Unlocking the complete blood count as a risk stratification tool for breast cancer using machine learning: a large scale retrospective study.

Optimizing early breast cancer (BC) detection requires effective risk assessment tools. This retrospective study from Brazil showcases the efficacy of machine learning in discerning complex patterns within routine blood tests, presenting a globally accessible and cost-effective approach for risk evaluation. We analyzed complete blood count (CBC) tests from 396,848 women aged 40-70, who underwent breast imaging or biopsies within six months after their CBC test. Of these, 2861 (0.72%) were identified as cases: 1882 with BC confirmed by anatomopathological tests, and 979 with highly suspicious imaging (BI-RADS 5). The remaining 393,987 participants (99.28%), with BI-RADS 1 or 2 results, were classified as controls. The database was divided into modeling (including training and validation) and testing sets based on diagnostic certainty. The testing set comprised cases confirmed by anatomopathology and controls cancer-free for 4.5-6.5 years post-CBC. Our ridge regression model, incorporating neutrophil-lymphocyte ratio, red blood cells, and age, achieved an AUC of 0.64 (95% CI 0.64-0.65). We also demonstrate that these results are slightly better than those from a boosting machine learning model, LightGBM, plus having the benefit of being fully interpretable. Using the probabilistic output from this model, we divided the study population into four risk groups: high, moderate, average, and low risk, which obtained relative ratios of BC of 1.99, 1.32, 1.02, and 0.42, respectively. The aim of this stratification was to streamline prioritization, potentially improving the early detection of breast cancer, particularly in resource-limited environments. As a risk stratification tool, this model offers the potential for personalized breast cancer screening by prioritizing women based on their individual risk, thereby indicating a shift from a broad population strategy.

Comparison of peripheral blood automated hematopoietic progenitor cell count and flow cytometric CD34+ cell count.

BACKGROUND: Stem cell apheresis in the context of autologous stem cell transplantation requires an accurate cluster of differentiantion 34 (CD34+) count determined by flow cytometry as the current gold standard. Since flow cytometry is a personnel and time-intensive diagnostic tool, automated stem cell enumeration may provide a promising alternative. Hence, this study aimed to compare automated hematopoietic progenitor enumeration carried out on a Sysmex XN-20 module compared with conventional flow cytometric measurements. METHODS: One hundred forty-three blood samples from 41 patients were included in this study. Correlation between the two methods was calculated over all samples, depending on leukocyte count and diagnosis. RESULTS: Overall, we found a high degree of correlation (r = 0.884). Furthermore, correlation was not impaired by elevated leukocyte counts (>10 000/µL, r = 0.860 vs <10 000/µL, r = 0.849; >20 000/µL, r = 0.843 vs <20 000/µL, r = 0.875). However, correlation was significantly impaired in patients with multiple myeloma (multiple myeloma r = 0.840 vs nonmyeloma r = 0.934). SUMMARY: Stem cell measurement carried out on the Sysmex XN-20 module provides a significant correlation with flow cytometry and might be implemented in clinical practice. In clinical decision-making, there was discrepancy of under 15% of cases. In multiple myeloma patients, XN-20 should be used with caution.

Reference intervals of cell population data parameters in Sysmex XN-Series and its patterns of changes from early adulthood to geriatric ages in South Korea.

INTRODUCTION: Cell population data (CPD) parameters may be putative biomarkers for the screening of various diseases including some infections and myelodysplastic syndrome. This study aimed to establish the age- and sex-specific reference intervals (RIs) for the CPD parameters in the Korean population. METHODS: The reference population for the RIs of CPD parameters comprised 124 856 subjects aged 20-99 years. CPD parameters were obtained from Sysmex XN-2000 (Kobe, Japan) datasets from 17 health promotion centers in 13 South Korean cities. We determined significant partitions for age and sex, and calculated RIs according to Clinical and Laboratory Standards Institute C28-A3 guidelines. RESULTS: The side scattered light intensity in the neutrophil area and the lymphocyte area did not require sex-related partitioning except in those over the age of 50, among whom the lower limit (LL) and upper limit (UL) were lower in females. However, the side scattered light distribution width in the lymphocyte area required age- and sex-related partitioning, in which LL and UL were higher in females. The LL and UL of the fluorescent light distribution width were higher in males in the neutrophil area and higher in females in the lymphocyte area, but age-related partitioning was not required. The forward scattered light intensity in the neutrophil area, lymphocyte area, and monocyte area did not require age-related partitioning in males. CONCLUSION: This study has determined comprehensive age- and sex-specific RIs for CPD parameters, which could help to prove the clinical significance of these parameters in the Sysmex XN-2000.

