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Halepota HF, Tan JSK, Reddy SK, Tang PH, Ong LY, Lee YT, Chan MY, Soh SY, Chang KTE, Ng ASB, Loh AHP. Association of anesthetic and surgical risk factors with outcomes of initial diagnostic biopsies in a current cohort of children with anterior mediastinal masses. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000303. [DOI: 10.1136/wjps-2021-000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/06/2021] [Indexed: 11/03/2022] Open
Abstract
BackgroundDiagnostic biopsies of pediatric anterior mediastinal masses (AMMs) are high-risk procedures in which general anesthesia (GA) is traditionally avoided. However, awareness of historically recognized risk factors and corresponding perioperative management have improved over time and may now no longer strictly preclude the use of GA. Therefore, in this study, we examined the association of anesthetic and surgical risk factors and modalities with resulting procedural and survival outcomes in a current patient cohort.MethodsWe retrospectively reviewed charts of 35 children with AMMs who underwent initial diagnostic biopsies between January 2001 and August 2019, and determined tracheal compression and deviation from archival CT scans and procedural and disease outcomes.ResultsTwenty-three (65%) patients underwent GA while 12 (35%) received sedation. Among patients with available CT measurements, 13 of 25 (52%) had >50% anteroposterior tracheal diameter reduction. Patients with >50% anteroposterior tracheal compression received sedation more frequently (p=0.047) and were positioned upright (p=0.015) compared with patients with ≤50% compression, although 4 of 13 and 9 of 12, respectively, still received GA. Intraoperative adverse events (AEs) occurred in four (11.4%) patients: three received GA, and all were positioned supine or lateral. AEs were not associated with radiographic airway risk factors but were significantly associated with morphine and sevoflurane use (p<0.001) and with thoracoscopic biopsies (p=0.035). There were no on-table mortalities, but four delayed deaths occurred (three related to disease and one from late procedural complications).ConclusionsIn a current cohort of pediatric AMM biopsies, patients with >50% anteroposterior tracheal compression were more frequently managed with a conservative perioperative management strategy, though not completely excluding GA. The corresponding reduction in frequency of procedural AEs in this traditionally high-risk group suggests that increased awareness of procedural risk factors and appropriate risk-guided perioperative management choices may obviate the procedural mortality historically associated with pediatric AMM biopsies.
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Ferreira-Facio CDS, Botafogo V, Ferrão PM, Canellas MC, Milito CB, Romano S, Lopes DV, Teixeira LC, Oliveira E, Bruno-Riscarolli E, Mello FV, Siqueira PFR, Moura P, Macedo FN, Forny DN, Simião L, Pureza AL, Land MGP, Pedreira CE, van Dongen JJM, Orfao A, da Costa ES. Flow Cytometry Immunophenotyping for Diagnostic Orientation and Classification of Pediatric Cancer Based on the EuroFlow Solid Tumor Orientation Tube (STOT). Cancers (Basel) 2021; 13:cancers13194945. [PMID: 34638431 PMCID: PMC8508207 DOI: 10.3390/cancers13194945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 11/15/2022] Open
Abstract
Simple Summary Pediatric solid tumors are a heterogenous group of diseases that comprise ≈ 40% of all pediatric cancers, early diagnosis being key for improved survival. Here we designed, tested, and validated a single eight-color tube for the diagnostic screening of pediatric cancer—solid tumor orientation tube (STOT)—based on multiparameter flow cytometry vs. conventional diagnostic procedures. Prospective clinical validation of STOT in 149 samples (63 tumor mass, 38 bone marrow, 30 lymph node, and 18 body fluid samples) screened for pediatric cancer, apart from 26 blood specimens that were excluded from analysis, showed concordant results with the final WHO/ICCC-3 diagnosis in 138/149 cases (92.6%). This included correct diagnostic orientation by STOT in 43/44 (98%) malignant and 4/4 (100%) benign non-hematopoietic tumors, together with 28/38 (74%) leukemia/lymphoma cases. The only recurrently missed diagnosis was Hodgkin lymphoma (0/8), which would require additional markers. These results support the use of STOT as a complementary tool for fast and accurate diagnostic screening, orientation, and classification of pediatric cancer in suspicious patients. Abstract Early diagnosis of pediatric cancer is key for adequate patient management and improved outcome. Although