Chronic Lymphocytic Leukemia - · PDF filefor patients with Chronic Lymphocytic Leukemia (CLL). ... - The confidence index ... or KWOC is the most accurate WBC count

Chronic Chronic Lymphocytic Lymphocytic LeukemiaLeukemia

CELLCELL--DYN DYN 40004000

Here is a typical result seenHere is a typical result seenfor patients with Chronicfor patients with ChronicLymphocyticLymphocytic LeukemiaLeukemia(CLL). The WBC and(CLL). The WBC anddifferential are directlydifferential are directlyreportable. The followingreportable. The followingflags are present:flags are present:

VARLYMVARLYMnvWBCnvWBCIRIR


VARLYMVARLYM-- This is a generic type of This is a generic type of

flag indicating that a flag indicating that a population of lymphocytes population of lymphocytes exist which may either be exist which may either be reactive or malignant. In reactive or malignant. In this case the lymphocytes this case the lymphocytes are malignant cells and are malignant cells and they can be seen in the 0 they can be seen in the 0 degree Size/ 7 degree degree Size/ 7 degree Complexity scatterplot as a Complexity scatterplot as a separate population of separate population of lymphocytes. They are lymphocytes. They are also highly also highly flourescent flourescent and and can be seen in the 0 degree can be seen in the 0 degree Size/FL3 scatterplot.Size/FL3 scatterplot.


VARLYMVARLYM-- The confidence index The confidence index

shows the instrument’s shows the instrument’s assessment of the assessment of the probability that a variant probability that a variant subpopulation subpopulation is present. is present. In this case, there is a In this case, there is a 70% probability the 70% probability the variant lymphocytes are variant lymphocytes are present.present.


nvWBCnvWBC-- If a significant number If a significant number

(>10%) of nonviable (>10%) of nonviable WBCs or WBCs with WBCs or WBCs with cytoplasmic cytoplasmic membranes membranes permeable to the permeable to the flourescent flourescent dye are dye are present, the present, the nvWBC nvWBC flag flag appears.appears.


IRIR-- Immature Reticulocytes Immature Reticulocytes

are suspected of being are suspected of being present on the basis of present on the basis of their high their high flourescenceflourescence. . The WBC are well The WBC are well separated from the separated from the reticulocytes reticulocytes and do not and do not interfere. Increased interfere. Increased numbers of immature numbers of immature reticulocytes reticulocytes is an is an indication of active indication of active regeneration of the bone regeneration of the bone marrow.marrow.

CELLCELLDYN DYN 37003700

Here is the Here is the same patientsame patientspecimen run specimen run on the CELLon the CELLDYN 3700. DYN 3700. This instrumentThis instrumentutilizes bothutilizes bothimpedance impedance and opticaland opticaltechnologiestechnologies

in order to provide accurate results. For example, the Impedancin order to provide accurate results. For example, the Impedance WBC (WIC) e WBC (WIC) and the optical WBC (WOC) are used together because both measureand the optical WBC (WOC) are used together because both measurements havements havestrengths and limitations. strengths and limitations.


Because theBecause thelimitations of eachlimitations of eachmethod differ,method differ,providing bothproviding bothmethods enhancesmethods enhancesthe instrument’sthe instrument’sability to provide aability to provide amore accurate WBCmore accurate WBCcount in the presencecount in the presenceof certain interferingof certain interferingsubstances andsubstances and

pathological conditions. In this case the WBC is directly reporpathological conditions. In this case the WBC is directly reportable. A manual table. A manual blood film review is required to release the differential resultblood film review is required to release the differential results. s.


KWOCKWOC-- This flag indicates This flag indicates

that there was a that there was a significant significant difference between difference between the WIC and WOC the WIC and WOC values, and that a values, and that a kinetic decline in the kinetic decline in the WOC count rate WOC count rate was detected. A was detected. A kinetic decline is kinetic decline is usually caused by usually caused by the presence ofthe presence offragile WBCs. The kinetic decline is compensated for by mathemafragile WBCs. The kinetic decline is compensated for by mathematically tically correcting the WOC value. Therefore, the kinetically corrected correcting the WOC value. Therefore, the kinetically corrected WOC count WOC count or KWOC is the most accurate WBC count.or KWOC is the most accurate WBC count.