Immature Erythroid Precursors and/or Erythrocyte Dysplasia in Peripheral Blood.

BACKGROUND: With the progress of technology in automated hematology analyzers, in the vast majority of cases, nucleated red corpuscles (NRC) can be automatically identified by most types of automated hematology analyzers, thus correcting the leukocyte count and avoiding pseudoleukocytosis by the analyzers themselves. The objective of the study was to explore pseudoleukocytosis due to immature erythroid precursors and/or erythrocyte dysplasia in the peripheral blood resulting from different rare situations. METHODS: Four rare cases showing pseudoleukocytosis due to immature erythroid precursors and/or erythrocyte dysplasia in the peripheral blood were analyzed and the effects on complete blood count (CBC) performed on a Sysmex XN-2000 analyzer and microscopic morphological features of the peripheral blood were investigated. These cases were selected for their vital value in describing all pseudoleukocytosis due to immature erythroid pre-cursors and/or erythrocyte dysplasia in the peripheral blood. The causes of immature erythroid precursors and/or erythrocyte dysplasia in the peripheral blood were analyzed. RESULTS: In all these cases, proportions of NRC and leukocyte counts were affected to varying degrees by the presence of numerous immature erythroid precursors and/or obvious erythrocyte dysplasia in the peripheral blood. All cases associated with an alarm concerning NRC presentation, and abnormal scattergrams of WDF and WNR, thus leading to pseudoleukocytosis. CONCLUSIONS: Laboratory artifacts led by NRC may be an indicator towards the occurrence of numerous immature erythroid precursors and/or obvious erythrocyte dysplasia in the peripheral blood, and active extramedullary hematopoiesis, breakdown of the bone marrow barrier, and the stress response of acute bleeding and severe multiple infection.

The flagging features of the Sysmex XN-10 analyser for detecting platelet clumps and the impacts of platelet clumps on complete blood count parameters.

OBJECTIVES: Platelet clumps present in anticoagulant specimens may generate a falsely decreased platelet count and lead to an incorrect diagnosis. A clear understanding of the ability of a haematology analyser (HA) to detect platelet clumps is important for routine work in the clinical laboratory. METHODS: Citrate-anticoagulated whole-blood samples were collected from various patients as a negative group. Adenosine diphosphate (ADP)-induced platelet aggregation was performed on those negative samples to mimic platelet-clump-containing (positive) samples. The 'platelet clumps' and 'platelet abnormal' flags generated by the Sysmex XN-10 instrument were used to assess the flagging performance of this HA and demonstrate its flagging features. The complete blood count (CBC) results of paired negative and positive samples were compared to evaluate the impact of platelet clumps on the CBC parameters. RESULTS: A total of 187 samples were eligible for this study. The total accuracy, sensitivity, and specificity of the platelet clumps flag were 0.786, 0.626, and 0.947, respectively. The total accuracy, sensitivity, and specificity of the platelet abnormal flag were 0.631, 0.348, and 0.914, respectively. A separate assessment focusing on the positive samples with low platelet counts showed that the total sensitivities of the platelet clumps and platelet abnormal flags were 0.801 and 1.000, respectively. Platelet clumps may interfere with the leukocyte count and with platelet and erythrocyte indices. CONCLUSIONS: Platelet clumps can influence not only platelet indices but also leukocyte and erythrocyte counts. The Sysmex XN-10 instrument is sensitive to positive samples with low platelet counts but insensitive to those with high platelet counts.

Pruritus: Diagnosis and Management.

Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. An exposure history may reveal symptom triggers. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. Primary skin lesions indicate diseased skin, and secondary lesions are reactive and result from skin manipulation, such as scratching. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

Significance of serum Th1/Th2 cytokine levels in underlying disease classification of childhood HLH.

