AJCP  / Original Article
Improved Recognition of Hematogones From Precursor
B-Lymphoblastic Leukemia by a Single Tube Flow
Cytometric Analysis
Michelle D. Don, MD , Washington Lim, CLS, Amanda Lo, MD, Brian Cox, MD,
Qin Huang, MD, PhD, Sumire Kitahara, MD, Jean Lopategui, MD, and Serhan Alkan, MD
From the Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA.
Key Words: Flow cytometry; Hematogones; B-lymphoblastic leukemia; Minimal residual disease (MRD)
Am J Clin Pathol June 2020;153:790-798
DOI: 10.1093/AJCP/AQAA007
ABSTRACT
Objectives:  To improve diagnostic accuracy in
differentiating hematogones from leukemic blasts in
cases of precursor B-lymphoblastic leukemia/lymphoma
(B-ALL), particularly those that are posttreatment
or after bone marrow transplant, and to provide an
algorithmic approach to this diagnostic challenge.
Methods:  A seven-color antibody panel including
CD10, CD19, CD45, CD38, CD34, CD58, and CD81
was generated to assess the feasibility of a single
tube panel and provide an algorithmic approach to
distinguish hematogones from B-ALL. Fifty-three
cases were analyzed, and results were correlated with
histology and ancillary studies.
Results:  There was a significant difference in mean
fluorescent intensity (MFI) for CD81 and CD58
when comparing hematogones and B-ALL populations
(P < .001). B-ALL cases had a mean (SD) MFI of 24.6
(27.5; range, 2-125) for CD81 and 135.6 (72.6; range,
48-328) for CD58. Hematogones cases had a mean (SD)
MFI of 70.2 (19.2; range, 42-123) for CD81 and 38.8
(9.4; range, 23-58) for CD58.
Conclusions:  The flow cytometry panel with the above
markers and utilization of the proposed algorithmic
approach provide differentiation of hematogones from
B-ALL. This includes rare cases of hematogones and
B-ALL overlap where additional ancillary studies are
necessary.
790 Am J Clin Pathol 2020;153:790-798
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Hematogones (HGs) are immature B cells found in
small numbers within otherwise normal bone marrow.
Increased HGs are seen in regenerating bone marrow fol-
lowing chemotherapy or after bone marrow transplant.1-5
HGs are also expanded in conditions such as chronic
inflammatory diseases, immune thrombocytopenic pur-
pura, Gaucher disease, cytomegalovirus infection, au-
toimmune or congenital cytopenias, and mycobacterial
infection.6-10 A  common immunophenotypic profile of
HGs includes moderate expression of CD45, with CD19,
CD10, CD34, and TDT, which can overlap with that seen
in precursor B-lymphoblastic leukemia (B-ALL).
Three different maturation stages have been described
in HGs: early stage, which usually lacks CD20 expression;
intermediate stage; and late stage where CD20 expression
is similar to mature B-lymphoid cells. Intermediate stage
shows marker expression of both early and late stages,11
and it expresses varying intensities of CD20. Evaluation
of HGs by flow cytometry (FC) is often characterized by
the expected variable expression of CD20.12 Despite char-
acterization of FC patterns, there is significant overlap
between HGs with B-ALL, and there is no reliable ap-
proach to distinguish them with 100% consistency and
reliability.
Lúcio et al11 and McKenna et al12,13 described in de-
tail the FC signatures of HGs as they mature. Briefly, the
earliest HGs express bright CD34, Tdt, dim CD19, bright
CD10, dim CD22, bright CD38, no CD20, and dim to
no CD45. As they progress to stage 2, the cells demon-
strate moderate to dim CD10, moderate CD19, dim to
bright CD20, bright CD38, and loss of CD34 and Tdt
© American Society for Clinical Pathology, 2020. All rights reserved.
