Hematology Case Study: A 69 Year Old Female with Breast Implants

Case History

A sixty nine year old female who underwent right breast reconstruction about 13 years ago due to breast cancer presents to the doctor office with right breast pain and right breast enlargement over the last two months. She has lost some weight and does not recall any trauma to this area. She had a textured saline implant. Examination reveals no definite palpable masses. MRI of right breast showed intact saline implant with moderate amount of fluid surrounding the implant within the intact external capsule. No adenopathy was noted. Right breast implant was removed and complete capsulectomy was performed.

Image 1. A. Section of breast capsule with rare atypical hyperchromatic cells (arrow). B. Cytospin preparation of the fluid surrounding the implant with numerous atypical lymphocytes. C. Cell block of the fluid with large atypical lymphocytes. D, E. Lymphocytes are positive for CD30 (image D) and negative for ALK-1 (image E). F. CD30 positive cells in the section of the implant.

Diagnosis

Breast implant-associated anaplastic large cell lymphoma.

Discussion

Breast implant associated anaplastic large cell lymphoma is a provisional entity that is morphologically and immunophenotypically similar to ALK-negative anaplastic large cell lymphoma. It arises primarily in association with a breast implant. It is a very rare entity with an incidence of 1 in 500,000 to 3 million women with implants. Tumor cells may be localized to the seroma cavity or may involve pericapsular fibrous tissue. Sometimes it can form a mass lesion. Locoregional lymph node may be involved. The mean patient age is 50 years. Most patient presents with stage 1 disease, usually with peri-implant effusion. The mean interval from implant placement to lymphoma diagnosis is 10.9 years. There is no association with the type of implant. Histologic examination shows two different types of proliferations. In patients with seroma, the proliferation is confined to the fibrous capsule (“in situ” iALCL). However, the distribution of neoplastic lymphocytes could be heterogeneous with some cellular areas with numerous large pleomorphic cells of varying size and some fibrotic areas with rare atypical lymphocytes. It is beneficial to look at the seroma fluid in addition to capsule sections, because sometimes the neoplastic lymphocytes are predominantly present in fluid (as in our case). Patients presenting with tumor mass show more heterogeneous proliferations infiltrating surrounding tissues (“infiltrative” iALCL). They consists of either sheets are clusters of large neoplastic cells accompanied by a large number of eosinophils. By immunohistochemistry, the tumor cells are strongly positive for CD30. CD2 and CD3 are more often positive than CD5. CD43 is almost always expressed. Most cases are CD4 positive. The prognosis is very good in patients with disease confined to the capsule. The median overall survival is 12 years. However, patients with a tumor mass could have a more aggressive clinical outcome.

References

1. Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoetic and Lymphoid Tissues (Revised 4th edition). IARC: Lyon 2017.

2. Jaffe, E , Arber, D, et al. Hematopathology (second edition) 2017.

-Junaid Baqai, MD, was born in Chicago, IL but spent most of his life in Karachi, Pakistan. He graduated from DOW Medical College in Pakistan and did his residency in anatomic and clinical pathology at Danbury Hospital, CT followed by hematopathology fellowship from William Beaumont Hospital, Michigan and oncologic-surgical pathology fellowship from Roswell Park Cancer Institute, New York. He currently serves as Medical Director of hematology, coagulation and flow cytometry at Memorial Medical Center and Medical Director of Laboratory at Taylorville Memorial Hospital.

Hematopathology Case Study: A 76 Year Old Man with Lymphadenopathy

Case History

76 year old man with a history of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with new anterior mediastinal mass and increasing lymphadenopathy.

Lymph Node Biopsy

H&E

Diagnosis

Tissue sections show a diffuse atypical lymphoid infiltrate that completely effaces the normal nodal architecture. The infiltrate is composed of numerous small lymphocytes with round to mildly irregular nuclei, clumped chromatin, inconspicuous nucleoli and scant cytoplasm. There are also expanded pale areas that contain intermediate sized cells with more open chromatin and distinct single to multiple nucleoli. These cells are most consistent with prolymphocytes/paraimmunoblasts and form the proliferation centers characteristic of CLL/SLL. Occasional centroblastic-type B-cells are noted within these proliferation centers. In addition, there are scattered single to multinucleated cells that have irregular nuclear membranes with pale, vesicular chromatin and prominent inclusion-like, eosinophilic nucleoli. These cells morphologically resemble Hodgkin cells, Reed-Sternberg cells, mummified forms and other variants. These large cells are more evident in areas with a histiocyte rich background and around foci of necrosis. Occasionally, apoptotic bodies and mitotic figures are seen.

 Immunohistochemical studies show that the vast majority of the small-intermediate lymphocytes express B-cell markers CD20 (dim) and PAX5 and co-express CD5 and CD23 (subset). This is consistent with a background of CLL/SLL. The large atypical cells are positive for CD30, PAX5 and CD20 (variable). CD3 highlights numerous scattered background small T-cells, which are increased in the areas with the large cells. In situ hybridization for Epstein Barr viral RNA (EBER ISH) is mainly staining the large atypical cells. By Ki-67, the proliferation fraction is overall increased (40%) with increased uptake by the large atypical cells.