OBJECT: Goal of this research was to investigate values of serum cytokines in childhood HLH with different triggers, with the expectation to find secretion spectrum of 5 main types of underlying diseases. METHOD: 118 newly diagnosed HLH were included, and serum concentrations of 6 cytokines were tested before treatment began. Absolute cytokine levels and ratios between them were then studied in the HLH groups collectively and separately RESULTS: In general, IFN-γ, IL-10 and IL-6 showed differences among 5 HLH groups. Specifically, relative levels of these three cytokines to each other were meaningful in distinguishing 4 types of HLH. Level of IL-6 was higher than those of IFN-γ or IL-10 in HLH driven by Systemic auto-inflammatory disorders (SAIDs) or Langerhans Cell Histiocytosis (LCH), while primary HLH and EBV-HLH shared elevated ratio of IL-10 to IL-6. Although more than one distinctive ratios were found in 3 HLH groups, combination of these parameters didn't offer optimal balance between sensitivity and specificity. CONCLUSION: As a group of easily gained laboratory findings, cytokine levels were reliable in the procedure of roughly classifying HLH cases with the help of patients' clinical phenotype. However, adequate data is still needed to explore the significance of these indicators in identifying one particular underlying disease accurately.

The impact of therapeutic hypothermia on peripheral blood cell in newborns with hypoxic ischemic encephalopathy

Abstract The effect of hypothermia treatment on white blood cell (WBC), neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR) and platelet-to-lymphocyte ratio (PLR) values as an indicator of inflammation was evaluated in newborns with hypoxic ischemic encephalopathy (HIE). The study was performed that the before-therapeutic hypothermia (TH) and after-TH WBC, lymphocytes, neutrophils, monocytes and NLR, LMR and PLR values of the complete blood cell count were retrospectively evaluated. The results of the patient group were compared with the results of healthy newborns. A total of 78 patients who underwent TH were evaluated in our study. Mean values before and after TH were NLR3.8/2.7, LMR 5.6/8.6, and PLR 60.3/67.1 respectively. A statistical significance was present for NLR values before and after TH in those with seizure in our study (4.15±2.95/3.01±2.54) but no statistical significance was found for LMR or PLR. In neonates with HIE, effect of TH on complete blood cell count and inflammatory mechanisms (mediated neutrophil and lymphocyte) may be minimal.

IL-27 as a potential biomarker for distinguishing between necrotising enterocolitis and highly suspected early-onset food protein-induced enterocolitis syndrome with abdominal gas signs.

BACKGROUND: The initial clinical manifestations and abdominal imaging findings of neonates with necrotising enterocolitis (NEC) and food protein-induced enterocolitis syndrome (FPIES) are sometimes similar; however, their prognosis and therapies are different. We aimed to evaluate the utility of interleukin (IL)-27 as a differentiation marker between NEC and highly suspected early onset (HSEO)-FPIES. METHODS: All samples used in this study were obtained from the neonatal diagnosis centre of Children's Hospital of Chongqing Medical University. In the case-control study, neonates with NEC (n = 13), HSEO-FPIES (n = 9), and jaundice (control, n = 8) were enroled to determine the serum IL-27 levels using commercial enzyme-linked immunosorbent assay (ELISA) kits. In the validation cohort study, the NEC (n = 87), HSEO-FPIES (n = 62), and jaundice (control, n = 54) groups were included to analyse the diagnostic efficiency of IL-27 for discriminating between NEC and HSEO-FPIES using a receiver operating characteristic (ROC) curve. FINDINGS: In the case-control study, IL-27 levels were higher in the NEC group than in the HSEO-FPIES group (p = 0·005). In the cohort study, the area under the ROC curve (AUC) of IL-27 for differentiating NEC from HSEO-FPIES was 0·878, which was higher than the AUCs of IL-6 (0·761), C-reactive protein (0·800), white blood cell count (0·637), neutrophils (0·765), lymphocytes (0·782), neutrophil to lymphocyte ratio (0·781), and platelet count (0·729). INTERPRETATION: Serum IL-27 is a novel biomarker that may potentially discriminate NEC from HSEO-FPIES in neonates. FUNDING: None.

Complete blood cell count-derived ratios can be useful biomarkers for neurological diseases.