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along with gain of CD45. The third stage of HG mat-
uration shows loss of CD10, moderate to bright CD19,
moderate and variable CD20, bright CD22, and bright
CD45. Several studies examined subtle differences in ex-
pression of additional markers for HGs and B-ALL. Two
notable markers are CD58 and CD81. CD58 is lympho-
cyte function–associated antigen 3 and is expressed by
both hematopoietic and nonhematopoietic cells,14,15 with
overexpression in leukemic blasts compared with HGs.14
CD81 is an integral surface membrane protein that is as-
sociated with CD19 and involved in signal transduction
of B cells.16 Studies show CD81 expression is decreased
in B-ALL and can be used as a marker to distinguish be-
tween leukemic blasts and HGs.16-19
Due to similar morphologic and immunophenotypic
features, distinguishing a hematologic malignancy from
normal bone marrow cell populations can be a diagnostic
challenge. In addition, HGs are usually more numerous at
baseline in children, which is 75% of B-ALL cases.5,9,20,21
Accurately assessing leukemic burden and distinguishing
from regenerating HGs are essential in the clinical evalua-
tion of treatment response. Additional markers to identify
hematogones were evaluated, and a seven-color antibody
panel to reliably distinguish HGs from B-ALL was gen-
erated, with an algorithmic approach for distinguishing
HGs from B-ALL in everyday practice presented here.
Materials and Methods
Fifty-three (33 HGs; 20 cases of B-ALL) cases were
collected from September 2017 to February 2019, in-
cluding 48 bone marrow aspirates and five peripheral
blood cases. Selection was based on strong supporting
clinical and cytogenetic/molecular evidence for the desig-
nation of the CD19, CD10, and dim CD45 populations
being either B-ALL or HGs. Cases of residual or recurrent
B-ALL were confirmed by similar immunophenotypic
aberrancies seen in the diagnostic samples for those pa-
tients and by matching chromosomal and translocation
abnormalities to diagnostic materials.
HG cases came from patients with anemia, pan-
cytopenia, chronic infections, immunodeficiency dis-
orders, and histories of B-ALL or other hematologic
malignancies in remission. The increased immature
populations were confirmed as nonleukemic based
on benign follow-up clinical course and nonmatching
immunophenotypic and/or cytogenetic profiles as
the patients’ historical B-ALL in cases of remission.
Cytogenetic analysis was performed using standard
karyotype and fluorescence in situ hybridization
(FISH) analysis.
© American Society for Clinical Pathology
AJCP  / Original Article
Immunophenotyping was performed using WBCs
and fluorescent-conjugated monoclonal antibodies (di-
rect immunofluorescence method). RBCs were lysed and
viable cell suspensions incubated in a single seven-color
tube with CD10FITC (clone ALB1; Beckman Coulter),
CD58PE (clone AICD58; Beckman Coulter), CD19ECD
(clone J3-119; Beckman Coulter), CD38 PC5.5 (clone
LS198.4.3; Beckman Coulter), CD34 APC (clone 581;
Beckman Coulter), CD81 PB (clone JS64; Beckman
Coulter), and CD45KO (clone J33; Beckman Coulter)
conjugated monoclonal antibodies. Labeled cells were
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analyzed by FC (Navios Flow Cytometers; Beckman
Coulter). Samples were prepared using an ammonium
chloride single-tube lysis method to obtain a WBC count
of 5,000 to 10,000 cells/µL, where 50 to 100,000 total
events were collected.
Daily quality control beads protocol (Navios Flow
Cytometer quality control beads protocol) were used for
alignment and fluorescent intensity standardization.
Data were analyzed using FCS Express software (De
Novo Software) for phenotypic expression and mean
fluorescent intensity (MFI) of each marker. The popu-
lation of interest was selected based on low side scatter
and dim CD45 expression of the cells, termed blast
gate. Subpopulations expressing CD19 were examined.
Coexpression with CD10 and CD34 was confirmatory
in identifying the population of interest. B-ALL cases
with aberrant markers were documented for their unique
immunophenotypic expression to serve as a leukemic
“fingerprint” as deemed needed in follow-up marrows.
The geometric MFI was determined in the immature
lymphoid cell populations for CD58, CD81, CD34, and
CD38. To account for differences in day-to-day instru-
ment settings and fluorochrome batches used, MFIs for
CD38 and CD58 markers were also determined in the
granulocyte population and used as internal controls.
Results
The patient age ranged from 2 to 87 years. The me-
dian age for patients with B-ALL was 31  years (range,
5-73  years) with a male to female ratio of 1.75:1, while
the median age for those without leukemia was 45 years
(range, 2-87 years) with a male to female ratio of 4.7:1.