multiparameter flow cytometry (MFC) has proven of great utility in the diagnosis and classification of hematologic malignancies, its application to non-hematopoietic pediatric tumors remains limited. Here we designed and prospectively validated a new single eight-color antibody combination—solid tumor orientation tube, STOT—for diagnostic screening of pediatric cancer by MFC. A total of 476 samples (139 tumor mass, 138 bone marrow, 86 lymph node, 58 peripheral blood, and 55 other body fluid samples) from 296 patients with diagnostic suspicion of pediatric cancer were analyzed by MFC vs. conventional diagnostic procedures. STOT was designed after several design–test–evaluate–redesign cycles based on a large panel of monoclonal antibody combinations tested on 301 samples. In its final version, STOT consists of a single 8-color/12-marker antibody combination (CD99-CD8/numyogenin/CD4-EpCAM/CD56/GD2/smCD3-CD19/cyCD3-CD271/CD45). Prospective validation of STOT in 149 samples showed concordant results with the patient WHO/ICCC-3 diagnosis in 138/149 cases (92.6%). These included: 63/63 (100%) reactive/disease-free samples, 43/44 (98%) malignant and 4/4 (100%) benign non-hematopoietic tumors together with 28/38 (74%) leukemia/lymphoma cases; the only exception was Hodgkin lymphoma that required additional markers to be stained. In addition, STOT allowed accurate discrimination among the four most common subtypes of malignant CD45− CD56++ non-hematopoietic solid tumors: 13/13 (GD2++ numyogenin− CD271−/+ nuMyoD1− CD99− EpCAM−) neuroblastoma samples, 5/5 (GD2− numyogenin++ CD271++ nuMyoD1++ CD99−/+ EpCAM−) rhabdomyosarcomas, 2/2 (GD2−/+ numyogenin− CD271+ nuMyoD1− CD99+ EpCAM−) Ewing sarcoma family of tumors, and 7/7 (GD2− numyogenin− CD271+ nuMyoD1− CD99− EpCAM+) Wilms tumors. In summary, here we designed and validated a new standardized antibody combination and MFC assay for diagnostic screening of pediatric solid tumors that might contribute to fast and accurate diagnostic orientation and classification of pediatric cancer in routine clinical practice.
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Affiliation(s)
- Cristiane de Sá Ferreira-Facio
- Internal Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil; (C.d.S.F.-F.); (V.B.); (L.C.T.); (E.O.); (E.B.-R.); (P.F.R.S.); (M.G.P.L.)
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Vitor Botafogo
- Internal Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil; (C.d.S.F.-F.); (V.B.); (L.C.T.); (E.O.); (E.B.-R.); (P.F.R.S.); (M.G.P.L.)
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Patrícia Mello Ferrão
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Maria Clara Canellas
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Cristiane B. Milito
- Department of Pathology, Faculty of Medicine, Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil;
| | - Sérgio Romano
- Laboratory of Anatomical Pathology and Cytopathology, Instituto Nacional de Câncer (INCa), Rio de Janeiro 20220-400, Brazil;
| | - Daiana V. Lopes
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Lisandra C. Teixeira
- Internal Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil; (C.d.S.F.-F.); (V.B.); (L.C.T.); (E.O.); (E.B.-R.); (P.F.R.S.); (M.G.P.L.)
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Elen Oliveira
- Internal Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil; (C.d.S.F.-F.); (V.B.); (L.C.T.); (E.O.); (E.B.-R.); (P.F.R.S.); (M.G.P.L.)
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Enrico Bruno-Riscarolli
- Internal Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil; (C.d.S.F.-F.); (V.B.); (L.C.T.); (E.O.); (E.B.-R.); (P.F.R.S.); (M.G.P.L.)
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Fabiana V. Mello
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Patrícia F. R. Siqueira
- Internal Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil; (C.d.S.F.-F.); (V.B.); (L.C.T.); (E.O.); (E.B.-R.); (P.F.R.S.); (M.G.P.L.)
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Patrícia Moura
- I’Dor Institute, Hospital Estadual da Criança, Rio de Janeiro 21330-400, Brazil; (P.M.); (F.N.M.)
| | - Francisco Nicanor Macedo
- I’Dor Institute, Hospital Estadual da Criança, Rio de Janeiro 21330-400, Brazil; (P.M.); (F.N.M.)
| | - Danielle N. Forny
- Department of Pediatric Surgery, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil;
| | - Luíza Simião
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Ana Luíza Pureza
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
| | - Marcelo Gerardin Poirot Land
- Internal Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil; (C.d.S.F.-F.); (V.B.); (L.C.T.); (E.O.); (E.B.-R.); (P.F.R.S.); (M.G.P.L.)