The morphologic and immunophenotypic findings are consistent with involvement by the patient’s known small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) with aggressive morphological features. The aggressive features include expanded proliferation centers and an elevated Ki-67 proliferative index (40%). Additionally there are histiocyte/T-cell rich areas composed of multiple EBV positive large atypical cells with morphologic and immunophenotypic features compatible with Hodgkin/ Reed-Sternberg cells. These areas are most in keeping with evolving classic Hodgkin lymphoma. Sheets of large cells indicative of large cell transformation are not seen, although increased scattered large centroblastic-type B cells are present.

Discussion

Lymph node involvement by CLL/SLL will typically show a diffuse proliferation of small lymphocytes with effacement of the normal nodal architecture.  The small lymphocytes have round nuclei, clumped chromatin and scant cytoplasm. Scattered paler areas known as proliferation centers are characteristic of this entity. The proliferation centers are composed of a mixture of cell types including small lymphocytes, prolymphocytes and paraimmunoblasts. Prolymphocytes are small to medium in size with relatively clumped chromatin, whereas paraimmunoblasts are larger cells with round to oval nuclei, dispersed chromatin, eosinophilic nucleoli and slightly basophilic cytoplasm. Some cases show increased and enlarged proliferation centers with a higher proliferation rate. This must be distinguished from large cell transformation.1

Aggressive features of CLL/SLL include proliferation centers that are broader than a 20x field or becoming confluent. An increased Ki-67 proliferation >40% or >2.4 mitoses in the proliferation centers can also portend a more aggressive course. These cases tend to have worse outcomes than typical CLL/SLL and better outcomes than cases that have undergone Richter transformation to diffuse large B-cell lymphoma (DLBCL). Transformation to DLBCL occurs in 2-8% of patients with CLL/SLL. Less than 1% of patients with CLL/SLL develop classic Hodgkin lymphoma (CHL). In order to diagnose CHL in the setting of CLL/SLL, classic Reed-Sternberg cells need to be found in a background appropriate for CHL, which includes a mixed inflammatory background. The majority of these CHL cases will be positive for EBV.1

Richter’s transformation is defined as an aggressive evolution of CLL. While the most common type of transformation is to a high-grade B-cell Non-Hodgkin lymphoma, other histological transformations have been described. This includes CHL, lymphoblastic lymphoma, hairy cell leukemia and high-grade T-cell lymphomas. The prognosis for patients who present with transformation to CHL is poor compared to de novo CHL.2 A large study from the M.D. Anderson Cancer Center described 4121 patients with CLL/SLL and found that only 18 patients or 0.4% developed CHL. The median time from CLL to CHL diagnosis was 4.6 years. Fourteen of the patients received chemotherapy. The overall response rate was 44% with a complete response rate of 19%. The median overall survival was 0.8 years and all patients eventually died from disease recurrence or progressive disease.3 This dismal prognosis is similar to patients with Richter transformation to DLBCL and much worse than patients with de novo CHL, which is curable in >85% of cases.1

References

  1. Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoetic and Lymphoid Tissues (Revised 4th edition). IARC: Lyon 2017.
  2. Janjetovic S, Bernd HW, Bokemeyer C, Fiedler W. Hodgkin’s lymphoma as a rare variant of Richter’s transformation in chronic lymphocytic leukemia: A case report and review of the literature. Mol Clin Oncol. 2016;4(3):390–392.doi:10.3892/mco.2016.727.
  3. Tsimberidou, AM, O’Brien, S and Kantarjian, HM, et. al. Hodgkin transformation of chronic lymphocytic leukemia. Cancer. 2006;107(6).doi.org/10.1002/cncr.22121.

Chelsea Marcus, MD is a Hematopathology Fellow at Beth Israel Deaconess Medical Center in Boston, MA. She has a particular interest in High-grade B-Cell lymphomas and the genetic alterations of these lymphomas.

Slide Review and You

Welcome back everybody!

Last month, I wrote about some projects I did while rotating through the pathology program at Danbury Hospital in Connecticut. This month I’m in a more clinical setting with a hematology/oncology clerkship at Northwell’s Staten Island University Hospital. But, over the past few months of rotations (and arguably a lot longer before medical school) I’ve been noticing a part of laboratory medicine which often intersects with our clinical colleagues at the bedside. I’ve told you about the pitfalls and successes in the relationships between surgeons and anatomic pathologists before, where frozen sections are critical and time is of the essence. And we’ve all seen collaboration between the bench and bedside before—think microbiology and infectious disease, blood bank and literally everyone, etc. Still, one collaborative effort sort of happens behind the shadows, behind phone calls and lab reports, and sometimes with no communication at all! So, what kind of vigilante medicine am I talking about? Who is this Batman of medicine? It’s just our friends in hematology.

