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Library of Congress Cataloging‐in‐Publication Data
Names: Ortolani, C. (Claudio), author.
Title: Flow cytometry of hematological malignancies / Claudio Ortolani. Description: Second edition. | Hoboken, NJ : Wiley-Blackwell, 2021. | Includes bibliographical references and index. | Description based on print version record and CIP data provided by publisher; resource not viewed.
Identifiers: LCCN 2020028333 (print) | LCCN 2020028334 (ebook) | ISBN 9781119611301 (epub) | ISBN 9781119611271 (Adobe PDF) | ISBN 9781119611257 (cloth)
LC record available at https://lccn.loc.gov/2020028333
LC record available at https://lccn.loc.gov/2020028334
Cover Design: Wiley
Cover Image: courtesy of Claudio Ortolani
Set in 9.5/12pt Minion by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
Foreword to the Second Edition
It has been about a decade since Dr. Claudio Ortolani gave us the first edition of Flow Cytometry in Hematologic Malignancies, and in that time flow cytometry has solidified its place as a routine diagnostic test in the diagnosis and classification of leukemias and lymphomas. Over the decade, dozens of new markers have been discovered, many of which are now a standard part of the flow cytometry arsenal. It is thus timely that Dr. Ortolani has chosen to update his work with this new second edition. As before, this work is extensively researched and prodigiously referenced, with more than 1300 new references not included in the first edition, bringing the total to more than 4500 relevant citations. These references not only cover the new markers, but also include new information about common markers in use for years, and descriptions of the markers covered by the first edition have been expanded to discuss these new advances.
In compiling this book, Dr. Ortolani has maintained the unique structure of the first edition, with the first part of the book oriented around individual antigens, and the second around diseases, supplementing the comprehensive text with characteristic images to illustrate the key points raised. The first section includes detailed information about normal tissue distribution of antigens, and also includes a discussion of some key pitfalls in the interpretation of cytometric findings of many antigens, before discussing pathologic conditions in which the antigens may be found. The disease section has been extensively
revised and now follows the 2016 version of the WHO classification, while also including some newer entities not mentioned in the WHO monograph. In keeping with the changes in classification, this book now includes a much more extensive discussion of phenotypic properties of the different types of T‐cell lymphomas and histiocytic neoplasms than was available previously.
This book will be a valuable resource for anyone interested in flow cytometry and hematologic malignancies. Trainees can easily find detailed phenotypic information about any disease they are learning about, while even an expert, struggling with an unusual case with a phenotype that appears contradictory to an expected diagnosis, can quickly learn whether others have found similar patterns in that diagnosis; moreover, because the citations are so extensive, it is possible simply by considering the numbers of references to a phenotype to assess the weight of evidence for a particular interpretation. Those of us in the field are grateful that Dr. Ortolani took the time to update his work and produce a reference that will be useful for many years to come.
Michael J. Borowitz, MD, PhD Professor of Pathology and Oncology Director of Hematopathology and Flow Cytometry Johns Hopkins Medical Institutions Baltimore, MD, USA
Foreword to the First Edition
Flow cytometry is a crucial tool in the diagnosis of hematolymphoid neoplasms, determining prognosis and monitoring response to therapy. Clinical flow cytometric immunophenotyping, however, is a complex field requiring extensive expertise in normal and abnormal patterns before clinical tests can be appropriately interpreted. Those new to the field are left with the conundrum of how best to achieve this expertise. At particular disadvantage is the resident or clinical fellow seeking to interpret flow cytometric data on a specific patient. The typical flow cytometry reference text is written in an encyclopedic format with extensive narrative that is not conducive to looking up the meaning of unusual test results. Furthermore, the general flow cytometry textbook, although a useful reference, cannot completely cover all the aspects needed to interpret clinical flow cytometry data. Therefore, Flow Cytometry of Hematological Malignancies fills a much needed role in hematopathology and hematology/ oncology. The presentation is oriented toward the diagnostic laboratory in the academic center as well as in the general hospital.