CD38 expression in HGs demonstrated a mean MFI
of 294.2 (range, 114-429) and, by our analysis, showed a
very consistent pattern at the level of the second decade
on the FC histograms. We attest that lower or brighter in-
tensity of CD38 in the HG population on FC histograms
was not observed. However, discrimination from B-ALL
was limited since some of the leukemic blast populations
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Don et al / Improved Recognition of Hematogones From B-ALL
had a similar level of intensity. Hence, CD38 expression
that does not show typical gating at the second decade but
rather is anywhere else indicates the population is likely
B-ALL. Accordingly, CD38 expression at the second
decade can be either HGs or leukemia ❚Figure 1❚. The re-
lapsed B-ALL population frequently had expression of
CD38 intensity similar to the initial diagnosis. The means
for blast and HG populations, when compared with each
other, demonstrated a significant difference (P = .05;
Welch t test).
HGs showed dimmer CD58 expression than in-
ternal granulocytes, with a mean (SD) MFI of 38.8 (9.4;
range, 23-58). The leukemic blasts showed a mean (SD)
increased MFI of 135.6 (72.6; range, 48-328) ❚Figure  2❚.
In observing FC histograms, compared with internal
granulocytes, HGs were dimmer and true blast showed
brighter CD58 expression ❚Figure 3❚. Overlap was seen in
two cases of B-ALL, which had CD58 expression falling
within the upper limit of the range for CD58 expression
of HGs. Overall, there was a significant difference be-
tween the mean MFIs for CD58 of HGs compared with
leukemic blasts (P < .001, Welch t test).
HG showed high CD81 expression with a mean (SD)
MFI of 70.2 (19.2; range, 42-123). However, leukemic
blasts showed dim CD81 expression with a mean (SD)
MFI of 24.6 (27.5; range, 2-125) ❚Figure 4❚. Four B-ALL
cases had CD81 MFI within the range for HGs. Overall,
the difference in MFI between HGs and blasts was signif-
icant, with a P value less than .001 (Welch t test).
Given these findings, an algorithm is proposed for
differentiating between leukemic blasts and HGs by FC
on all cases with an immature B-cell population with clin-
ical concern for acute leukemia ❚Figure 5❚. After confirma-
tion of an immature B-cell population in the dim CD45/
low side-scatter gate, it is recommended that further eval-
uation with a single seven-color tube that includes CD10,
CD58, CD19, CD38, CD34, CD81, and CD45 is used.
Bright expression of CD38, at the level of the second
decade, could suggest HGs or blasts; any other expression
for CD38 suggests leukemia. Next, use the expression pat-
terns of CD58 and CD81. Based on data in this study, dim
expression of CD58 relative to the patient’s internal gran-
ulocytes with an MFI no greater than 48.2 (1 SD below
the MFI for CD58 expression in HGs), as well as brighter
CD81 expression with MFI greater than 53 (1 SD above
the MFI for CD81 expression in HGs), favors HG. Bright
expression of CD58 relative to the patient’s granulocyte
population with an MFI greater than 63 (1 SD above the
MFI for CD58 expression in leukemic blasts) and dim ex-
pression of CD81 with an MFI less than 51 (1 SD below
the MFI for CD81 in HG) favor leukemic blasts. Caution
must be taken in cases where one of the two markers does
792 Am J Clin Pathol 2020;153:790-798
DOI: 10.1093/ajcp/aqaa007
not follow the proposed pattern. Comparison to previous
FC findings from the same patient and utilization of
other ancillary studies such as chimerism analysis, cyto-
genetic and molecular studies are recommended.
A case of a 23-year-old woman with a history of
B-ALL, 100 days after stem cell transplant, showed high
numbers of cells (46.68% of analyzed cells) falling in the
low side-scatter/dim CD45 gate. The population was pos-
itive for CD19, CD10, and CD38 falling at the second
decade on FC histograms. Utilization of our seven-color
FC tube panel was necessary to distinguish between HGs
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and blasts. There was dim expression of CD58 relative
to the internal granulocytes and brighter expression of
CD81 (Figure 3). The average MFI was 32 for CD58 and
was 69 for CD81 ❚Figure 6❚. These findings are consistent
with HGs. Further support was seen in the normal female
karyotype, as the previous karyotype from a bone marrow
aspirate involved by B-ALL showed deletion 9p.