When you’re working the hematology bench in the lab, it’s pretty commonplace for a physician on a hematology service to call and ask for a peripheral smear to review. Many times, it’s for the purpose of teaching residents, fellows, or medical students but more often than not it’s a confirmatory exercise. See, when that hematologist asks to review a slide, she’s probably coming down to the lab to look at the morphology of red cells and white cells to help in their differential diagnosis. They might have a patient with a suspected thalassemia or hemoglobinopathy and, before starting the full work up of lab tests, just want to see if there are any RBC morphology traits or target cells that stand out. Thrombocytopenia? Let’s make sure there’s no platelet clumping. Maybe they’ve got a patient with some kind of liver or kidney pathology and are on the hunt for acantho- or echinocytes. Or better yet, someone went hiking, there’s an infectious etiology on their differential—let’s go hunting for babesia, malaria, oh or even erlichia!

Image 1. Here’s a few examples of three parts of a patient’s smear that are contributory to a particular pathology in vivo. Think you know what it is? I bet you’d be surprised…not all that hyper-segments is a B12/Folate deficiency. But technically it is; read about cobalamin and homocysteine pathology in a neonatal patient here: http://www.bloodjournal.org/content/128/21/2584 (Source: Blood 2016)

I know what you’re thinking. Wait—that’s our job as medical laboratory scientists; our literal job. Our instruments, that we validate, and correlate, and make sure work fantastically give us flags. We investigate those flags and look at smears ourselves! We collaborate with other lab techs, and with our pathologist colleagues and send out final lab results with all kinds of helpful information: including platelet clumping, microorganisms, RBC and WBC morphology, and loads more. What gives?

Hold on to your lab coats. I’ll get there in a minute.

Slide review and differential training in medical school and residency

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Image 2. There is nothing wrong with your television set. Do not attempt to adjust the picture. You are about to experience the awe and mystery which reaches from the inner mind to… the bench tech working in hematology. The one who went to school for this? Medical school and residency are starkly devoid of any in-depth, comprehensive learning for differentials.

A Differential, Differential

So let me address the issue I brought up: why do hematologists come down to the lab to look at the slides themselves, when perfectly capable BOC certified, degree-holding medical laboratory scientists and pathologists sign out validated differentials? It might not happen this way at all hospitals, but I think the answer is a simple two-part problem.

First, as with the many things I’ve learned in medical school, one of the lab-centric pieces of information that is well understood is that, well, no one really knows what the lab does and how it operates. Virtually nobody knows the depth and breadth of the testing that pathologists manage, let alone the scientific precision and accuracy that instrument validation requires. Learning that MLS techs are certified, can hold graduate degrees, and even do their own research is often surprising to most of our clinical colleagues. And—I will tell you for a fact—that pathology and laboratory testing methodology is not covered in medical school the way you might think. Pathology is more of a class of distinguishing the identifying details of a disease, not understanding the interdisciplinary diagnostic teamwork that goes into those CBC index results on a computer screen on the clinical floors.

Second, hematologists are specialists just like any other practicing clinician. They know their stuff! They manage patient diagnosis, treatment, and follow-up with the most up to date literature, national cancer guidelines, and anything else available to better their patients’ outcomes. Despite the notes in the CBC results that there are numerous macrocytes with hypersegmented neutrophils, or 3+ schistocytes reported in a manual differential—seeing is believing. It helps to see the slide yourself and get a feel for the disease “state” with your own eyes. Moreso, it could be a learning opportunity. It’s well within a clinicians’ scope to come down and look at a peripheral smear, I actually encourage it. But it should come with a few caveats…I’ll get to those too…

I-CARE

One of the places I was proud to hang my lab coat was actually my first job as an assistant lab technician in the blood bank at Rush University Medical Center in Chicago. Before I got my MLS and way before grad school or med school, I was a blood bank “expediter.” Super fancy title, but all I did was make sure specimens were logged in and blood products were up to par with labels on their way out. Clerical but critical! (Let me have this, please…haha) Anyway, part of the culture at that hospital has stayed with me all these years. I’ve talked before about culture and the way it permeates an institution’s practice like at the Mayo Clinic, but for my first foray into clinical work their acronym was clutch: I CARE.

  • I for innovation
  • C for collaboration
  • A for accountability
  • R for respect and
  • E for excellence

Why am I telling you this? No, there are no royalties. I just think it’s an easy way to remind ourselves about the meaning of interdisciplinary medicine and they way we should work together across specialties, and from bench to bedside. When we incorporate those values into our work for the purpose of improving patient care and outcomes, everyone wins. In this case, effective utilization of resources tells us that peripheral slide review means different things to different people. In the setting of hematologic work-ups, flags and review at the bench can signal something to the clinician which could spark a conversation with the pathologist. All parts contributing to a whole of patient care. Vigilante medicine is bad news. Collaboration is key.

One place I was lucky enough to be a part of this interdisciplinary collaboration was Swedish Covenant Hospital. One of the hematology physicians would routinely call me and ask to look as peripheral smears down in the lab, often as a group with med students, residents, and fellows. I’d throw the image of his patients’ slides on a large flat screen and go over what certain traits meant with regard to morphology and identification from the lab setting. Dr. Cilley would add what this all meant clinically and discuss treatment algorithms and next steps. That was collaboration at it’s finest: lab tech working with pathologists, clinicians working with the lab, and patient’s benefiting from all of it.

