Improved Outcome of Primary Plasma Cell Leukemia in the Current Era with the Use of Novel Agents and Autologous Bone Marrow Transplants-A Single Centre Experience.

Primary Plasma cell leukemia (pPCL) is an aggressive variant of plasma cell dyscrasias. Diagnostic criteria of plasma cell leukemia were recently updated by international myeloma working group to with more than 5% circulating plasma cells or absolute plasma cell count of more than 500/µL. We performed a retrospective analysis of patients diagnosed with pPCL in our department from 2017 to 2022. Clinical characteristics including the symptoms at presentation, organomegaly, bony involvement and extramedullary involvement were collected. Laboratory parameters including the biochemistry serum protein electrophoresis, serum immunofixation, serum free light chain assay, immunoglobulin profile were sent. Treatment and follow up data was collected. Fifteen patients were diagnosed (8 females and 7 males), median age 59 years (34-70). Six were lost to follow up and nine patients who received treatment at our hospital were analyzed for survival outcome. First line treatment was bortezomib- dexamethasone and immunomodulatory drugs (IMiD). Six (66%) achieved partial response or more and 3 had progressive disease. Five of the nine patients (55%) underwent autologous transplantation. Two out of 5 patients (40%) in the transplant group and 3 of the 4 patients (75%) in the non transplant group have died of the progressive disease. Overall survival was 45% at a median follow up of 14 months. Median OS for patients who underwent auto SCT was 16 months (12-22) versus 10 months (8-12) for patients who did not undergo transplant (Student t test; p value 0.018). Three of the patients achieved MRD negativity after transplant and post transplant consolidation therapy. Survival appears to be improved in patients who respond to initial therapy and are able to achieve MRD negativity which should be the goal of treatment in these patients.

Acute panmylelosis with myelofibrosis - A rare case report with review of literature.

ABSTRACT: Acute panmyelosis with myelofibrosis (APMF) corresponds to <1% cases of acute myeloid leukemia, which could be an underestimation due to missed diagnosis. Due to its rapidly fatal course, it warrants a timely and correct diagnosis. We present a case of a 44-year male who came with a short history of fever, generalised weakness, revealed pancytopenia with occasional circulating blast in the peripheral blood smear. Bone marrow aspirate was dry tap,biopsy revealed panmyelosis with myelofibrosis with increased (22%) blasts. Flowcytometric immunophenotyping, cytogenetics and molecular tests were undertaken. Together with clinical details, immunophenotypic profile, cytogenetics and molecular studies, the diagnosis of Acute panmyelosis with myelofibrosis was made and managed accordingly. 32 The WHO 2017 describes APMF as an acute panmyeloid proliferation with increased blasts (≥20% in the bone marrow or peripheral blood) and accompanying marrow fibrosis. APMF is rare with poor prognosis thus, must be differentiated especially from Acute megakaryoblastic leukemia to arrive at the correct diagnosis which will help reduce/prevent the early mortality by providing timely chemotherapy followed by upfront hemopoietic stem cell transplantation.

Clinical and Laboratory Profiles of 17 Cases of Chronic Granulomatous Disease in North India.

A primary immune deficiency disorder is often suspected in children with recurrent deep seated and fungal infections and those admitted to pediatric intensive care units. Chronic granulomatous disease (CGD) is inherited disorder leading to infections caused due to defective superoxide production. Cases referred for testing for a primary immunodeficiency disorder were tested for Dihydrorhodamine 123 (DHR) assay by flow cytometry and nitroblue tetrazolium dye (NBT) slide test. The unstimulated and stimulated samples were tested for oxidative burst activity which gives bright fluorescence due to formation of Rhodamine 123 on flow cytometry and blue formazan pigment in NBT slide test. The test results were reported in real time. From a total of 330 patients screened for chronic granulomatous disease using DHR and NBT slide test, 17 patients (5.1%) were found to have CGD. These included 12 boys and 5 girls. They presented with deep seated infections, recurrent and multiple abscess, recurrent pneumonia and granulomatous lymphadenitis. The causative organisms were Mycobacteriae, Staphylococcus, Burkholderia cepacia, Pseudomonas, Aspergillus and Cytomegalovirus. In 6 out of 17 positive cases family studies were carried out. On follow up five children succumbed to disease, two patients underwent allogeneic bone marrow transplant, the chimerism status was demonstrated by repeat DHR assay at day 50 post-transplant. Rest are in follow up under prophylactic antibiotics and supportive care. As facilities for molecular testing are not easily available for primary immuno deficiency disorders, flow cytometry based clinical laboratories can help to screen for some of the frequently suspected disorders like chronic granulomatous disease. This has aided in paediatric care in our centre.