Flow Cytometry of Hematological Malignancies is organized in a novel manner that makes it especially useful for the medical student and residents/fellows still in training, while still providing a valuable resource for hematopathologists, hematologists/ oncologists and experts in the field of clinical flow cytometry. It lists antigens typically studied in clinical flow cytometry laboratories, from CD1 to CD138, followed by a discussion of general as well as flow cytometric features and hematolymphoid neoplasms expressing each antigen. Thus, when interpreting a clinical flow cytometry report, one can easily research an unusual antigen expressed by a leukemia or lymphoma. This pattern
of organization makes more sense than only presenting lists of neoplastic processes and the expected flow cytometric findings. One has to first know the diagnosis on a particular patient before such a reference can be useful. Flow Cytometry of Hematological Malignancies also provides the usual description of typical flow cytometric immunophenotypical findings in the various hematolymphoid neoplasms. This is useful as a reference for panel design as well as diagnosis.
Flow Cytometry of Hematological Malignancies is being published at a time when the field is expanding rapidly and flow cytometry is assuming an even greater role in management of patients with hematolymphoid neoplasia. Dr Ortolani, an outstanding flow cytometrist, possesses extensive expertise in the clinical arena. For over 30 years he was employed in the Clinical Pathology Department of the Venice General Hospital, running one of the first diagnostic flow cytometry units in Italy. His main clinical activity was the diagnosis of hematological neoplasms, with a particular interest in lymphoproliferative diseases. Dr Ortolani has also been very active in teaching flow cytometry in many national and international courses. He has written what I believe to be an outstanding textbook covering the essential aspects of clinical flow cytometry. Dr Ortolani is to be commended for this brilliant contribution that is sure to become a well-used textbook in clinical centers around the world.
Maryalice Stetler-Stevenson, PhD, MD
Chief, Flow Cytometry Laboratory National Cancer Institute, National Institutes of Health Bethesda, MD, USA
Foreword to the First Edition
The European Society for Clinical Cell Analysis (ESCCA) is proud to present this volume by Dr Claudio Ortolani. Flow Cytometry of Hematological Malignancies is a benchtop companion for all who are involved in the complex process of characterization and diagnosis of leukemias and lymphomas by immunophenotypical techniques and flow cytometry.
This volume is a useful quick reference text for the matching of CD antigens with malignant hematological diseases, as defined by the WHO 2008 classification, taking into account antibody clones, features and behavior, with particular emphasis on variant forms and unexpected presentations.
After several decades of clinical and laboratory practice in this field, Dr Claudio Ortolani has meticulously prepared this
book under the auspices of the ESCCA. It represents a major achievement for the dissemination of knowledge in one of the most important specialties within clinical cell analysis, as the book aims to improve and standardize the diagnostic process of malignant blood diseases. As a result, communication between clinicians and laboratory operators should benefit!
Bruno Brando ESCCA President Director, Hematology Laboratory and Transfusion Center, Legnano Hospital, Milan, Italy
Preface to the Second Edition
Ten years have passed since the first edition of this book, 10 fruitful years full of new acquisitions in the field of Hematology. Many doubts have been clarified, new questions have been raised, and – above all – new therapeutic targets have been reached. Although molecular biology keeps assuming ever greater importance, especially in the field of acute leukemias and myeloproliferative neoplasms; nevertheless, flow cytometry still remains one of the fundamental pillars of hematopathology and becomes even more and more important in particular areas such as the evaluation of the minimal residual disease and the study of the pharmacodynamic characteristics of experimental therapies with monoclonal antibodies.
In these 10 years, technology has also made substantial progress, and today we have much more efficient tools than before, but also much more complex ones, and consequently the
pre‐analytical and analytical components have become considerably complicated. Even if an attempt to account for these problems has been made, in‐depth treatment of most of them is beyond the scope of this book; they will be dealt with – hopefully – in the next edition, together with the many other topics neglected this time.
Claudio Ortolani MD Adjunct Professor of Laboratory of Diagnostic Cytometry Urbino University Urbino, Italy
The cytometric analysis of hematological malignancies is one of the most difficult applications of flow cytometry, requiring both a good knowledge of hematopathology and good control of the technique. Moreover, the effort of operators is made harder by the continuous evolution of the technology and by the continuous progress in the comprehension of the nature of the diseases. This book was compiled from a series of notes originally intended for people practically involved in the field of diagnostic flow cytometry, and it is an example of what the author would have liked to consult at the beginning of his own career. The goal of this book is to offer the reader a quick and updated source of information on the phenotype of the hematological malignancies recognized by the last WHO classification, with the major exception of Hodgkin lymphoma which because of its peculiar nature is still beyond the limits of flow cytometry, even if things promise to change in the next few years.