Video 1. ASCP’s 2015 Membership Video. I was super thrilled to be part of this video back in 2015 after winning the Midwest regional ASCP member of the year. If you’re bored enough to make it about 40 seconds into the video, that was my actual desk where Dr. Cilley and his residents would come to discuss patient slides. I would talk to them about morphology and hematologic clues with digital hardware and software to make it clear in group settings, rather than taking turns at the scope. Good times. (Source: https://www.youtube.com/watch?v=86fBRXGrZFo)
Video 2. Dr. Jeffrey Cilley talks about treating cancer as a “team approach” and he’s right. Hematology/Oncology to patient. Lab to clinician. Bench to bedside. (Source: https://www.youtube.com/watch?v=q0waKLyT1Dg)

Teamwork makes the dream work

About those caveats for collaboration I mentioned earlier… Let me put it briefly: it’s well within the scope of a clinician to come over to the laboratory and get some information on their patient’s lab results/testing. But why not consider the following:

  • If a physician calls to review a smear, offer to go over it with them. Likewise, to our clinical friends: if you go to the lab for a slide don’t be batman—ask the tech what they think!

Experienced techs are one of the hospital’s most valuable resources. Some folks I’ve worked with have been looking at slides longer than I’ve been using my eyes at all! They’ll save you and your residents the time when those terrifying intracellular microorganisms are really just overlying platelets. I mean, they’ve got a cute halo.

  • If you need help, just ask. This applies to everyone.

Talking with the tech about the slide is great start, but there’s more resources in the lab than most people know what to do with! Clinical physicians: check the shelves around the hematology microscope. Stuck on something? Find a CAP atlas or a proficiency survey booklet guide. Easy to read. Techs and pathologists: have someone who constantly comes down for slide review despite your immaculate and detailed SOPs on CBC results reporting? Have a quick chat about the work that goes into resulting those diffs—you might even improve your heme TAT, who knows?

  • If it’s well within the right of a physician to leave the unit and see a patient’s slide, logic says that maybe, just maybe, it should be okay for a pathologist to leave the lab and see a patient at the bedside!

Hospitals are full of never-ending rounding white coats, all asking patients questions, and all contributing specialty notes to their charts. But its not only to prevent patients from getting a decent nap. We’re all parts of a large interdisciplinary patient team. A recent Medscape survey found that somewhere around 3% of pathologists see patients, routinely! Got an interesting case in the lab, someone who’s part of lots of tumor boards, someone with an interesting case to write up, or even someone who nobody knows exactly what’s going on with? Try walking over to 4 south and have a conversation with Mr. Jones; it might help. At least he’ll know how many people are working on his care team!

The bottom line: we’re in this together, and like the flag on the ASCP ship says, we’re Stronger Together. Innovation, collaboration, accountability, respect, and excellence are—and should be—simple cornerstones of clinical medicine that translate across every discipline. When we share information and expertise, everyone gets better at what they do.

Bonus Image. This was a hard picture to take. Usually, a quick hematologist just comes down to see if there are any real schistocytes. But, after reading a draft of this post, BatDoc’s cool with chatting about red cell indices and automated flow cytometry methods in auto-diff validation. That’s the hero we deserve, and the one healthcare needs! (Source: https://gunaxin.com/batman-doesnt-police-stop-visiting-children-hospital)

Thanks for reading!

See you next time!

–Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student actively involved in public health and laboratory medicine, conducting clinicals at Bronx-Care Hospital Center in New York City.

What’s in a Differential?

When a complete blood count (CBC) and differential is ordered by a physician, most labs today have instrumentation capable of performing an automated differential. Depending on the instrument results and flags, we may need to perform a scan, review of the slide, or a manual differential. However, the definition of a manual differential today may be a bit different than the historical definition. A typical manual differential, when I first started working as a technologist, consisted of counting and differentiating 100 white blood cells under a microscope, and performing a red blood cell morphology along with a platelet estimate. Today, the 3 components of the manual differential have not changed, but more and more  labs are using an automated digital counting device, such as CellaVision. Whether counting cells under the microscope or scanning and verifying or reclassifying cells in CellaVision, it is important to always address all 3 parts of the manual review.

When an automated CBC has flagged that abnormal RBC morphology may be present, a peripheral blood smear should be reviewed. Reporting the red blood cell (RBC) morphology is an important component of a differential. Evaluation and interpretation of RBC morphology may provide the physician with important diagnostic information regarding the underlying cause of a variety of disorders, including anemia and systemic disease. Therefore, it is important to be able to accurately recognize and identify RBC morphologic abnormalities.

Red blood cell morphology can be subjective, and therefore inconsistent. Therefore, Laboratories must have training and competency programs as well as  procedures which dictate how they will report RBC morphology. Some labs use a numbering system, 1+, 2+, 3+, and others report, ‘rare’, ‘few’, moderate’ or ‘many’. Some morphological, such as rouleaux, can just be reported as present, with no quantified. Any method is acceptable, as long as there is consistency in reporting.

When performing RBC morphology,  these semi-quantitative report formats for should be based on clinical significance. Some RBC morphologies and inclusions are clinically significant,even when they are present in very low numbers. Sickle cells are one of these abnormalities that are significant even if only seen in very small numbers. Malaria or other parasites are clinically significant in any number. Fragmented cells such as schistocytes and helmet cells should also be noted if seen in any number. Other abnormalities which can be clinically significant in very low numbers are polychromasia, spherocytes and teardrop cells.