A case in which one marker did not follow the pro-
posed pattern is that of a 37-year-old woman with his-
tory of B-ALL refractory to standard chemotherapy and
after salvage chemotherapy. Bone marrow biopsy spec-
imen showed immature B cells expressing both CD19 and
CD10 (6.5% of analyzed cells) by FC analysis of the bone
marrow aspirate. CD38 expression was at the level of the
second decade; thus, differentiating between HGs and
recurrent leukemia was critical. CD81 showed dim ex-
pression on FC histograms, with an MFI of 22, favoring
B-ALL. The expression of CD58 was difficult to deter-
mine relative to the granulocyte population ❚Figure  7❚.
The average MFI for CD58 was 72, which favors HGs
❚Figure  8❚. Comparison to this patient’s previous bone
marrow biopsy specimens involved by acute leukemia
showed similar expression of CD58 and CD81. The pos-
sibility of residual/persistent disease in this sample could
not be excluded. Subsequently, karyotype showed a com-
plex clone seen in previously involved samples, consistent
with residual/persistent disease.
Discussion
Distinguishing between HGs and B-ALL is chal-
lenging given the morphologic and immunophenotypic
overlap. While cases with a high number of blasts popu-
lations are suspicious for B-ALL, problems occur when
there are expanded HG populations as seen in children,
immune and autoimmune disorders, and after chemo-
therapy and bone marrow transplants. It is known that
the percentage of HGs in otherwise normal bone marrow
of children can be as high as 25% to 50%.5,13,20 Likewise,
small immature populations cannot be assumed as HGs,
© American Society for Clinical Pathology

A B
E F
❚Figure 1❚  CD38 expression by CD19+/CD10+ immature B cells in four different cases identified as hematogones (A-D) con-
sistently falls at the second decade of expression on flow cytometry histograms. CD38 expression by CD19+/CD10+ cells in
four different cases identified as B-lymphoblastic leukemia/lymphoma falls below or above the second decade (E-G) or around
the second decade (H).
❚Figure 2❚  Mean fluorescent intensity (MFI) for CD58 in
hematogones is 38.8 with a standard deviation of 9.4. The
MFI for CD58 in leukemic blasts is 135.5 with a standard
deviation of 72.6. Using a Welch t test, there is a significant
difference between the MFI of hematogones and leu-
kemic blasts for CD58 with a P value less than .001. B-ALL,
B-lymphoblastic leukemia/lymphoma.
particularly in cases of post–bone marrow transplant
treated for B-ALL. The question of minimal residual di-
sease (MRD) is critical in these cases. General descriptions
of a normal HG immunophenotype have been proposed
© American Society for Clinical Pathology
AJCP  / Original Article
C D
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G H
with overall recommendations to observe a spectrum of
marker expression in HGs compared with tight clonal ex-
pression in B-ALL.13,22 Distinguishing the two, however,
can still be challenging. When possible, utilization of an-
cillary molecular and cytogenetic studies always further
facilitates distinguishing between HGs and B-ALL.
Markers of interest in delineating between HGs and
B-ALL include CD38, CD58, and CD81. Various studies
have examined the relative expression of these markers
in the two populations, as well as the relative expression
of CD10 and CD34.23 CD38 is expressed in the earliest
stages of B-cell development and has a fairly reliable ex-
pression pattern with bright CD38 expression in HGs
through all stages of maturation until downregulation
in mature B cells.13 Approximately 75% of B-ALL cases
express CD38, although not as bright as HG expression
of CD38 on FC analysis.5,13,24 The precise location of
CD38 expression of HGs on FC histograms should be
established and stable within individual laboratories. If
CD38 expression falls anywhere other than the known lo-
cation on a laboratory’s FC histogram for HGs, then the
immature B-cell population cannot be HGs. Pathologists
must become familiar with CD38 expression within their
laboratories. The applicability of CD38 underexpression
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A B C D

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E ❚Figure 3❚  Flow cytometry histograms from bone marrow aspirate of a 23-year-old
woman with a history of high-risk pre–B-lymphoblastic leukemia/lymphoma following
peripheral blood stem cell transplant. The immature B-cell population is consistent with
hematogones. A, Side scatter vs CD45 with increased immature B cells identified in
the dim CD45/low side-scatter gate termed “blast” gate (blue). B, Immature population
identified in panel A expresses CD19 and CD10. C, This population has bright expression
of CD38, at the level of the second decade. D, Expression of CD58 (blue) shows dim
expression, MFI = 32, relative to the internal granulocytes (green). E, Expression of CD81
(brown) is bright, with MFI = 69.