The author may have unwittingly sown a number of mistakes and imprecisions, and he will be grateful to all colleagues who report these to him. He also realizes that this book could not have been written without the help of many friends and colleagues. Being unable to cite all of them, the author wants to particularly thank his friend Bruno Brando, current President of the European Society for Clinical Cell Analysis, for the continuous moral and practical support he has given over the years.
Claudio
Ortolani MD Former Director of the Flow Cytometry Unit Clinical Pathology Department Venice General Hospital
Non clustered (or primarily known with other names) antigens
Bcl‐2 Protein, 119
Chemokines and Chemokine Receptors, 121
CRLF2, 128
Cytotoxic Proteins, 129
HLA‐DR, 130
Immunoglobulins, 132
KIR, CD158 isoforms, 136
Myeloperoxidase (MPO), 139
NG2, 140
PCA‐1, 141
ROR‐1, 141
SLAM Molecules and SLAM‐associated Protein (SAP), 142
SOX11, 144
T‐cell Receptor (TCR), 145
Terminal Deoxy‐nucleotidyl‐transferase (TdT), 148
Toll‐like Receptors (TLR), 150
VS38, 151
ZAP‐70, 152
CD1 Antigens
General features
CD1 antigens are a group of five different glycoproteins that weigh 43–49 kD and are encoded by a group of genes situated on the long arm of chromosome 1 [1].
CD1 antigens play a role in the presentation of lipidic and glycolipidic antigens to T and NKT cells [1,2], and can be divided in three groups, namely:
• Group I, encompassing CD1a, CD1b, and CD1c
• Group II, encompassing CD1d
• Group III, encompassing CD1e, which is an intracytoplasmic protein.
CD1 antigens are mainly expressed on cells belonging to T and B lineages and on antigen‐presenting cells (APC).
As for the T lineage, CD1a, CD1b, and CD1c antigens have been demonstrated on the membrane of the cortical or “common” thymocytes [3] and on the membrane of some T‐lymphocyte subsets in cord and neonatal peripheral blood [4]; according to some authors, a low expression of CD1 antigens can be demonstrated in the cytoplasm of T lymphocytes activated in vitro by phytohemagglutinin (PHA) [5]. CD1d has been reported at a high density on common thymocytes, and at a lower density on medullary thymocytes [6].
As for the B lineage, both CD1c and CD1d have been demonstrated on the precursors and on some subsets of mature B lymphocytes. More precisely:
• CD1c has been demonstrated on some subsets of B lymphocytes in the peripheral blood [7,8], in the spleen [7,8], and in the mantle of the germinal center [7]
• CD1c(+) B lymphocytes account for the majority of B cells in tonsils [9], in cord blood [4], in the peripheral blood of
newborns [4], and in the peripheral blood of subjects submitted to autologous or allogeneic bone marrow transplantation during the first year following transplant [8]
• CD1d has been demonstrated on the membrane of bone marrow B precursors [10], on B lymphocytes in peripheral blood [11,12], and on a subset of B lymphocytes in the mantle of the germinal center [11] and in the spleen [13].
As for the APC, CD1a, CD1b, and CD1c antigens have been commonly reported on dendritic cells [6]. Moreover:
• CD1a has been demonstrated on Langerhans cells [14], where it is expressed at an intensity of 1600 molecules per cell [15], on some CD11b(+) CD14(+) mononuclear cells reported in the peripheral blood of burnt subjects and interpreted as Langerhans cell precursors migrating from bone marrow to epidermis [16], on monocytes activated with granulocyte‐macrophage colony‐stimulating factor (GM‐CSF) in vitro [17], and on in vitro monocyte‐derived dendritic cells [18]
• CD1b has been demonstrated on monocytes activated with GM‐CSF in vitro [17] and on a subset of Langerhans cells [19]
• CD1c has been demonstrated on monocytes activated with GM‐CSF in vitro, on Langerhans cells [19], and on a minor subset of myeloid dendritic cells (MDC) characterized by CD11c(++) CD123(±) phenotype [20]
• CD1d has been demonstrated on “resting” monocytes [11], on dendritic cells of the dermis [21], on dendritic cells in peripheral blood [6], and on in vitro monocyte‐derived dendritic cells [21].