There are many other abnormal RBC morphologies which are only clinically significant if seen in larger numbers. Laboratories may choose to only report the presence of ovalocytes, target cells, burr cells, macrocytes, microcytes or hypochromia when greater than a defined percentage of cells exhibit these morphologies. Other laboratories choose to not report macrocytes, microcytes and hypochromia at all, instead relying on the physician to use the RBC indicies for their indication. The 2 most important things to remember, whatever your procedures are, is to be consistent, and not to ignore the:RBC morphology.

In addition to performing RBC morphology, a manual differential also requires platelet examination. A smear should be examined for a platelet estimate and abnormalities. This is particularly important when platelet clumps or an abnormal platelet scattergram are flagged on the CBC.  If an instrument uses optical platelet counts, large platelets can be missed. A fluorescent platelet count (PLT-F) , performed on Sysmex analyzers, will stain only platelets and give an accurate platelet count. The fluorescent count eliminates interferences seen with other methods. However, even when reporting a PLT-F, it may still required to review the smear for a platelet estimate, particularly with a very low count, or with clumped platelet flags. Clumped platelets are not an uncommon phenomenon, and an accurate platelet count can not be reported if significant clumping is present. The presence of giant platelets or hypogranular platelets, seen on the slide,  can also aid the physician in diagnosis or patient management.

CellaVision users have the added benefit of automation which simplifies the process of performing manual differentials. The system automatically locates and takes digital images of cells, including white blood cells, red blood cells and platelets.This simplifies the process of performing a manual differential. White  blood cells are pre-classified, RBC images are provided, and platelet images allow platelet estimates to be performed easily. The new advanced RBC application software can pre-classify RBCs.  This makes it even easier than before to perform reliable, standardized RBC morphology. (Watch for my next Hematology blog about the new RBC software!)

Particular disorders or abnormalities often involve characteristic changes to RBC morphology “Assessment of RBC morphology can be the best tool for laboratory hematology professionals to recommend clinical and laboratory follow‐up in a patient with anemia and to select the right tests for definitive diagnosis.”1 Too often, I have seen technologists perform a manual differential and either superficially skim over the RBC and platelet components, or totally forget them. Don’t forget your RBC morphology and platelet estimate and morphology! With today’s automated differential and autovalidation, 75-85% of CBCs are autovalidated. This allows us to spend quality time on those manual reviews that need to be done. Be sure to spend your time thoroughly reviewing the slides. A scan, slide review or manual differential, whether done under the scope of with CellaVision,tells the physician that we have looked at the slide or cells, which must include all 3 parts of manual review… WBCs , RBCs and platelets. Don’t sign it out until it’s complete!

References

  1. J. Ford, Red Blood Cell Morphology. International Journal of Laboratory Hematology. 2013
  2. https://www.labce.com/red-cell-morphology.aspx

-Becky Socha, MS, MLS(ASCP)CM BB CM graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

Hormone Blockers = Blood Letting for Female Athlete with high T?

Caster Semenya celebrates as she wins gold in the women’s 800 meters in the Commonwealth Games on April 13, 2018, on Australia’s Gold Coast (1). Jason O’Brien/Getty Images

I will continue this month along the thread of last month’s post, which addressed the controversy surrounding South African female mid-distance runner Caster Semenya. Caster has won many international mid-distance races (400-800m), but she has been suspected of naturally producing higher levels of testosterone.

Since last month, I’ve learned the reason for the higher testosterone is uncertain: it could be due to natural production (hyperandrogenism) or rumors of her being intersex1. Regardless, what I will discuss here is how the proposed actions of the International Olympic Committee would be expected to affect Semenya’s performance. Specifically, how would lowering testosterone levels affect her athletic performance?

Last month, we saw that muscle mass might be expected to decrease, but this may not affect athletic performance significantly.

Another important effect of testosterone is on red blood cell levels including hemoglobin, which by carrying oxygen to muscle is a central part of calculating VO2max. VO2max is maximal oxygen consumption. This is strongly linked to performance in cardiovascular athletic events.

Mid-distance running requires a large cardiovascular capacity. Maybe not the same level of Tour-de-France long distance bikers in the Alps, but still substantial. As a runner that feels pretty proud at having run a sub-3 minute 800m, I can say Caster’s feat of running it in less than 2 minutes is incomprehensible. From the burning feeling in my lungs and thudding, maximum heart rate at the end of the half-mile, I can attest that this event requires substantial cardiovascular efficiency.

Maximal oxygen consumption (VO2max) by exercising skeletal muscle is principally limited most by cardiac output and oxygen-carrying hemoglobin levels. This has been shown quite convincingly in a series of experiments in the 1950’s-70’s2,3 that probably wouldn’t be approved by the IRBs of today charged to protect research subject rights.