Evaluation of multiparametric flow cytometry in diagnosis & prognosis of myelodysplastic syndrome in India.

Background & objectives: Diagnosis of myelodysplastic syndromes (MDS) is subjective in low-grade cases with <5 per cent blasts or <15 per cent ring sideroblasts. Flow cytometry (FCM) has been used to diagnose MDS; but, it still has only an adjunctive role. This study was conducted to evaluate the role of FCM to diagnose MDS and correlate the number of aberrancies with revised international prognostic scoring system (R-IPSS). Methods: This study included 44 consecutive clinically suspected cases of MDS with refractory cytopenia(s) and 10 controls. Patients were divided into two groups: (i) proven MDS cases (n=26), and (ii) suspected MDS (n=18). Ogata quantitative approach, pattern analysis and aberrant antigen expression were studied. Results: Ogata score ≥2 correctly diagnosed 80.7 per cent (21/26) while aberrant antigen and pattern analysis with flow score of ≥3 could diagnose 92.3 per cent (24/26) patients with proven MDS. Combination of both with flow score ≥3 could diagnose 100 per cent patients. Eight patients in suspected MDS group with persistent cytopenia on follow up were labelled as probable MDS. Ogata score ≥2 was present in 5 of 8 and pattern analysis score ≥3 was present in six probable MDS patients. Combination of both with flow score ≥3 was present in seven of eight patients. Spearman's correlation between Ogata score and R-IPSS, pattern analysis and R-IPSS and combination of both scores and R-IPSS showed significant positive correlation in proven MDS as well as when proven and probable MDS patients were combined. Interpretation & conclusions: Our results showed that combined Ogata approach and pattern analysis, demonstration of ≥3 aberrancies in >1 cell compartment could diagnose most MDS patients. Patients with high flow scores had high R-IPSS scores. Patient with flow score ≥3 and borderline cytomorphology should be observed closely for the development of MDS.

A Prospective, Cross Sectional Study of PNH Clone in MDS Patients Using High Sensitivity Flowcytometry: A Single Center Experience.

Subclinical PNH can be present in patients with bone marrow failure like aplastic anemia and myelodysplastic syndrome (MDS). Such clone may have prognostic and therapeutic implications. In literature around 1-10% MDS cases have shown a PNH clone, however, data from India is relatively scarce. A high sensitivity PNH assay was employed using a single tube combination of FLAER, CD157, CD64, CD15 and CD45 antibodies in adult patients of MDS at presentation. A clone size of  > 0.01% was taken as significant. A total of 30 patients were included. PNH clone was present in 30% cases. Correlation done between PNH clone size and LDH values showed moderately positive correlation (r = 0.735, p = 0.001, r2 = 0.541). As per this study a LDH cut off of 247 IU is likely to predict a PNH clone (> 1%) with moderate sensitivity and specificity. High sensitivity PNH assay is able to detect small PNH clone. Calculating the cut-off of LDH to predict PNH positivity can help us judiciously prescribe this test in MDS patients in resource constrained settings.

Platelet function tests: A 5-year audit of platelet function tests done for bleeding disorders in a tertiary care center of a developing country.