Complete blood cell count-derived parameters such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) have recently shown to be highly sensitive biomarkers. Their usefulness has been proven as prognostic factors in several cancers, in the stratification of mortality in major cardiac events, as predictors and markers of infectious or inflammatory pathologies, and in many other conditions. Surprisingly, the study of these biomarkers in neurological diseases is somewhat limited. This paper aims to take stock of the data present in the literature regarding the complete blood cell count-derived ratios in this group of pathologies and to formulate a hypothesis, based on the most recent data concerning innate and acquired immunity, on which diseases of the nervous system could benefit in diagnostic and prognostic terms from the in-depth study of these new biomarkers.

Necessity of flow cytometry assessment of circulating plasma cells and its connection with clinical characteristics of primary and secondary plasma cell leukaemia.

Plasma cell leukaemia (PCL) is a rare and very aggressive plasma cell disorder. Preventing a dismal outcome of PCL requires early diagnosis with appropriate analytical tools. Therefore, the investigation of 33 patients with primary and secondary PCL was done when the quantity of circulating plasma cells (PCs) using flow cytometry (FC) and morphology assessment was evaluated. The phenotypic profile of the PCs was also analysed to determine if there is an association with clinical outcomes and to evaluate the prognostic value of analysed markers. Our results revealed that FC is an excellent method for identifying circulating PCs as a significantly higher number was identified by FC than by morphology (26·7% vs. 13·5%, P = 0·02). None of secondary PCL cases expressed CD19 or CD20. A low level of expression with similar positivity of CD27, CD28, CD81 and CD117 was found in both PCL groups. A decrease of CD44 expression was detected only in secondary PCL. Expression of CD56 was present in more than half of PCL cases as well as cytoplasmic nestin. A decreased level of platelets, Eastern Cooperative Oncology Group score of 2-3 and lack of CD20+ PC were associated with a higher risk of death. FC could be incorporated in PCL diagnostics not only to determine the number of circulating PCs, but also to assess their phenotype profile and this information should be useful in patients' diagnosis and possible prognosis.

Peripheral granular lymphocytopenia and dysmorphic leukocytosis as simple prognostic markers in COVID-19.

INTRODUCTION: Developing prognostic markers can be useful for clinical decision-making. Peripheral blood (PB) examination is simple and basic that can be performed in any facility. We aimed to investigate whether PB examination can predict prognosis in coronavirus disease (COVID-19). METHODS: Complete blood count (CBC) and PB cell morphology were examined in 38 healthy controls (HCs) and 40 patients with COVID-19. Patients with COVID-19, including 26 mild and 14 severe cases, were hospitalized in Juntendo University Hospital (Tokyo, Japan) between April 1 and August 6, 2020. PB examinations were performed using Sysmex XN-3000 automated hematology analyzer and Sysmex DI-60 employing the convolutional neural network-based automatic image-recognition system. RESULTS: Compared with mild cases, severe cases showed a significantly higher incidence of anemia, lymphopenia, and leukocytosis (P < .001). Granular lymphocyte counts were normal or higher in mild cases and persistently decreased in fatal cases. Temporary increase in granular lymphocytes was associated with survival of patients with severe infection. Red cell distribution width was significantly higher in severe cases than in mild cases (P < .001). Neutrophil dysplasia was consistently observed in COVID-19 cases, but not in HCs. Levels of giant neutrophils and toxic granulation/Döhle bodies were increased in severe cases. CONCLUSION: Basic PB examination can be useful to predict the prognosis of COVID-19, by detecting SARS-CoV-2 infection-induced multi-lineage changes in blood cell counts and morphological anomalies. These changes were dynamically correlated with disease severity and may be associated with disruption of hematopoiesis and the immunological system due to bone marrow stress in severe infection.

Diagnosis of patients with blood cell count for COVID-19: An explainable artificial intelligence approach / Diagnóstico de pacientes com hemograma para COVID-19: Uma abordagem com inteligência artificial explicável / Diagnóstico de pacientes con hemograma para COVID-19: un enfoque explicable de inteligencia artificial

Objective: Present an explainable artificial intelligence (AI) approach for COVID-19 diagnosis with blood cell count. Methods: Five AI algorithms were evaluated: Logistic Regression, Random Forest, Support Vector Machine, Gradient Boosting and eXtreme Gradient Boosting. A Bayesian optimization with 5-Fold cross-validation was used to hyper-parameters tuning. The model selection evaluated three results: cross validation performance, test set prediction performance and a backtest: performance on identifying patients negative for COVID-19, but positive for others respiratory pathologies. Shapley Additive explanations (SHAP) was used to explain the chosen model. Results: A Random Forest model was obtained with 77.7% F1-Score (IC95%:57.1;92.3), 85.9% AUC (IC95%:73.7;95.9), 74.4% Sensitivity (IC95%:50.0;92.1) and 97.5% Specificity (IC95%:93.6;100.0). The main features were leukocytes, platelets and eosinophils. Conclusion: The research highlights the importance of model interpretability, demonstrating blood cell count as a possibility for COVID-19 diagnosis. The methodological structure developed, using TRIPOD's guidelines, can be extrapolated to other pathologies.