First, transfusing blood increased hemoglobin concentration and similarly the VO2max and exercise endurance of participants.  (This practice was exploited most notably later on in the Tour de France).  In other studies3, blood was removed from participants before assessing their exercise tolerance (10% loss of hemoglobin à 13% reduction in VO2max). Another study removed 400mL, 800mL and 1,200mL over several days, which decreased hemoglobin by 10%, 15%, and 18% respectively. There was a concomitant decrease in endurance time (-13%, -21%, -30%) and VO2max as well (-6%, -10%, -16%)3.  A summary of blood transfusion and hemodilution studies is shown in Figure 1 from Otto JM et al4.

Figure 1. Reproduced from Otto JM et al (4)

In transgender women (gender incongruent with sex assigned male at birth), hormone therapy to increase estrogen levels (oral estradiol) and block testosterone (anti-androgen: spironolactone) reduces hemoglobin by 9% on average (from 15.2 g/dL to 13.9 g/dL)5. I would expect a smaller decrease for Semenya as she will likely not get a full dose hormone regimen used for transgender transition and because her testosterone levels wouldn’t be as high as biologic males’.  However, she would still be expected to have lower hemoglobin- similar to donating a half or whole unit of blood. If hemoglobin decreased even just 5%, that could affect her performance substantially when the difference between competitors boils down to seconds in mid-distance races.

Arguably, forced blood donation could produce the same effects as testosterone-lowering therapy. But it would be far too dramatic to suggest something like bloodletting by the International Olympic Committee.

In the end, I don’t feel qualified to say what should be done in this case. All I can say is that I don’t think lowering Caster Semanya’s testosterone levels will have the intended effect of decreasing muscle mass. On the other hand, it would decrease hemoglobin levels tempering her performance. But who should determine the point where her hormone levels should be? There is such a strong biologic connection between hormone levels and physiology that manipulating them for athletic fairness could be akin to playing puppeteer.

References

  1. North, Anna. ““I am a woman and I am fast”: what Caster Semenya’s story says about gender and race in sports” Vox. May 3, 2019
  2. BALKE B, GRILLO GP, KONECCI EB, LUFT UC. Work capacity after blood donation. J Appl Physiol. 1954 Nov; 7(3):231-8.
  3. Ekblom B, Goldbarg AN, Gullbring B. Response to exercise after blood loss and reinfusion. J Appl Physiol. 1972 Aug; 33(2):175-80.
  4. Otto JM, Montgomery HE, Richards T. Haemoglobin concentration and mass as determinants of exercise performance and of surgical outcome. Extrem Physiol Med. 2013; 2: 33.
  5. SoRelle JA, Jiao R, Gao E et al. Impact of Hormone Therapy on Laboratory Values in Transgender Patients. Clin Chem. 2019; 65(1): 170-179.

-Jeff SoRelle, MD is a Molecular Genetic Pathology fellow at the University of Texas Southwestern Medical Center in Dallas, TX. His clinical research interests include understanding how the lab intersects with transgender healthcare and advancing quality in molecular diagnostics.

Hematopathology Case Study: A 77 Year Old Man with Rash

Case History

The patient is a 77 year old man with a longstanding history of increased white blood cell (WBC) count who presented with a new rash and increasing absolute lymphocytosis.

Labs

Peripheral Blood Smear

Peripheral blood smear shows small to medium-sized lymphocytes with basophilic cytoplasm, cytoplasmic protrusions or blebs, round to oval nuclei with indented nuclear contours and some cells with prominent nucleoli.

Bone Marrow Biopsy

Bone marrow aspirate (top left) shows increased lymphocytes with similar features to those seen in the peripheral blood. The core biopsy (top right) shows an abnormal lymphocytic infiltrate. By immunohistochemistry, CD3 highlights markedly increased interstitial T-lymphocytes (30-40%) that predominantly express CD4. CD8 highlights only few scattered T-cells.

Flow Cytometry

Concurrent flow cytometry identifies an expanded population of lymphocytes comprising 73% of the total cellularity. Of the lymphocytes, 98% are T-cells. The T-cell population is almost entirely composed of CD4 positive cells (CD4/8 ratio = 301). The T-cells show expression of TCR (a/b), normal T-cell antigens CD3, CD2, CD5 and CD7 and express CD52 (bright).

Cytogenetics

Concurrent chromosome analysis shows that 90% of the metaphase bone marrow cells examined have a complex abnormal karyotype with a paracentric inversion of chromosome 14 that results in the TRA/D/TCL1 gene rearrangement. There is also a rearrangement resulting in three copies of 8q with partial loss of 8p as well as other chromosome aberrations.

Diagnosis

Altogether, the presence of an abnormal CD4 positive and CD52 (bright) lymphocyte population with the characteristic cytogenetic finding of inv(14), is diagnostic of T-cell prolymphocytic leukemia (T-PLL). This patient’s course is unusual in that he initially presented with indolent disease that ultimately progressed. The lymphocyte morphology was also somewhat atypical in that only occasional cells had prominent nucleoli. This is consistent with the “small cell variant” of T-PLL.