INTRODUCTION: The platelet function disorders remain largely undiagnosed or incompletely diagnosed in developing nations due to lack of availability of tests like lumiaggregometry, granule release assay or molecular testing. We performed a retrospective analysis of all the platelet function test (PFT) carried out in past 5 years by Light transmission aggregometery (LTA) using a panel of agonist. The indications and the test results were analyzed by two hematopathologist with the aim to look into the present diagnostic facilities or lack of it for correct diagnosis. This is essential for better management and genetic counselling. MATERIALS AND METHODS: The PFT was performed both on patients and healthy unrelated age specific controls by light transmission aggregometry on Chronolog platelet aggregometer using platelet rich plasma. The panel of agonists included ADP (10µm/l and 2.0 µm/l), epinephrine (10.0 µm/l), collagen (2µg/ml), arachidonic acid (0.75 mM) and ristocetin (1.25 mg/ml & 0.25 mg/l). RESULTS: The 5 years records of 110 cases were audited, 101 of these were tested for clinical bleeding , 35 adults and 66 children. The adults included 29 women and 6 men, 17 to 82 years of age. The children were 16 years to 3 months of age, 30 girls and 36 boys. Platelet function test abnormality was found in 31.6% (32/101) cases ,a majority remained undiagnosed of these about 21% had clinically significant bleeding.The cases diagnosed included Glanzmann Thromboasthenia-11 , von Willebrand Disease-6, Bernard Soulier'syndrome-1, storage pool disorder-6, mild defect of Epinephrine-3, isolated defect with collagen in1. CONCLUSION: An epidemiologically large proportion of platelet function disorders amongst people living in developing nations remain undiagnosed. This lacunae needs to be highlighted and addressed on larger scale. The options available are to increase the available armamentarium of tests or international collaboration with a specialized laboratory to aid in complete diagnosis.

Comparison of the characteristics of two hemoglobin variants, Hb D-Iran and Hb E, eluting in the Hb A2 window.

BACKGROUND: Cation exchange-high performance liquid chromatography (CE-HPLC) is most commonly used to evaluate hemoglobin (Hb) variants, which elute in the Hb A2 window. This study aimed to assess prevalence of an uncommon Hb variant, Hb D-Iran, and compare its red cell parameters and peak characteristics with those of Hb E that commonly elutes in the Hb A2 window. METHODS: Generally, we assess abnormal Hb using CE-HPLC as the primary technique along with alkaline and acid electrophoresis. All cases with Hb A2 window >9%, as assessed by CE-HPLCs during 2009-2013, were selected. RESULTS: Twenty-nine cases with Hb D-Iran variant were identified-25 heterozygous, 2 homozygous, 1 compound heterozygous Hb D-Iran/ß-thalassemia, and 1 Hb D-Iran/Hb D-Punjab. Overall prevalence of Hb D-Iran was 0.23%. Compared to patients with Hb E, those with Hb D-Iran had significantly higher Hb (12.1 vs. 11.3 g/dL, P=0.03), MCV (82.4 vs. 76.4 fL, P=0.0044), MCH (27.9 vs. 25.45 pg, P =0.0006), and MCHC (33.9 vs. 33.3 g/dL, P=0.0005). Amount of abnormal Hb (40.7 vs. 26.4%, P=0.0001) was significantly higher while retention time (3.56 vs. 3.70 min, P=0.0001) was significantly lower in Hb D-Iran than in Hb E. CONCLUSION: Hb D-Iran peak can be easily missed if area and retention time of the Hb A2 window are not carefully analyzed. To distinguish between variants, careful analysis of peak area and retention time is sufficient in most cases and may be further confirmed by the second technique-alkaline electrophoresis.

Concomitant Presence of Two Distinct Clones of Chronic Lymphocytic Leukemia and Plasma Cell Myeloma in a Patient.