CD2.28 HGs show dim expression of CD58 in early stages

❚Figure 4❚  Mean fluorescent intensity (MFI) for CD81 in
hematogones is 70.2 with a standard deviation of 19.2. The
MFI for CD58 in leukemic blasts is 24.6 with a standard
deviation of 27.5. Using an independent t test, there is a
significant difference between the MFI of hematogones
and leukemic blasts for CD58 with a P value less than .001.
B-ALL, B-lymphoblastic leukemia/lymphoma.
in B-ALL as a discriminant marker has been demon-
strated in various studies examining its utility in MRD
testing.25-27 We demonstrate stable CD38 expression in
HGs, which is helpful in that any other expression can be
deemed leukemic blasts.
CD58 is a 60-kDa transmembrane protein and
member of the immunoglobulin superfamily expressed by
hematopoietic and nonhematopoietic cells, and it func-
tions as a costimulatory molecule for T cells by binding
but lose it with maturation. Previous studies have dem-
onstrated that CD58 is also expressed in most B-ALL
cases.29-32 Veltroni et al32 recently analyzed expression of
CD58 in 172 cases of B-precursor acute lymphoblastic
leukemia and demonstrated CD58 expression in 171 cases.
However, CD58 as a single marker appeared to be insuf-
ficient according to Lee et al,31 and both Veltroni et al32
and Lee et  al31 observed considerable overlap in expres-
sion of CD58 between early HGs and B-ALL. In addi-
tion, Patkar et al27 noted a significant number of B-ALL
cases without overexpression of CD58. However, those
cases that do have overexpression of CD58 initially tend
to retain this feature following treatment when residual
disease or recurrence is detected.30,32 In our experience,
CD58 expression is significantly higher in blasts than in
HGs and has proven a reliable marker in distinguishing
the two populations. The mean (SD) MFI for CD58 of
leukemic blasts was 135.6 (72.6; range, 48-328). The mean
(SD) MFI for CD58 for HGs was 38.8 (9.4; range, 23-58).
These data show that an immature B-cell population ex-
pressing CD58 is a strong indicator of HG identification.
CD81 is an integral surface membrane protein that is as-
sociated with CD19 and involved in signal transduction
of B cells.15 Our data show that HGs showed significantly
higher average CD81 expression, with a mean (SD) MFI
of 70.2 (19.2; range, 42-123) compared with leukemic
lymphoblasts, which showed dim CD81 expression with a
mean (SD) MFI of 24.6 (27.5; range, 2-125). Overlap does

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❚Figure 5❚  Practical algorithmic approach in distinguishing between hematogones and B-lymphoblastic leukemia/lymphoma in
everyday practice. FISH, fluorescence in situ hybridization; MFI, mean fluorescent intensity.
A B
❚Figure 6❚  Average mean fluorescent intensity (MFI) for
CD81 (A) and CD58 (B) obtained from a bone marrow
sample of a 23-year-old woman with a history of high-risk
pre–B-lymphoblastic leukemia/lymphoma following periph-
eral blood stem cell transplant.
exist between HGs and leukemic blasts. We propose that
an individual laboratory must establish the mean MFI
for CD58 and CD81 and use these data when evaluating
for HGs vs B-ALL. Cases in which at least one marker is
outside of the expected range should be approached with
caution, using ancillary studies to more accurately distin-
guish the populations.
Other markers were consistent with findings in current
literature. CD19 is expressed early in B-cell lymphogenesis
with brighter expression as HG maturation proceeds.11,12
Conversely, CD34, which is expressed in early HGs, pro-
gressively lessens expression during maturation. The dif-
ference is more prominent with CD34, which tends to be
overexpressed in B-ALL than in HGs.33 However, variation
is seen depending on B-ALL subtypes and on prior treat-
ment effect, with CD34 also showing downmodulation.31
© American Society for Clinical Pathology
AJCP  / Original Article
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CD10, also known as common acute lympho-
blastic leukemia antigen, is a 90- to 100-kDa cell surface
metalloprotease.34,35 CD10 is present on numerous tis-
sues; however, in the hematopoietic system, it serves to
regulate B-cell proliferation via activation of inhibitory
propeptides and inactivation of stimulatory peptides.36
Although early HGs usually show bright CD10 expres-
sion that decreases intensity with maturation,11,12 they
may not be expressed in the earliest stages of lymphocytic
differentiation.35 CD10 is expressed in approximately 85%
to 90% of B-ALL cases34 and is relatively overexpressed in
leukemic lymphoblasts compared with HGs.13,27 However,
CD10 expression is dependent on the subtypes of leu-
kemia encountered, as pro–B-cell ALL lacks CD10 ex-
pression by definition.37,38 Furthermore, CD10 expression
is influenced by therapy and is downmodulated after
chemotherapy in many patients.30,32 CD10 interpretation
must be done in the context of clinical and ancillary fac-
tors, making the marker itself of no additional value in
distinguishing HGs from lymphoblasts.