Discussion

T-PLL is generally an aggressive disorder characterized by small to medium sized mature T-cells that are found in the peripheral blood, bone marrow, lymph nodes, spleen, liver and sometimes skin. T-PLL is rare and occurs in adults usually over 30 years old. The clinical presentation includes a lymphocytosis, often >100 x 10^9/L, hepatosplenomegaly and lymphadenopathy. Serous effusions and skin infiltration can be seen in a subset of cases. On microscopy, the cells are usually small to medium in size with basophilic cytoplasm, round to irregular nuclei and visible nucleoli. Characteristic cytoplasmic blebs or protrusions are a common feature. The immunophenotype is of a mature T-cell and cells are positive for CD2, CD3, CD5 and CD7. They are negative for TdT and CD1a. Another characteristic feature is bright expression of CD52. Sixty percent of cases are positive for CD4, while 25% show double expression of CD4 and CD8. The most frequent chromosome abnormality is inversion of chromosome 14 at q11 and q32, which is seen in 80% of patients. Translocations involving chromosome X and 14 are also seen, as well as abnormalities of chromosome 8. The overall prognosis is generally poor with a median survival of 1-2 years. Patients with expression of CD52 may respond well to the monoclonal anti-CD52 antibody alemtuzumab, but other treatment options are limited.1

The small cell variant (SV) of T-cell prolymphocytic leukemia was once referred to as T-cell chronic lymphocytic leukemia due to a predominant population of small lymphocytes with condensed chromatin and lack of conspicuous nucleoli. In addition, unlike the aggressive course seen in most patients with T-PLL, patients with this morphology tended to have an indolent or more chronic disease course. Eventually, it became clear that this was merely a variant of T-PLL due to similar immunophenotypic and cytogenetic findings. Ultimately, the term T-cell CLL was retired from use.2

In a comparison of patients with SV T-PLL to three large studies of classic T-PLL patients, the SV patients were found to have a higher frequency of a normal karyotype and increased double negative (CD4-/CD8) immunophenotype. Interestingly, 38% of the SV patients did not receive treatment for the entire duration of follow-up, while 19% required treatment after initially just being observed. This time period ranged between 2 months to 3 years. The remaining patients were treated at diagnosis. Most of the patients ultimately progressed and the cause of death was disease progression in 86% of the patients who died during follow-up. Overall, SV T-PLL tended to show less aggressive clinical behavior than classic T-PLL, however many aggressive cases of patients with the small cell variant have been seen. Likewise, more indolent cases of classic T-PLL featuring cells with larger nuclei with prominent nucleoli have also been described.2

While cases of SV T-PLL may initially present with more indolent disease, they almost always progress to a similarly aggressive disease course as seen in classic T-PLL. T-PLL is generally resistant to most conventional chemotherapies. As mentioned earlier, cases of T-PLL tend to express bright CD52, which is a glycoprotein present on the surface of mature lymphocytes. CAMPATH-1H is an anti-CD52 monoclonal antibody that may result in complement-mediated lysis and antibody-dependent cellular cytotoxicity. In a study by Dearden et. al., thirty-nine patients with T-PLL received CAMPATH-1H treatments. The overall response rate was 76% with 60% achieving complete remission. These rates are significantly higher than those reported for conventional therapies like CHOP. Unfortunately, almost all of the patients ultimately progressed and all but 2 had relapsed following 1 year of therapy. This indicates that CAMPATH-1H is good for first line therapy, but is not a curative treatment for this aggressive and most often deadly disease. 3

References

  1. Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoetic and Lymphoid Tissues (Revised 4th edition). IARC: Lyon 2017.
  2. A. Rashidi and S. Fisher. T-cell chronic lymphocytic leukemia or small-cell variant of T-cell prolymphocytic leukemia: a historical perspective and search for consensus. European Journal of Haematology. 2015(Vol 95).
  3. C. Dearden, E. Matutes and B. Cazin, et. al. High remission rate in T-cell prolymphocytic leukemia with CAMPATH-1H. Blood. 2001(98)1721-1726.

Chelsea Marcus, MD is a Hematopathology Fellow at Beth Israel Deaconess Medical Center in Boston, MA. She has a particular interest in High-grade B-Cell lymphomas and the genetic alterations of these lymphomas.

Hematopathology Case Study: A 71 Year Old Man with a History of Multiple Myeloma

Case History

A 71 year old man with a history of multiple myeloma presented with urinary incontinence and confusion and was found to have hyperkalemia with renal failure. Imaging showed extensive inguinal lymphadenopathy with concern for new lymphoma.

Excisional Lymph Node Biopsy

H&E 40x

Diagnosis

Sections show an enlarged lymph node with complete effacement of the normal lymph node architecture by sheets of medium and large plasmablastic cells. The cells have round nuclear contours, large prominent nucleoli and moderate amounts of amphophilic cytoplasm. Frequent apoptotic cells and scattered mitoses are seen.

Immunohistochemical stains show that the neoplastic cells are immunoreactive for CD138, CD38, CD19 (dim) and MUM1. They are negative for CD20, which highlights only small admixed B-cells. The cells are kappa restricted by kappa and lambda immunostain. The Ki-67 proliferation index is greater than 90%.

Taken together, the morphologic and immunophenotypic features are of a high grade plasmablastic neoplasm. The differential diagnosis includes plasmablastic myeloma and a plasmablastic lymphoma. Given the patient’s history of a kappa restricted plasma cell dyscrasia, plasmablastic myeloma is favored.

