Professional Documents
Culture Documents
How To Download Practical Flow Cytometry in Haematology 100 Worked Examples 1St Edition Ebook PDF Version Ebook PDF Docx Kindle Full Chapter
How To Download Practical Flow Cytometry in Haematology 100 Worked Examples 1St Edition Ebook PDF Version Ebook PDF Docx Kindle Full Chapter
In our first publication ‘Practical Flow Cytometry in Haema- are also listed according to disease classification toward the
tology Diagnosis’ we presented an outline approach to the end (page 390) so that the text can also be used as a reference
use and applications of flow cytometric immunophenotyping manual.
in the diagnostic haematology laboratory. We showed how The analysis of blood, bone marrow and tissue fluid
this technique could be used to study blood, bone marrow specimens requires a multi-faceted approach with the
and tissue fluid samples in a variety of clinical scenarios integration of scientific data from a number of disciplines.
to achieve a diagnosis, taking into account important No single discipline can operate in isolation or errors will
features from the clinical history and examination alongside occur. Flow cytometry technology is in a privileged position
haematology, morphology, biochemistry, immunology, in that it can provide rapid analysis of specimens; it is
cytogenetic, histopathology and molecular data. This text often the first definitive investigation to produce results and
was illustrated with a series of ‘worked examples’ from real help formulate a working diagnosis. The results from flow
clinical cases presenting to our institution. These cases have cytometry can help to structure investigative algorithms to
proven to be very popular and so a companion publication ensure that the appropriate histopathological, cytogenetic
dedicated to 100 new ‘worked examples’ seemed justified and molecular studies are performed in each case. Tissue
and is presented here. samples are often limited in volume and difficult to acquire
The principles used in the approach to each case are so it is important to stratify investigations accordingly and
exactly the same as used in the first publication and cases to get the most from the material available. It is not good
are illustrated with tissue pathology and cytogenetic and scientific or economic practice to run a large series of poorly
molecular data, which are integrated to generate, where focussed analyses on every case. Appropriate studies need to
appropriate, a diagnosis based on the WHO Classification be executed in defined circumstances and flow cytometry
of Tumours of Haematopoietic and Lymphoid Tissues. can guide subsequent investigations in a logical fashion. In
We present a spectrum of clinical cases encountered in some situations a rapid succinct diagnosis can be achieved;
our department from both adult and paediatric patients immunophenotyping excels in the identification of acute
and of course, if the title is to be justified, flow cytometry leukaemia. Cytogenetic studies and molecular data give
plays a role in every case. Furthermore, we present both important prognostic information in these patients. But
neoplastic and reactive disorders and the cases appear of course the recognised genetic aberrations need to be
in no particular order so that the reader should have no demonstrated if the diagnosis is to be substantiated. Acute
pre-conceived idea as to the nature of the diagnosis in any promyelocytic leukaemia can often be confidently diagnosed
case. May−Grünwald−Giemsa (MGG)-stained films of using morphology alongside immunophenotyping data, but
peripheral blood and bone marrow aspirates are presented a PML translocation to the RARA fusion partner, needs
with flow cytometry data alongside haematoxylin and eosin to be shown. Flow cytometry cannot operate in isolation;
(H&E)-stained bone marrow and tissue biopsy sections. despite having the ‘first bite of the cherry’ the differential
Immunohistochemistry is used to further clarify the tissue diagnosis can still be wide open. There are a good number
lineage and cell differentiation. Cytogenetic studies using of worked examples illustrated here where immunophe-
metaphase preparations are used to identify translocations notyping was not able to indicate a specific diagnosis. The
and chromosome gains and losses whilst interphase fluores- disease entities with anaplastic or ‘minimalistic’ phenotypes
cence in situ hybridisation (FISH) studies and polymerase frequently cause difficulty. Appropriate histopathology and
chain reaction (PCR) are used to identify gene fusions, FISH, performed on the basis of flow cytometric findings,
break-aparts and deletions. The presentation is brought to a highlighting abnormal protein expression and gene rear-
conclusion and the particular features that are important in rangement respectively, can make a major contribution to
making a diagnosis are highlighted and discussed. The cases diagnosis and disease classification. Only when a specific
vii
viii Preface
diagnosis is made and prognostic parameters are assessed Haematology Diagnosis’ and some working knowledge is
can the optimal management plan be considered for each required to interpret the cases described. We also anticipate
individual patient. Finally, the goal posts are constantly a reasonable ability in morphological assessment and a
moving and developments in the molecular basis of disease, capacity to identify morphological variations seen in various
refining disease classification, are evolving rapidly. Whether disease states. In spite of this we do endeavour to describe
we are considering eosinophilic proliferations, the myriad of the diagnostic logic that we have applied to each worked
myeloproliferative neoplasms, lymphoproliferative disorders example and demonstrate how cellular immunophenotypes
or acute leukaemias we are constantly noting develop- have helped determine the nature of the disorder.
