+HLAInageB:CD34str+HLA--DRstr+CD117+DRstr+CD117+AAllHLAllHLA--DR+caseswerealsoCD34+andDR+caseswerealsoCD34+andCD117+,consistentwithfeaturesofearlymyeloidCD117+,consistentwithfeaturesofearlymyeloidprogenitorcellsprogenitorcells„„InageC:CD34InageC:CD34--HLAHLA--DRDR--CD117CD117--highSSChighSSCResults3:ImmunophenotypicFeaturesIdentifyAPLatDifferentStagesofMaturationavastmajorityofcases:initiallytobeavastmajorityofcases:initiallytobe““suspicioussuspicious””forAPLforAPLTheexceptions:Theexceptions:CD11bCD11b--CD11cCD11c--,overlookedinitially,overlookedinitially„„1case:CD34str+HLA1case:CD34str+HLA--DRstr+,AMLwithoutfurtherclassificationDRstr+,AMLwithoutfurtherclassification„„2cases:asmallpopulationofCD34+suspiciousfor2cases:asmallpopulationofCD34+suspiciousformyelodysplasiamyelodysplasia„„4cases:CD1174cases:CD117--missedcorrectflowmissedcorrectflowcytometriccytometricdiagnosisinitiallydiagnosisinitiallyWithoutanadequatebloodormarrowaspiratesmearWithoutanadequatebloodormarrowaspiratesmearResults3:ImmunophenotypicFeaturesIdentifyAPLatDifferentStagesofMaturation„„5cases:normal5cases:normalkaryotypekaryotypedetectedsubsequentlybyFISHdetectedsubsequentlybyFISHanalysisanalysis„„11cases:anunbalancedtranslocationder(15)ider(17)(q10)11cases:anunbalancedtranslocationder(15)ider(17)(q10)„„3cases:t(11;17)(q23;q21)AdiagnosisofAPLwas3cases:t(11;17)(q23;q21)AdiagnosisofAPLwasconfirmedbysubsequentconfirmedbysubsequentkaryotypingkaryotyping..„„Inall19cases,FCMeffectivelyprovidedthepreliminaryInall19cases,FCMeffectivelyprovidedthepreliminarydiagnosisdiag