PNH Testing in BC (VGH):

2011-2014

Anika Arora, Summer Student 2014

Bakul I. Dalal
 Introduction
• PNH is a rare disease.
• Prevalence: 1:200,0001
• BC = 25 patients
• Incidence: ___ / __ population / yr
• BC = __ patients / yr
• PNH is a debilitating disease
• Fatigue out of proportion to anemia
• Excruciating spasmodic painful episodes
• Thrombosis
• Poor quality of life
1. Hill A, et al, 2012
 Introduction contd…
• PNH is a treatable condition
• Complement factor 3 antibody (Eculizumab)
• Complement factor 5 antibody
• It is thus important to identify the PNH patients
• Clinical features of PNH (VGH data 2009):
• Hemolysis (12/17 patients)
• Thrombosis (4/17 patients)
• Cytopenias (17/17 patients)

Al Riami and Dalal, 2009

 PNH Pos Cells
• PNH phenotype (i.e. GPI-deficient) cells can be
seen in
• Classical PNH
• Other BMF syndromes
 Indications for PNH Testing
• Identifying PNH
• Stratifying BMF patients (aplastic anemia,
myelodysplasia)
 Indications for PNH Testing
• Hemolysis:
• With hemoglobinuria or elevated plasma Hb
• Unexplained hemolysis with thrombosis or
cytopenias or abd pain, or iron deficiency
• Thrombosis
• Unusual sites
• With hemolysis or cytopenias
• Bone marrow failure
• SAA, RCUD
• Unknown etiology
Borowitz et al, 2010
 Patients & Methods
• Time period: (3.5 years) January 2011-June 2014
• Number of tests: 969
• Number of patients: 894
• Repeat testing: 154 tests in 60 patients
• No of repeats
• 1: n= 39
• 2: n= 13
• 3+: n= 8
• Age: <1-91 years (median 45.5)
• Sex: M/F 437/457
 Patients & Methods contd…
• Tests by year:
• 2011 210
• 2012 252
• 2013 327
• 2014 (projected) 346
• Tests by location:
• In-house: 527
• Referred in: 442
 PNH Testing in BC
PNH Tests Per Annum

400
346
350 327

300
252
250 210
198
ber of Tests

200 166
150 113
Num

98
100 80
46 50 52
50 27
11
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
 PNH Testing by Locations

PNH Tests by Location 5/2012 - 6/2014

450
402 Total: 669 Tests
400

350

300
Number of Patients

250
218

200

150

100

40
50
9
0
VGH Ref-Other SPH LGH
Testing Locations
 PNH Reporting by Pathologist
PNH Reporting by Pathologist

200 185 186

178
180 173
158
160

140
Number of Cases

120

100

80
59
60

40 28

20
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 Positive Tests
• 85/969 (8.6%) in 46 patients
• Clone size (grans/monos/RBCs):
• Large clone (5-100%) =28 patients
• Small clone (<5%) =20 patients
 Large PNH Clone Size (>5%)
• Discrepancy in granulocyte and monocyte clone
• Gran – mono clone: +32 to -47%
• Three patients >20% difference
• One patient 43% vs 91%, 50% vs 70%, 90 vs
57
 Material & Methods (contd…)
Indications for testing
• Derived from:
• Copath report
• Sunset CBC
• PCIS imaging and clinical notes
• Care Connect
 Positivity and Clone Size by
Reason for Testing
Reason for Testing No. of Patients # Patients Positive Clone Size >5% Clone size <5%

PNH 15 14 14 0

Uni/bi-cytopenia 319 5 1 4

Anemia (CA) 220 3 1 2

Leukopenia 99 1 0 1

Thrombocytopenia 105 3 0 3

Pancytopenia 130 6 4 2

Hemolysis 74 4 2 2

Thrombosis 133 5 2 3

Aplastic Anemia 33 10 5 5

MDS 51 5 2 3

Other 47 1 0 1

Not Stated 69 3 0 3

Query PNH 32 0 0 0

Leukemia 17 1 1 0

Number of Patients 920* 54 31 23

*some patients had two “reasons for testing”

 Repeat Testing
• Repeat testing: 154 tests in 60 patients
• No of repeats: Repeated once (n=39), twice (n=13),
or more (n=8)
• PNH neg = PNH neg 29
• PNH pos = PNH pos 29
• Discrepancy 02*
* patient-1 Thrombosis. RBC pos 0.01%, WBC neg.
Rpt all neg.
*patient-2 Known PNH post SCT, PNH cells declining
from 2% over 8 years to now negative.
 Strengths
• Uniform US/Canadian Guidelines for testing (with
minor modifications)
• High resolution testing
• Results consistent on repeat specimens
• Consistent EPT results
• More precise CD64 gating for monocytes
 Weaknesses
• Does not include testing done at other sites
(Victoria). i.e. not a province-wide data.
• Testing indications may not be entirely accurate.
• Based on requisition, CBC off sunset, BM report
off sunset.
• Patient chart not reviewed in every case.
 Conclusions
• Number of PNH tests increasing annually
• 82/969 tests over 3.5 years
• Clone size (grans/monos/RBCs):
• <0.1% = 20 in 14 patients
• <5% =13 in 8 patients
• 5-100% =49 in 29 patients
• Where do we go from here?
• Screening of PNH requests?
• So far, no screening.
• Communication with requesters?