ments and adjusting diagnosis and prognosis accordingly. This text will be of interest to all practicing haematologists
This is an era of evolving diagnostic challenge and rapid and to histopathologists with an interest in haematopathol-
molecular evolution where the practising clinician needs to ogy but it is particularly directed at trainee haematologists
keep abreast of the significant developments in all areas of and scientists preparing for FRCPath examinations.
haematopathology.
The flow cytometric principles applied to each case have
been described in detail in ‘Practical Flow Cytometry in
Acknowledgement
We are grateful for the substantial assistance of Dr Avril Glasgow with regard to the provision of the cytogenetic data
Morris DipRCPath, Principal Clinical Scientist, West of and images relevant to the clinical cases presented here.
Scotland Genetic Services, Southern General Hospital,
ix
List of Abbreviations
xi
xii List of Abbreviations
The patients presented in 100 Worked Examples were all case as the clinical diagnosis evolved. Some retrospectively
real cases encountered and investigated in a regional flow relevant data may be missing but this reflects the true nature
cytometry laboratory serving a population of approximately of these actual patient scenarios and the investigations that
2.5 million over a period of 18 months. These are indi- were considered necessary at that time. Serum calcium
vidually presented with a history that reflects the actual values given are all corrected in accordance with serum
events for each patient, commencing with the presenting albumin level.
clinical features and the initial basic laboratory tests and
then proceeding to flow cytometry, bone marrow aspi-
rate morphology, bone marrow trephine biopsy histology Flow cytometry analysis
with immunohistochemistry studies and other specialised
cytogenetic and molecular analyses. Flow cytometry studies were all performed using a Becton
Dickinson FACS Canto II analyser. The findings are pre-
sented as a list of positive and negative results in relation
to the antigen and target cell population and the gating
Full blood counts
strategies applied to each case are explained. A series of
scatter plots and histograms are presented to illustrate
The full blood counts and marrow counts (for appropriate
specific informative points. The expression of most mem-
dilutions in relation to antibody) were performed on a Sys-
brane antigens is graded as positive when more than 20%
mex XN analyser. The differential leucocyte counts are auto-
of gated events are positive; the exceptions being CD34,
mated counts from the analyser. It should be noted that some-
CD117 and cytoplasmic antigens where a threshold of
times, in an automated count, abnormal cells are misidenti-
10% has been used. Where the percentage positivity for a
fied and the leucocyte sub-populations differ from a manual
given membrane antigen in the gated target population is
differential performed on a blood film. Such misidentifica-
borderline positive so that some cells appear negative and
tions are indicated by inverted commas.
some positive we have used the term ‘partial’ to describe
antigen expression. Cytoplasmic expression of an antigen is
indicated with the prefix ‘c’ (cytoplasmic expression of CD3
Biochemistry and immunology being cCD3) but on some scatter plots ‘cyt’ or ‘cyto’ has been
studies used. The intensity of antigen expression in terms of median
fluorescence intensity is graded as dim, moderate or bright
All relevant biochemistry and immunology data is given in compared to our laboratory reference ranges for normal cells
relation to the context of each patient presentation and in of each relevant lineage. See Figures 1.1a–g for a schematic
terms of investigations that were thought to be relevant to the representation of these principles.