Objetivo: Propor uma abordagem com inteligência artificial explicável para diagnóstico de COVID-19 com hemograma. Métodos: Cinco algoritmos de IA foram testados: Regressão Logística, Florestas Aleatórias, Máquina de Vetores de Suporte, Gradient Boosting e eXtreme Gradient Boosting. Os hiper-parâmetros foram definidos através da otimização bayesiana com validação cruzada 5-Fold. A seleção de modelo utilizou três resultados de desempenho para definir o melhor modelo: validação cruzada, conjunto de teste e rendimento na identificação de pacientes negativos para COVID-19, porém positivos para outras patologias respiratórias (backtest). Ao final, Shapley Additive explanations (SHAP) foi utilizado para explicar o modelo escolhido. Resultados: Obteve-se um modelo Random Forest com F1-Score de 77.7% (IC95%:57.1;92.3), AUC de 85.9% (IC95%:73.7;95.9), Sensibilidade de 74.4% (IC95%:50.0;92.1) e Especificidade de 97.5% (IC95%:93.6;100.0). As principais variáveis foram leucócitos, plaquetas e eosinófilos. Conclusão: A pesquisa destaca a importância da interpretabilidade do modelo, demonstrando o hemograma como uma possibilidade para diagnosticar COVID-19. A estrutura metodológica desenvolvida no estudo, utilizando as diretrizes do TRIPOD, pode ser extrapolada para detecção de outras patologias.

Objetivo: Proponer un enfoque explicable de inteligencia artificial (IA) para el diagnóstico de COVID-19 con el uso de hemograma. Métodos: Cinco modelos de IA fueron evaluados: Logistic Regression, Random Forest, Support Vector Machine, Gradient Boosting e eXtreme Gradient Boosting. Los hiper-parámetros fueron definidos a través de optimización bayesiana con validación cruzada 5-Folds. La selección del modelo se utilizó tres resultados: rendimiento del validación cruzada, rendimento en conjunto de pruebas y el análisis de desempeño en identificación de pacientes negativos para COVID-19, pero positivos para otras patologías respiratorias (backtest). Shapley Additive explanations (SHAP) fue utilizado para explicar el modelo elegido. Resultados: Se obtuvo un modelo Random Forest con F1-Score de 77.7% (IC95%:57.1;92.3), AUC de 85.9% (IC95%:73.7;95.9), Sensibilidad de 74.4% (IC95%:50.0;92.1) y Especificidad de 97.5% (IC95%:93.6;100.0). Las principales variables fueron leucocitos, plaquetas y eosinófilos. Conclusión: La investigación presenta la importancia de la interpretabilidad del modelo, demostrando el uso de hemograma como posibilidad para diagnosticar COVID-19. La estructura elaborada, siguiendo las directrices de TRIPOD, puede ser extrapolar para otras patologías.

Resting state brain network functional connectivity is not associated with inflammatory markers and blood cell counts in older adults.

OBJECTIVE: Systemic inflammation and monocyte counts have previously been associated with changes in resting state functional connectivity (rsFC) in cross-sectional neuroimaging studies. We therefore investigated this association in a longitudinal study of older patients. METHODS: We performed a secondary analysis of longitudinal data from older patients who underwent functional magnet resonance imaging (fMRI) scans before and 3 months after elective surgery. Additionally, serum levels of C-reactive protein and Interleukin-6 as markers of inflammation and leukocyte, lymphocyte and monocyte counts were determined. Correlations between these markers and pre- or postoperative rsFC between regions previously associated with inflammatory markers were investigated using general linear regression models. RESULTS: We found no significant correlations between inflammatory markers or blood cell counts and mean connectivity within four resting state networks (RSNs), neither preoperatively nor postoperatively. Significant inter-region rsFC was found within these RSNs between a few regions either pre- or postoperatively, but no inter-region connections were consistently observed in both pre- and postoperative fMRI scans. CONCLUSIONS: Inflammatory markers and monocyte counts were not associated with rsFC in our study, contrasting previous results. SIGNIFICANCE: Multiple measurements in the same individuals, as performed here, provide a way to reduce the high risk of false positive results in fMRI studies. TRIAL REGISTRATION: Clinicaltrials.gov (registration number NCT02265263).