| | - Carlos Eduardo Pedreira
- Systems and Computing Engineering Department (COPPE-PESC), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro 21941-972, Brazil;
| | - Jacques J. M. van Dongen
- Department of Immunohematology and Blood Transfusion (IHB), Leiden University Medical Center (LUMC), 2333 ZA Leiden, The Netherlands;
| | - Alberto Orfao
- Translational and Clinical Research Program, Centro de Investigación del Cáncer and IBMCC (CSIC-University of Salamanca), Cytometry Service, NUCLEUS, Department of Medicine, University of Salamanca (USAL), Institute of Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain
- Correspondence: (A.O.); (E.S.d.C.); Tel.: +34-9232-9481 (A.O.); +55-21-3938-4725 (E.S.d.C.)
| | - Elaine Sobral da Costa
- Internal Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, Brazil; (C.d.S.F.-F.); (V.B.); (L.C.T.); (E.O.); (E.B.-R.); (P.F.R.S.); (M.G.P.L.)
- Cytometry Service, Institute of Paediatrics and Puericultura Martagão Gesteira (IPPMG), Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-612, Brazil; (P.M.F.); (M.C.C.); (D.V.L.); (F.V.M.); (L.S.); (A.L.P.)
- Correspondence: (A.O.); (E.S.d.C.); Tel.: +34-9232-9481 (A.O.); +55-21-3938-4725 (E.S.d.C.)
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Várady G, Cserepes J, Németh A, Szabó E, Sarkadi B. Cell surface membrane proteins as personalized biomarkers: where we stand and where we are headed. Biomark Med 2014; 7:803-19. [PMID: 24044572 DOI: 10.2217/bmm.13.90] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Personalized medicine requires the development of a wide array of biomarker diagnostic assays, reflecting individual variations and thus allowing tailored therapeutic interventions. Membrane proteins comprise approximately 30% of total human proteins; they play a key role in various physiological functions and pathological conditions, although, currently, only a limited number of membrane proteins are applied as biomarkers. In many normal tissues, cell surface membrane proteins are not easily accessible for diagnostic sampling, and tumor-derived membrane preparations - while serving as potential tumor biomarkers - may not reflect physiological protein expression. In addition to post-translational modifications, which may include glycosylation, phosphorylation and lipid modifications, the trafficking of membrane proteins is also regulated. Moreover, a tight cellular quality control monitors membrane protein maturation, and continuous removal and reinsertion, involving special signaling systems, occurs in many cases. However, cell surface membrane proteins already serve as valuable prognostic and predicative biomarkers, for example, in hematological and immunological diseases, by the determination of the cluster of differentiation markers. In this review, we demonstrate the relevance of cell surface membrane biomarkers in various diseases and call attention to the potential application of red blood cell (erythrocyte) membrane proteins in this regard. Surprisingly, red blood cells express hundreds of membrane proteins, which seem to reflect a general genetic and regulatory background, and may serve as relatively stable and easily accessible personalized membrane biomarkers. Quantitative membrane protein detection in red blood cells by flow cytometry may bring a breakthrough in this regard.
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Affiliation(s)
- György Várady
- MTA-SE Molecular Biophysics Research Group, Semmelweis University, Budapest, Hungary
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Shen H, Tang Y, Dong A, Li H, Shen D, Yang S, Tang H, Gu W, Shu Q. Staging and monitoring of childhood rhabdomyosarcoma with flow cytometry. Oncol Lett 2014; 7:970-976. [PMID: 24944652 PMCID: PMC3961456 DOI: 10.3892/ol.2014.1854] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 12/17/2013] [Indexed: 01/24/2023] Open
Abstract
Patients with metastatic rhabdomyosarcoma (RMS) have a poor prognosis. The detection of contaminating RMS cells in the bone marrow (BM) is important in clinical staging and risk assessment. The cytological examination of the BM remains the gold standard for the diagnosis of RMS, but has a limited sensitivity. In the present study, 32 BM and two cerebrospinal fluid (CSF) samples from 11 patients with suspected metastasis were analyzed by flow cytometry (FCM) with ganglioside D2 (GD2) conjugated with fluorescein isothiocyanate, cluster of differentiation (CD)90-phycoerythrin, CD45-peridinin chlorophyll protein and CD56-allophycocyanin monoclonal antibody cocktail in parallel to morphological examination at diagnosis or during treatment. Five samples (14.7%) were positive for RMS onup morphological examination. By FCM, 16 samples (47.1%) were positive for RMS. A significant difference was identified between the two methods. The four-color FCM assay successfully detected RMS cells in BM samples to a level of 0.01% (1 per 104 cells). RMS cells demonstrated a phenotype with CD56+/CD90+/CD45−/GD2− expression, which is different from the CD56+/CD90+/CD45−/GD2+ expression phenotype in neuroblastoma cells. The follow-up of four patients by FCM demonstrated that two patients became minimal residual disease-negative following two and four cycles of chemotherapy, respectively, and survived. The other two cases remained FCM-positive despite receiving four courses of chemotherapy and consequently succumbed to progressive disease. In addition, FCM analysis of the CSF samples from one patient confirmed a diagnosis of CSF metastasis with RMS. In conclusion, FCM may have a role not only in staging and monitoring the effects of therapy, but also in providing diagnostic confirmation of CSF metastasis with RMS.