CD1d has also been demonstrated in keratinocytes of psoriatic skin [22], in the cells of human scalp hair follicles [22], in the epithelial cells of the gut and other organs [23], and in adipocytes [24].
CD1a, CD1b, CD1c, and CD1d have been demonstrated in the “foam cells” of the atherosclerotic plaque [25].
The cytometric demonstration of molecules belonging to the CD1 family should be performed taking the following points into account:
• cytometric studies have demonstrated that activated T lymphocytes express CD1c on the membrane only when kept at room temperature, and fail to mount the molecule on the surface when kept at +4 or to +37°C [26]
• the expression of CD1a on the surface of the leukemic blasts can fluctuate spontaneously after a short period of incubation in vitro [27].
The antibodies specific for CD1 antigens do not behave in the same way.
It should be kept in mind that CD1a features four different epitopes, the first of which is recognized by clones D47, Na1/34, and L119, the second by clone L404, and the third by clone L504 [28]; it should be noted that CD1a on the cells of B‐cell chronic lymphocytic leukemia (B‐CLL) can be demonstrated only with clones other than OKT6 or Na1/34 [29].
The clones 7C4 and IOT6b recognize different epitopes of CD1b [30].
Diagnostic features
CD1 in myelodysplastic and chronic myeloproliferative diseases
CD1a can be detected by immunohistochemistry (IHC) in the neoplastic cells of the cutaneous localization of chronic myelomonocytic leukemia (CMML); a case is known displaying S‐100(−), CD1a(+), CD4(+), CD56(+), CD123(−), and Langerin/ CD207(−) phenotype, mimicking the phenotype of the indeterminate dendritic cell tumor (IDCT) [31].
CD1a, CD1b, and CD1c are expressed on the membrane of the blast cells in the 20% of cases of chronic myeloid leukemia in blastic crisis (CML‐BC) [27].
The expression of CD1d has been reported on the cells of the juvenile myelomonocytic leukemia (JMML) [32].
CD1 antigens in neoplastic diseases of B‐cell
precursors
In a group of 80 patients affected by childhood B‐cell acute lymphoblastic leukemia (B‐ALL), the expression of CD1d has been demonstrated in 15% of the cases [10]. CD1d expression is significantly associated with pre‐B phenotype, rearrangement of the gene KMT2A (formerly known as MLL), and shorter global survival [10].
CD1 antigens in neoplastic diseases of T‐cell precursors
In T‐cell acute lymphoblastic leukemia (T‐ALL) the expression of CD1a antigen has been detected in a percentage of cases ranging from 40% to 50% of cases [27,4565]. CD1a antigen is generally expressed on the cells of T lymphoblastic leukemia/ lymphoma (T‐ALL/LBL) related to the stage of cortical or “common” thymocyte [3,27] (Fig. 1.1). According to the European Group for the Immunological Characterization of Leukemias (EGIL) classification of T‐ALL, CD1a antigen is typically present in the T III form but missing in the T I, T II, and T IV forms [34]. If CD13 is negative, the expression of CD1a is related to good survival [35], while the expression of CD1a together with CD10 is associated with the presence of the t(5;14)(q35;q32) translocation [33,4594,4595].
CD1 antigens in acute myeloid leukemias
The expression of CD1a and of CD1d has been repeatedly reported on the surface of the blasts of the acute myeloid leukemias (AML) [27,32,33]. According to some authors, the expression of CD1a and CD1d is restricted to French–American–British (FAB) subtypes characterized by a monocytic component [32]. In a percentage of cases, the expression of CD1a can be accompanied by the presence of other histiocytic markers (S‐100, CD163, Langerin/CD207) and is interpreted as a sign of histiocytic differentiation [36].