xv
xvi Technical Notes
105 105
104 104
CD19 CD19
103 103
102 102
(a) (b)
105 105
104 104
CD19 CD19
103 103
102 102
(c)
Figure 1.1 Visual representation of strength of fluorescence in flow cytometry (not actual patient specimens), showing an isotype control and
eight CD19-positive samples which show fluorescence intensity with CD20 varying from negative to bright. (a) Isotype control, used to set
thresholds. (b) Negative (consistent with a CD19-positive, CD20-negative B-cell precursor neoplasm). (c) Partial positive, indicating that CD20
antigen expression varies from negative to positive (consistent with a precursor B-cell neoplasm). (c adjusted) Indicating that the threshold
for positivity might be reduced by the cytometrist where a discrete dim positive population is identified. (d) Dim CD20 antigen expression
(consistent with chronic lymphocytic leukaemia). (e) Moderate intensity, indicating medium strength of CD20 antigen expression (consistent
with B-cell non-Hodgkin lymphoma). (f) bright, indicating strong CD20 antigen expression (consistent with hairy cell leukaemia). (g) Two distinct
populations, one partial and dim and one bright (could indicate two unrelated B-lineage neoplasms or transformation of a low grade lymphoma).
(h) Contrasting with (g), a heterogeneous single population with fluorescence intensity varying from negative to moderate with a minority
being bright.
Technical Notes xvii
105 105
104 104
CD19 CD19
103 103
102 102
105 105
104 104
CD19 CD19
103 103
102 102
(f) (g)
105
104
CD19
103
102
(h)
[The End]
INDEX
Aborigines of Australia, the severity with which they punish sexual
offences, 71 sqq.
Abraham and Sarah, 60 sq.
Abyssinia, 66, 81
Action and opinion, their relative values for society, 155
Adulterer and injured husband, physical relationship supposed to
exist between, 104 sq.
—— called a murderer, 65, 104
Adultery, expiation for, 44 sq.; disastrous effects supposed to flow
from, 44 sqq., 60 sq.; punishment of, 46, 50 sq., 63 sqq.;
supposed to be dangerous to the culprits, their spouses, and
their offspring, 102 sqq. See also Infidelity.
Africa, superstitious veneration for kings in, 12 sqq.; superstition as a
support of property in, 38 sqq.; disastrous effects supposed to
flow from sexual immorality in, 54 sqq.; British Central, 66, 79,
105; British East, 77, 81, 92, 105, 115, 123; German East, 92,
105, 106; North, 119
Akamba, the, of British East Africa, 77 sq., 105
Akikuyu, the, of British East Africa, 92, 105, 115, 128
Aleutian hunters, 106
Algonquin Indians, their modes of keeping off ghosts, 139
Amboyna, taboo in, 27 sq.
America, Indians of North, 130 sq.; the discovery of, 173
Amulets for the protection of fruit-trees, 29 sqq.
Analogy between the reproduction of men, animals, and plants, 99
sqq.
Ancestor-worship, 7
Anger of gods or spirits at sexual offences, 44, 46, 47, 50, 51, 54, 55
sq., 57, 61, 63, 107
Angola, 108; Cazembes of, 11
Angoni, the, of British Central Africa, 79, 132
Annam, savages of, 46
Annamites, the, 33
Anne, Queen, 18
Anointing the nail instead of the wound, 166
Antambahoaka, the, of Madagascar, 59
Anthropology, social, the scope of, 157 sqq.
Anyanja, the, of British Central Africa, 66, 79, 105
Arab merchant in Darfur, 39
Araucanians of Chili, 84
Arawaks of British Guiana, 83
Areopagus, trials for murder before the, 156
Argos, massacre at, 115
Aricara Indians, 118
Armenians, their mutilation of the dead, 133
Assam, tribes of, 45
Attic law as to homicides, 114
Atua, guardian spirit, 118
Atua tonga, divinity, 8
Aunt, incest with, 50, 51
Australia, aborigines of, the severity with which they punish sexual
offences, 71 sqq.
——, Western, 74
Australian aborigines, their precautions against ghosts, 137
Avebury, Lord, 159
Avoidance, ceremonial, of relations by marriage, 75 sqq.; a
precaution against incest, 75, 84 sqq., 93; of wife’s mother, 75
sqq., 86 sq., 90 sq.; between father-in-law and daughter-in-law,
76; between various relations, 76 sq.; between father and
daughter, 78, 85, 87; between father-in-law and son-in-law, 79
sq.; of wife of wife’s brother, 80; of brothers-in-law and sisters-
in-law, 81; of future parents-in-law, 81, 83; between woman and
her father-in-law, 82; between a man and his father-in-law, 82,
83; of blood relations, 84 sqq.; between brother and sister, 85,
86, 87, 88, 90; between mother and son, 85, 86, 87
Awemba, the, of Northern Rhodesia, 66, 79, 103 sq., 120