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Affiliation(s)
- Hongqiang Shen
- Division of Hematology and Key Laboratory of Reproductive Genetics, Zhejiang University, Ministry of Education, Hangzhou, Zhejiang 310003, P.R. China
| | - Yongmin Tang
- Division of Hematology and Key Laboratory of Reproductive Genetics, Zhejiang University, Ministry of Education, Hangzhou, Zhejiang 310003, P.R. China
| | - Ao Dong
- Division of Hematology and Key Laboratory of Reproductive Genetics, Zhejiang University, Ministry of Education, Hangzhou, Zhejiang 310003, P.R. China
| | - Huamei Li
- Division of Hematology and Key Laboratory of Reproductive Genetics, Zhejiang University, Ministry of Education, Hangzhou, Zhejiang 310003, P.R. China
| | - Diying Shen
- Division of Hematology and Key Laboratory of Reproductive Genetics, Zhejiang University, Ministry of Education, Hangzhou, Zhejiang 310003, P.R. China
| | - Shilong Yang
- Division of Hematology and Key Laboratory of Reproductive Genetics, Zhejiang University, Ministry of Education, Hangzhou, Zhejiang 310003, P.R. China
| | - Hongfeng Tang
- Division of Pathology, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China
| | - Weizhong Gu
- Division of Pathology, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China
| | - Qiang Shu
- Division of Surgery, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China
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Shen H, Tang Y, Xu X, Tang H, Gu W. Simultaneous cytomorphological and multiparameter flow cytometric analysis of ALK-positive anaplastic large cell lymphoma in children. Oncol Lett 2012; 5:515-520. [PMID: 23420373 PMCID: PMC3573140 DOI: 10.3892/ol.2012.1034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 11/13/2012] [Indexed: 12/22/2022] Open
Abstract
The aim of this study was to investigate the pathological features of anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL) in children and to establish the effectiveness of screening and diagnosing ALCL with multiparameter flow cytometry immunophenotyping (FCI) of lymphoid tissue samples. A total of 121 lymph node tissue specimens obtained from 121 patients with a suspected diagnosis of lymphoma were analyzed with cytomorphological and FCI analysis. Fifteen cases were diagnosed as ALK-positive ALCL based on the pathological features and immunohistochemical results. Of these, there were 3 different types, common type (10 cases), lymphohistiocytic type (4 cases) and neutrophil-rich type (1 case). Thirteen cases (10 common, 2 lymphohistiocytic and 1 neutrophil-rich type) were diagnosed as ALCL using FCI. These cases were CD30-positive and aberrantly expressed at least two T-cell antigens, including CD4 (84.6%), CD2 (76.9%), CD7 (61.5%), CD3 (53.8%) and CD5 (38.4%). Neoplastic cells accounted for only a small proportion of the total cells in FCI, with a median of 19.3% (range, 7.9-31.8%), which was significantly higher than those in the control groups (all <1.0%). The sensitivity of FCI for diagnosing ALCL in lymph node samples was 86.7% with a specificity of 100%. The majority of neoplastic cells demonstrated high light forward and high light side scatter, similar to monocytes or granulocytes in dot plots. FCI may be used as an adjunct to histopathological examination for rapid and reliable diagnosis of pediatric ALCL. Flexible gating strategies and careful analysis are required to identify neoplastic cells with FCI.
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Affiliation(s)
- Hongqiang Shen
- Division of Hematology-Oncology, Key Laboratory of Reproductive Genetics (Zhejiang University), Ministry of Education, Hangzhou 310003, P.R. China
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