Combined use of peripheral blood blast count and platelet count during and after induction therapy to predict prognosis in children with acute lymphoblastic leukemia.

ABSTRACT: Several studies have reported an association between the rapidity of reduction in peripheral blood blast count or recovery of normal hematopoiesis and treatment outcome during therapy in children with acute lymphoblastic leukemia (ALL). However, little is known about the impact of both of these aspects on prognosis in pediatric ALL. Accordingly, the purpose of this study was to evaluate whether the combined use of blood blast count and platelet count could predict event-free survival (EFS) and overall survival (OS) when minimal residual disease (MRD) detection was not available.A total of 419 patients aged 0 to 14 years diagnosed and treated for ALL between 2011 and 2015 were enrolled.Patients with a blast count ≥0.1 × 109/L on day 8 exhibited significantly lower survival rates than that in those with blast counts <0.1 × 109/L. The EFS and OS in patients with platelet count ≥100 × 109/L on day 33 were significantly higher than those with platelet counts <100 × 109/L. In univariate and multivariate analyses, patients with low blast count on day 8 and high platelet count on day 33 were significantly associated with better EFS and OS. The combination of blast cell count on day 8 and platelet count on day 33 demonstrated a strong association with MRD-based risk stratification.Complete blood count is an inexpensive, easy to perform, and reliable measurement in children with ALL. The combination of blast count and platelet count during and after induction chemotherapy was a significant and independent prognostic factor for treatment outcome in pediatric ALL.

Enrichment of circulating trophoblasts from maternal blood using laminar microscale vortices.

OBJECTIVE: Enrichment of circulating trophoblasts (CTs) from maternal blood at week 11-13 of gestation, using laminar microscale vortices, and evaluation of the performance of the VTX-1 Liquid Biopsy System in terms of CT recovery and purity. METHOD: Eight mililiter of blood was collected from 15 pregnant women and processed with the VTX-1 Liquid Biopsy System. Y-chromosome specific quantitative PCR was performed to estimate the number of enriched male CTs. To evaluate the VTX-1 performance, the target cell recovery was characterized by spiking experiments with a trophoblast cell line. Furthermore, the total quantity of DNA after enrichment was used to calculate the number of retained maternal cells. RESULTS: Successful recovery of male CTs was established in 7 out of 10 first trimester samples from pregnant women carrying a male fetus. The number of CTs, recovered from 8 ml of blood, was estimated between two and six. Spiking experiments resulted in a CT recovery of ±35 % with ±1524 retained maternal blood cells. CONCLUSION: CTs can be enriched from maternal blood with high purity, using laminar microscale vortices, starting from 8 ml of blood.

Screening peripheral blood smear: A tale of the "TAIL".

Examining a well-stained slide in a systematic manner is the key to being a good pathologist. For a blood smear, it involves examining first at low power (40× or 100×) for broader details and then going on to high power (400×) for finer details, from the tail end to the body of the slide. The 'tail end' is the key to early diagnosis.

Next-generation sequencing in the diagnosis of non-cirrhotic splanchnic vein thrombosis.