Discussion

Multiple myeloma is a neoplasm of clonal plasma cells that accounts for 10% of all hematologic malignancies. It is most commonly seen in adult and elderly patients with a male predominance. Plasma cells are generally characterized by the presence of a “clockface” nuclei and distinct perinuclear Hof or clearing of the cytoplasm containing a large number of Golgi bodies. The morphology of plasma cell tumors can range from small mature plasma cells to anaplastic or plasmablastic morphology. In this case, the cells showed plasmablastic (PB) morphology, which is characterized by a large nucleus, large nucleolus, fine reticular nuclear chromatin pattern, lack of nuclear Hof and less abundant cytoplasm than typical plasma cells.1

The differential diagnosis for cases with this morphology primarily includes PB lymphoma and PB myeloma with extramedullary involvement. PB lymphoma is seen more commonly in HIV positive patients or patients with other causes of immunodeficiency. It typically occurs in adults and has a male predominance. The tumor generally presents outside of nodes and is most frequently seen in the oral cavity/jaw. Patients tend to present with advanced stage and bone marrow involvement. While PB lymphoma is categorized as a distinct subtype of diffuse large B-cell lymphoma, PB myeloma is considered an atypical morphologic variant of multiple myeloma and is treated with therapy geared towards plasma cell neoplasms. 2

Making the distinction between these entities is difficult due to similarities in morphology and immunophenotype. Ultimately, the diagnosis is generally made based on the clinical context. In one series of “plasmablastic” neoplasms by Ahn, et. al., 6 out of 11 cases were called PB lymphoma, 2 out of 11 were called multiple myeloma and 3 were called indeterminate. Among the PB lymphoma patients, 4 were either HIV positive or had a history of immunosuppression. All 6 cases were positive for CD138 and negative for CD20 with EBV in situ hybridization positivity in 3 out of 6 cases. The multiple myeloma cases had evidence of end organ damage without lymphadenopathy. One indeterminate case had peritoneal nodules, lytic lesions and an EBV positive neoplasm in the bone marrow, which precluded a definitive diagnosis. 3

The immunophenotypic pattern seen in this case is typical of these neoplasms and is characterized by the expression of plasma cell antigens (CD138, CD38, MUM1) with either weak or negative expression of B-cell antigens (CD20). A study by Vega et. al. looked at the immunophenotypic profiles in nine cases of PB lymphoma and seven cases of PB myeloma. They found that the profiles were nearly identical.  All cases were positive for MUM1/IRF4, CD138 and CD38 and negative for CD20, consistent with a plasma cell immunophenotype. PAX5 and BCL6 were weakly positive in 2/9 and 1/5 PB lymphomas and were negative in all PB myelomas. A high Ki-67, overexpression of P53 and loss of p16 and p27 were present in both tumors. There was no evidence of HHV8 detected in either neoplasm. The presence of EBV-encoded RNA, was seen in all PB lymphoma cases tested and negative in all plasma cell myeloma cases. This was found to be statistically significant. 4

Unfortunately, both PB lymphoma and PB myeloma are aggressive high grade neoplasms with a poor prognosis. A study conducted by Greipp et. al. assessed the prognostic significance of plasmablastic morphology in a cohort of patients from the Eastern Cooperative Oncology Group Myeloma Trial E9486. They looked at bone marrow aspirates from 453 newly diagnosed multiple myeloma cases in a 5 year period. Of the 453 aspirates, 8.2% were classified as PB morphology.  The overall survival of patients with PB morphology was significantly shorter than patients with non-PB morphology with a median of 1.9 years compared to 3.7 years. There did not appear to be a relationship between PB morphology to other clinical or laboratory features such as age, sex, bone lesions or type of M-protein. 5

References

  1. M Srija, P Zachariah, V Unni, et. al. Plasmablastic myeloma presenting as rapidly progressive renal failure in a young adult, Indian Journal of Nephrology, Volume 24(1): 2014, Page 41-44.
  2. JJ Castillo, M Bibas, RN Miranda, The biology and treatment of plasmablastic lymphoma, Blood, Volume 125, 2015, Page 2323-2330.
  3. J Ahn, R Okal, J Vos, et. al. Plasmablastic Lymphoma vs Myeloma With Plasmablastic Morphology: An Ongoing Diagnostic Dilemma, American Journal of Clinical Pathology, Volume 144(2): 2015, Page A125.
  4. F Vega, CC Chang, LJ Medeiros, et. al. Plasmablastic lymphomas and plasmablastic plasma cell myelomas have nearly identical immunophenotypic profiles. Modern Pathology, Volume 18: 2005, Page 806-815.
  5. PR Greipp, T Leong, J Bennett, et. al. Plasmablastic Morphology – An Independent Prognostic Factor With Clinical and Laboratory Correlates: Eastern Cooperative Oncology Group (ECOG) Myeloma Trial 39486 Report by the ECOG Myeloma Laboratory Group, Blood, Volume 91: 1998, Page 2501-2507.

Chelsea Marcus, MD is a Hematopathology Fellow at Beth Israel Deaconess Medical Center in Boston, MA. She has a particular interest in High-grade B-Cell lymphomas and the genetic alterations of these lymphomas.