VARLYMVARLYM-- This suspect This suspect

flag was flag was generated generated because the because the KWOC is the KWOC is the reported reported WBC and the WBC and the Neutrophil/Neutrophil/LymophocyteLymophocyteratio falls ratio falls below below expected expected limits.limits.


FWBCFWBC-- This suspect This suspect

flag was flag was generated generated because the because the presence of presence of fragile WBCs fragile WBCs is suspected is suspected and because and because the WOC the WOC count has been count has been kinetically kinetically corrected.corrected.


DFLT (LM)DFLT (LM)-- This indicates that This indicates that

default or preset default or preset criteria were used criteria were used to determine the to determine the fivefive--part differential part differential and therefore, some and therefore, some of the populations of the populations are suspect. The are suspect. The suspect populations suspect populations are indicated in are indicated in parentheses and in parentheses and in this case the this case the lymphocytes andlymphocytes andmonocytemonocyte populations are suspect. A stained smear should be examined topopulations are suspect. A stained smear should be examined toverify the differential values.verify the differential values.


Here is the sameHere is the samepatient specimen runpatient specimen runon the CELL DYNon the CELL DYN3200. When processing3200. When processingsamples in the Patientsamples in the Patientmode, if fragile WBCsmode, if fragile WBCsare present the WBCare present the WBC(WOC) count may be(WOC) count may beabnormally low due toabnormally low due tothe gradual destructionthe gradual destructionof the of the cytoplasmiccytoplasmic

membrane of these fragile cells by themembrane of these fragile cells by the lysinglysing agents during the Run cycle. In agents during the Run cycle. In addition, there is an atypical population of lymphocytes seen claddition, there is an atypical population of lymphocytes seen clearly in the 0early in the 0degree/10 graph (1). This is likely to be the fragile WBCs.degree/10 graph (1). This is likely to be the fragile WBCs.


If there is no significantIf there is no significantstromastroma interference interference (<2.9% of the total(<2.9% of the totalWOC count) (2), or ifWOC count) (2), or ifLYM% >80% and cellLYM% >80% and cellcount >4.0 k/count >4.0 k/uLuL, the, theFWBC flag is displayed,FWBC flag is displayed,alerting the user to runalerting the user to runthe specimen in thethe specimen in theFragile WBC modeFragile WBC mode(Fragile WBC is selected(Fragile WBC is selectedas the Specimen Type). as the Specimen Type).

The WBC flag is also present, indicating that the WOC count is iThe WBC flag is also present, indicating that the WOC count is invalid. The arrow nvalid. The arrow in the scatterplot indicates the region of in the scatterplot indicates the region of stromastroma interference.interference.


Typically, fragileTypically, fragileWBCs are abnormalWBCs are abnormallymphocytes that arelymphocytes that arepresent in CLL andpresent in CLL andare the “smudge cells”are the “smudge cells”that appear when thethat appear when theblood smear is made. blood smear is made. The VAR LYM flagThe VAR LYM flagappears as a result of appears as a result of the instrumentthe instrumentdetecting an atypicaldetecting an atypicalor variant populationor variant populationof lymphocytes. of lymphocytes.


When specimens areWhen specimens arerun in the Fragilerun in the FragileWBC mode, anWBC mode, analternate methodalternate methodusing the HGBusing the HGBsegment (instead ofsegment (instead ofthe WBC segment) isthe WBC segment) isused to measureused to measuresamples containingsamples containingfragile WBCs. fragile WBCs. TheTheHGB sample segment, HGB sample segment, after being measured in the HGB flow cell, is transferred to theafter being measured in the HGB flow cell, is transferred to the Optical Flow Cell Optical Flow Cell instead of being sent to a waste chamber as in normal Patient cyinstead of being sent to a waste chamber as in normal Patient cycles. cles.