A 74 years old male patient, presented with history of generalized weakness, fatigue, loss of appetite and breathlessness on exertion for past one and a half months. On examination, he was found to have significant pallor and generalized lymphadenopathy (cervical, axillary and inguinal). The skeletal survey showed punched out lytic lesions in skull and pelvic bones. The peripheral smear examination showed lymphocytosis with absolute lymphocyte count of 25,000/µL. The bone marrow aspirates revealed a hypercellular marrow with 74 % lymphocytes & 14 % plasma cells, suggestive of chronic lymphoplasmacytic disorder. The bone marrow biopsy had two morphologically distinct populations of lymphocytes & plasma cells. The immunohistochemical markers on bone marrow biopsy showed hat plasma cells were positive for CD138 with kappa light chain restriction. Flow cytometry showed B cell population with CD19/CD5 co expression, CD5/CD23 coexpression, were positive for CD22, CD20 and negative for FMC-7 and lambda light chain. In addition, plasma cells were also identified as CD45 negative cells and showed CD38/CD138 co-expression with variable CD19 and CD56 positivity. Serum protein electrophoresis revealed M band, serum immunofixation electrophoresis corresponded to IgA -Kappa. The final diagnosis of chronic lymphocytic leukemia with concomittant presence of plasma cell myeloma was concluded. This case imparts an important message to look for presence of coexisting entities in a single specimen and highlights the benefits of testing both plasma cell and B-cell compartments when the clinical features are not entirely consistent Flow cytometry together with protein electrophoresis can help to clinch difficult and rare dual diagnosis. These cases are rare and pose therapeutic challenge.

Congenital peripheral ameloblastic fibroma with intraosseous involvement in a 2-week-old infant: A case report with review of literature.

Ameloblastic fibroma is a rare, slow-growing benign mixed odontogenic tumor. It constitutes 2% of odontogenic tumors and is reported to occur at an age ranging from 6 months to 42 years. The youngest being a 7-week-old infant. We report a case of peripheral ameloblastic fibroma in a 2-week-old infant. The lesion presented since birth. It involved the maxilla with an extraosseous component involving the gingiva. A more or less conservative surgical approach of enucleation and curettage of the lesion was done under general anesthesia, trying to conserve the adjacent tooth buds. Only a few cases of congenital peripheral ameloblastic fibroma have been reported so far.

FNAC of inflammatory myofibroblastic tumour of the subcutis: a diagnostic dilemma.

Inflammatory myofibroblastic tumour formerly also known as inflammatory pseudotumour, was recognized initially in the lung and has been described in other visceral organs. It's occurrence in the subcutis is not well documented and its cytological appearance may be misinterpreted as malignant. This is the first case report of inflammatory myofibroblastic tumour of the subcutis in pediatric age group. A 12 year old female child presented with a subcutaneous swelling in the left anterior chest wall. FNA was performed and the cytological appearances were interpreted as malignant. Histopathology and immunohistochemistry revealed an inflammatory myofibroblastic tumour of the subcutis. FNA cytology is not very helpful in distinguishing inflammatory myofibroblastic tumour from malignant lesions especially soft tissue sarcomas. Awareness of it's occurrence in the subcutis is of importance for it's proper identification and treatment.

Cytomorphology of a case of primary cutaneous B-cell lymphoma.

Primary cutaneous lymphoma designates a heterogenous group of disorders arising from skin T and B cells with no evidence of extra cutaneous disease at the time of diagnosis and six months thereafter. We report the cytomorphological features of a case of primary cutaneous lymphoma, B cell type in a 60 year old female presenting with multiple large bosselated red coloured swellings all over the scalp. Clinical examination revealed no other swelling or lymphadenopathy. On cytology a diagnosis of B-cell cutaneous lymphoid hyperplasia (B-CLH) was given, however cutaneous lymphoma could not be ruled out. On biopsy and immuno-histochemistry a diagnosis of primary cutaneous lymphoma B cell type was made. Patient was started on specific chemotherapy of lymphoma to which she responded completely. Here we highlight the cytomorphologic, histopathological and immunohistochemical features of this rare lesion with a particular emphasis on the diagnostic dilemma encountered on cytology.