Before the use of the panel presented in this article,
we used a panel similar to that presented in Borowitz,
et al.39 Other markers, including CD74, CD123, and
BCL2, were investigated by us (data not shown), but it
was ultimately determined that the addition of CD81
provided the most accurate method of distinguishing
HGs from lymphoblasts.
The algorithmic approach presented in this study for
practical evaluation of HGs vs B-ALL is much needed
given morphologic and heavy immunophenotypic
overlap. This study demonstrates distinguishing
immunoexpression that can be assessed by objective and
quantifiable methods to show statistical significance in
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E ❚Figure 7❚  Flow cytometry histograms from bone marrow aspirate of a 37-year-old woman
with a history of B-lymphoblastic leukemia/lymphoma refractory to chemotherapy following
salvage therapy. The immature B-cell population is ultimately determined to be leukemic
blasts. A, Side scatter vs CD45 with a population, 6.53% of analyzed cells, of immature B
cells identified in the dim CD45/low side-scatter gate termed “blast” gate (blue). B, Immature
population identified in panel A expresses CD19 and CD10. C, This population has bright ex-
pression of CD38, at the level of the second decade. D, Expression of CD81 is dim (brown),
MFI = 22, relative to the usual expression of CD81 in hematogones. E, Expression of CD58
(blue) is difficult to determine relative to the internal granulocytes (green), MFI = 72.

A B
❚Figure 8❚  Average mean fluorescent intensity (MFI) for
CD81 (A) and CD58 (B) obtained from a bone marrow
sample of a patient with history of B-lymphoblastic leu-
kemia/lymphoma refractory to chemotherapy following
salvage therapy.
distinguishing populations. Because of the known prob-
lems with nonstandardization of FC evaluation in the cur-
rent literature, as even recently addressed by Wood,40 this
work provides reproducible methods for evaluation and
comparison, independent of different fluorochrome lots,
different FC models, and subjective interpretation of rel-
ative brightness of populations.40 Particularly for CD58,
this was done by using each patient’s granulocyte popula-
tion as a baseline for comparison of relative increases or
decreases of marker expression to characterize our HG
and leukemic blast populations. In addition, assessment
of the utility of previously studied ancillary markers, in-
cluding CD58 and CD81, for this common problem of
lymphoblast distinction was performed, and we propose
using both markers together in a single tube as standard
of practice. Utilization of this seven-color FC tube and
proposed algorithm can help support hematopathologists
in everyday practice approach this difficult distinction be-
tween HGs and leukemic blasts.
We emphasize that no single marker can deter-
mine the population and recommend using the above
markers in a single tube. At a minimum, if routine
quantification modalities of evaluating populations
are not feasible for different laboratories, this study
provides guidance on how laboratories may consider
calibrating studies on their flow cytometers and
fluorochromes based on these numerical parameters
of relative MFI for CD81 and with internal granulo-
cytic controls for CD58. This will allow for improved
evaluation of immunoexpression once expected areas
where HG and B-ALL populations fall on histograms
are established for that laboratory. In our experience,
using this algorithm provides consistent resolution
in 98% of cases with great accuracy. In rare cases
with equivocal results (ie, conflicting CD58 vs CD81
expression), comparing immunophenotypic expres-
sion of the original leukemia and combining with
ancillary studies such as chimerism, cytogenetics,
FISH, and molecular sequence analysis may be used
to precisely determine the immature population.
With regard to laboratories that cannot perform
seven-color flow cytometry, a more limited panel

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DOI: 10.1093/ajcp/aqaa007

could potentially be explored, including the markers
CD19, CD45, CD38, CD58, and CD81. Such a panel
has not been tested by us but could be evaluated and
validated in a laboratory.
Corresponding author: Serhan Alkan, MD; Serhan.alkan@cshs.org.
Supported in part by the Department of Pathology, Cedars-
Sinai Medical Center, Los Angeles, CA.
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