CD3
CD4
CD1a
CD8
SSC (A)
(B) (C)
CD45
Figure 1.1 Peripheral blood from a subject affected by T‐ALL. The blasts (red) express phenotype CD45(dim+) (A), CD1a(+) (B), CD3(+) (heterogeneous) (B), CD4(+) (C), CD8(+) (partial) (D).
Table 1.1 Differential diagnosis of CD5(−) CD10(−) B‐CLPDs
B‐CLPD CD1d CD200
HCL Positive Positive
LPL Dimly positivePositive
MZL Positive Negative
B‐CLPD: B chronic lymphoproliferative disease; HCL: hairy cell leukemia; LPL: lymphoplasmacytic lymphoma; MZL: marginal zone lymphoma.
CD1 antigens in neoplastic diseases of mature B cells
It has been reported that B‐cell prolymphocytic leukemia (B‐PLL) cells express CD1c [9,37], that Burkitt lymphoma (BL) cells do not express CD1c [7], and that hairy cell leukemia (HCL) cells express CD1a [38] and CD1c [9]. The cells of B‐CLL have been reported to express CD1a [9,29], CD1c [7], and CD1d; it is noteworthy that CD1a on B‐CLL cells could be demonstrated only with clones other than OKT6 or Na1/34 [29].
CD1d is usually expressed by the cells of the B‐CLPDs, but at an intensity depending on the type of disease. Its intensity in B‐CLL is typically lower than in normal B cells, but it is progressively higher on MCL, HCL‐variant (HCL‐v), lymphoplasmacytic lymphoma (LPL), splenic marginal zone lymphoma (SMZL), and HCL cells [12]. The combined exploration of CD1d and CD200 seems very promising in the differential diagnosis of CD5(−) CD10(−) B‐CLPDs as well, inasmuch as a recent study has shown that HCL is CD1d(+) CD200(+), LPL is CD1d(−/±) CD200(+), and MZL is CD1d(+) CD200(−) [39] (Table 1.1).
CD1d antigen seems of particular interest in B‐CLL workup, because its intensity of expression and the percentage of CD19(+) CD1d(+) cells are bad prognostic predictors [40,41]; according to some authors [42,43], but not to others [40], CD1d intensity seems to correlate with the absence of somatic hypermutations [43].
Multiple myeloma (MM) cells express CD1d in the early stages but tend to reduce its expression with disease progression [44].
CD1 antigens in neoplastic diseases of mature T and natural killer (NK) cells
The expression of CD1a antigens has been reported in rare cases of peripheral T‐cell lymphoma (PTCL) [45] and in an isolated case of adult T‐cell leukemia/lymphoma (ATLL) [46].
Overexpression of CD1d mRNA has been detected in Sezary’s cells by RT‐PCR [47], but this report has not yet been confirmed by phenotypic studies.
CD1 antigens in neoplasms of histiocytes and dendritic cells
As for the neoplasms of histiocytic and dendritic cells, CD1a, CD1b, and CD1c have been demonstrated with immunohistochemical techniques in the Langerhans cell histiocytosis (LCH) [19,48,49]. One of the most typical features of the pulmonary involvement in LCH is the occurrence of more than 5% of CD1(+) cells in the bronchoalveolar lavage fluid (BALF) [50]. Cells with CD1a(+), CD207(+), CD11b(±), and CD11c(++) phenotype have been detected in the peripheral blood of patients with active LCH [51]. CD1a expression has been reported in an anecdotal case interpreted as acute leukemia of Langerhans cell precursors based on the presence of Birbeck granules and of the ability of blasts to develop dendritic processes when cultured in vitro [52].
CD1a has been demonstrated with immunohistochemical techniques in the IDCT [53], but neither in the follicular dendritic cell sarcoma (FDCS) nor in the interdigitating dendritic cell sarcoma (IDCS) [49].
Partial expression of CD1a and expression of CD1c have been reported on the cells of an exceptional case of leukemia classified as Langerhans cell/dendritic cell leukemia, which occurred in a patient suffering from myelodysplastic syndrome (MDS). This case displayed CD11c(+), CD123(−), CD141(+), CD303(−), CD304(±/−), and CD207/Langerin(+/−) phenotype [54].