This allows for moreThis allows for moreprolongedprolonged lysinglysing ofofthe cells, resulting inthe cells, resulting inthe specimen the specimen containing only intactcontaining only intactnuclei. These nucleinuclei. These nucleiare counted and theare counted and theresults of thisresults of thismeasurement ismeasurement isknown as the Nuclearknown as the NuclearOptical Count orOptical Count or

NOC. The NOC count is fully reportable, and the FWBC flag is prNOC. The NOC count is fully reportable, and the FWBC flag is present along esent along with the VAR LYM flag to alert the operator that a blood film shwith the VAR LYM flag to alert the operator that a blood film should be reviewed ould be reviewed to assess the presence of variant or fragile lymphocytes.to assess the presence of variant or fragile lymphocytes.


Two independent measurementTwo independent measurementmethods are used in the CELLmethods are used in the CELLDYN 1700 System: the DYN 1700 System: the electrical impedance method electrical impedance method for determining WBC, RBC,for determining WBC, RBC,and PLT data and also theand PLT data and also themodified modified cyanmethemoglobincyanmethemoglobinmethod for determining HGB.method for determining HGB.Histograms are used toHistograms are used tographically show average size graphically show average size of cells within a specific cellof cells within a specific cellpopulation, the distribution ofpopulation, the distribution ofcells around a mean and thecells around a mean and thepresence of significantpresence of significantsubpopulationssubpopulations..


Suspect Parameter FlagsSuspect Parameter Flagsare generated after theare generated after theinstrument evaluates theinstrument evaluates themeasured data for ameasured data for aparticular parameter orparticular parameter orgroup of parameters. group of parameters. The result may beThe result may besuspect due tosuspect due tointerfering substances orinterfering substances orthe inability of thethe inability of theinstrument to measure ainstrument to measure aparticular parameter particular parameter due to a sampledue to a sampleabnormality.abnormality.


The appearance of the ROThe appearance of the ROflag in this example was likelyflag in this example was likelycaused by the abnormalcaused by the abnormallymphocytes present in CLL. lymphocytes present in CLL. Other causes for this flagOther causes for this flaginclude: nucleated RBCs,include: nucleated RBCs,platelet clumps, giantplatelet clumps, giantplatelets, platelets, cryoglobulinscryoglobulins, fibrin, fibrinclots and incomplete lysis ofclots and incomplete lysis ofred blood cells. A red blood cells. A Lym Lym RO orRO orLymLym RM flag invalidates theRM flag invalidates theWBC count. The other “R”WBC count. The other “R”flags only invalidate theflags only invalidate thedifferential count.differential count.


The CELLThe CELL--DYN 1200DYN 1200uses a focused flowuses a focused flowimpedance method forimpedance method fordetermining WBC, RBC,determining WBC, RBC,and PLT data. Focusedand PLT data. Focusedflow technology minimizesflow technology minimizesthe number of coincidencethe number of coincidenceevents (two cells passingevents (two cells passingthrough the impedancethrough the impedancetransducer at the sametransducer at the sametime). time).


The instrument usesThe instrument useselectronic sizing toelectronic sizing todetermine threedetermine threedistinct white celldistinct white cellsubpopulationssubpopulations. These. Theseresults are graphicallyresults are graphicallydisplayed and Suspectdisplayed and SuspectParameter Flags mayParameter Flags mayappear if a result isappear if a result issuspect due to suspect due to interfering substances.interfering substances.


In this example, the ROIn this example, the ROflag is present and isflag is present and ismost likely caused by themost likely caused by thepresence of abnormalpresence of abnormallymphocytes associatedlymphocytes associatedwith CLL. Other causeswith CLL. Other causesfor this flag to appearfor this flag to appearinclude: nucleated include: nucleated RBCs, platelet clumps,RBCs, platelet clumps,giant platelets,giant platelets,cryoglobulinscryoglobulins, fibrin , fibrin clots, and incompleteclots, and incompletelysis of red blood cells. lysis of red blood cells.


AA LymLym RO or RO or LymLymRM flag invalidatesRM flag invalidatesthe WBC count. Thethe WBC count. Theother “R” flags onlyother “R” flags onlyinvalidate theinvalidate thedifferential count.differential count.

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Chronic Lymphocytic Leukemia - · PDF filefor patients with Chronic Lymphocytic Leukemia (CLL). ... - The confidence index ... or KWOC is the most accurate WBC count