BACKGROUND & AIMS: Myeloproliferative neoplasms (MPNs) are the most frequent cause of non-tumoural non-cirrhotic splanchnic vein thrombosis (NC-SVT). Diagnosis of MPN is based on blood cell count alterations, bone marrow histology, and detection of specific gene mutations. Next-generation sequencing (NGS) allows the simultaneous evaluation of multiple genes implicated in myeloid clonal pathology. The aim of this study was to evaluate the potential role of NGS in elucidating the aetiology of NC-SVT. METHODS: DNA samples from 80 patients (75 with idiopathic or exclusively local factor [Idiop/loc-NC-SVT] and 5 with MPN and NC-SVT [SVT-MPN] negative for Janus kinase 2 gene [JAK2] [V617F and exon 12], calreticulin gene [CALR], and thrombopoietin gene [MPL] mutations by classic techniques) were analysed by NGS. Mutations involved in myeloid disorders different from JAK2, CALR, and MPL genes were categorised as high-molecular-risk (HMR) variants or variants of unknown significance. RESULTS: In 2/5 triple-negative SVT-MPN cases (40%), a mutation in exon 12 of JAK2 was identified. JAK2-exon 12 mutation was also identified in 1/75 patients with Idiop/loc-NC-SVT. Moreover, 28/74 (37.8%) of the remaining Idiop/loc-NC-SVT had at least 1 HMR variant. Sixty-two patients with Idiop/loc-NC-SVT were not receiving long-term anticoagulation and 5 of them (8.1%) had recurrent NC-SVT. This cumulative incidence was significantly higher in patients with HMR variants than in those without. CONCLUSIONS: NGS identified JAK2-exon12 mutations not previously detected by conventional techniques. In addition, NGS detected HMR variants in approximately one-third of patients with Idiop/loc-NC-SVT. These patients seem to have a higher risk of splanchnic rethrombosis. NGS might be a useful diagnostic tool in NC-SVT. LAY SUMMARY: Next-generation sequencing (NGS) performs massive sequencing of DNA allowing the simultaneous evaluation of multiple genes even at very low mutational levels. Application of this technique in a cohort of patients with non-cirrhotic non-tumoral portal vein thrombosis (NC-SVT) and a negative study for thrombophilic disorders was able to identify patients with a mutation in exon 12 not previously detected by conventional techniques. Moreover, NGS detected High Molecular Risk (HMR)-variants (Mutations involved in myeloid disorders different from JAK2, CALR and MPL genes) in approximately one third of patients. These patients appear to be at increased risk of rethrombosis. All these findings supports NGS as a potential useful tool in the management of NC-SVT.

Hyperprogressive disease during PD-1 blockade in patients with advanced hepatocellular carcinoma.

BACKGROUND & AIMS: Programmed cell death-1 (PD-1) inhibitor treatment can cause hyperprogressive disease (HPD), but the incidence, outcome, and predictive factors of HPD are unknown in patients with hepatocellular carcinoma (HCC). Herein, we assessed the existence and factors predictive of HPD in patients with advanced HCC treated with nivolumab. METHODS: We enrolled 189 patients with advanced HCC treated with nivolumab. Occurrence of HPD was investigated using tumour growth dynamics based on tumour growth kinetics (TGK) and tumour growth rate (TGR) before and after treatment, or time to treatment failure. We additionally analysed patients treated with regorafenib (n = 95) or best supportive care (BSC)/placebo (n = 103) after progression on sorafenib to compare tumour growth dynamics. RESULTS: Flare-up of tumour growth was observed in a fraction of patients upon PD-1 blockade, indicating the occurrence of HPD. Based on distinct patterns of disease progression exclusively observed in the nivolumab-treated cohort, but not in the regorafenib- or BSC/placebo-treated cohorts, 4-fold increases in TGK and TGR ratios as well as a 40% increase in TGR were the cut-off values used to define HPD; 12.7% of the patients (24/189) treated with nivolumab met all these criteria. Patients with HPD had worse progression-free survival (hazard ratio [HR] 2.194; 95% CI 1.214-3.964) and overall survival (HR 2.238; 95% CI 1.233-4.062) compared to patients with progressive disease without HPD. More than 90% of patients with HPD missed the opportunity for subsequent treatment because of rapid clinical deterioration. An elevated neutrophil-to-lymphocyte ratio (>4.125) was associated with HPD and an inferior survival rate. CONCLUSIONS: HPD occurs in a fraction of patients with HCC who receive PD-1 inhibitor treatment. Analyses of the baseline immune profile and on-treatment tumour growth dynamics could enable optimal patient selection and earlier identification of HPD. LAY SUMMARY: Hyperprogressive disease is an unexpected response pattern observed in patients treated with an immune checkpoint inhibitor. This study revealed that hyperprogressive disease occurs in a fraction of patients with advanced hepatocellular carcinoma treated with an anti-PD-1 antibody, providing evidence to encourage careful monitoring of patients to prevent clinical deterioration induced by PD-1 blockade.