CD1 antigens in other pathological conditions
CD1a has been reported on the cells of the so called “indolent T‐lymphoblastic proliferation” (iT‐LBP) [55], an entity not recognized by the 2017 WHO classification (see also the dedicated paragraph).
CD2 Antigen
General features
CD2 is a 45–58 kD glycoprotein belonging to the superfamily of the immunoglobulins, which is encoded by a gene situated on the short arm of chromosome 1. CD2 is an adhesion molecule, constitutes the ligand of the CD58 molecule [56] and interacts with CD48 and CD59 molecules as well [57].
CD2 is normally expressed on thymocytes, on whose membrane it begins to appear at the prothymocyte level [58], and on mature T lymphocytes [59].
Not all mature T lymphocytes co‐express CD2; in the peripheral blood small subsets of T lymphocytes exist that show CD3(+) CD2(−) phenotype and are characterized by the expression of T‐cell receptor (TCR) either with αβ [60] or γδ chains [61].
The expression of CD2 is not restricted to the T lineage. Indeed, it is well known that CD2 is expressed:
• on 70–90% of the NK cells negative for CD3 [62,63], where it is upregulated by activation [64]
• on a minority of follicular dendritic cells (FDC) [65]
• on a subset of mononuclear peripheral cells interpreted as precursors of MDCs [66]
• on a subset of peripheral monocytes characterized by the co‐expression of Fcε receptor (FcεRI) [67]
• on a subset of plasmacytoid dendritic cells (PDCs) [68]
• on a small subset of B cells in fetal liver [69], in fetal bone marrow [69], in thymus [70], in peripheral blood [71], and in the bone marrow of normal subjects [71].
Cytometric features
The staining of peripheral normal lymphocytes with an anti‐CD2 monoclonal antibody (MoAb) generates a positive histogram with a narrow gaussian‐like peak, clearly separated from the negative component, with a channel peak representing the presence of 24 ± 7 E03 ABC (antibody‐binding capacity) [72].
Bimodal histograms can often be seen, especially when immune system activation is ongoing, because a higher number of CD2 molecules is expressed on activated cells [73] (Fig. 1.2).
In these cases, the CD2(bright+) population tends to show higher values of forward and side scatter than the CD2(dim+) population.
CD2(bright+) cells nearly exclusively express CD45R0, while the CD2(dim+) population display either CD45R0 or CD45RA [74]; the staining of CD2(+) CD45RA(+) cells with an anti‐CD2 MoAb generates a histogram with a channel peak representing the presence of 21 ± 4 E03 ABC while the staining of CD2(+) CD45R0(+) lymphocytes with the same MoAb generates a histogram with a channel peak representing the presence of 55 ± 9 E03 ABC [72].
In accordance with the state of chronic activation caused by HIV infection, the lymphocytes of HIV‐infected subjects seem to express a higher amount of CD2 molecules [75], whereas a reduced expression has been documented on the lymphocytes of elderly subjects [76]. According to some authors, the expression of CD2 on NK cells is inhomogeneous, being more intense in the CD16 dim CD56 bright subset than in the CD16 bright CD56 dim subset [77].
Not all the anti‐CD2 MoAbs behave in the same way; some clones are able to inhibit the E‐rosette formation [78], while others are able to activate T lymphocytes in vitro [79].
Diagnostic features
CD2 in myelodysplastic and chronic myeloproliferative diseases
CD2 has been reported in a third of cases of CMML [80].
CD2 in neoplastic diseases of mast cells
CD2 has been reported together with CD22 and CD25 on the neoplastic mast cells in systemic mastocytosis (SM) and acute mast cell leukemia (AMCL) [81–83]. However, an aberrant CD2 (and CD25) expression can be found on mast cells in the bone marrow of subjects without evidence of neoplasms of mast or myeloid stem cell [84].
SSC
CD2
(A)
(B)
CD2
CD25
Figure 1.2 The histogram produced by the cytometric analysis of CD2 is bimodal (A), because the activated CD25(+) lymphocytes (red) express more CD2 molecules than CD25(−) lymphocytes (blue) (B).
