Improved mapping of coastal salt marsh habitat change at Barnegat Bay (NJ, USA) using object-based image analysis of high-resolution aerial imagery

Tidal wetlands are valued for the ecosystem services they provide yet are vulnerable to loss due to anthropogenic disturbances such as land conversion, hydrologic modifications, and the impacts of climate change, especially accelerating rates of sea level rise. To effectively manage tidal wetlands in face of multiple stressors, accurate studies of wetland extent and trends based on high-resolution imagery are needed. We provide salt marsh delineations for Barnegat Bay, New Jersey, by means of object-based image analysis of high-resolution aerial imagery and digital elevation models. We performed trends analyses of salt marsh extent from 1995 to 2015 and estimated drivers of marsh area change. We found that in 1995, 8830 ± 390 ha were covered with marsh vegetation, while in 2015 only 8180 ± 380 ha of salt marsh habitat remained. The resulting net loss rate of 0.37% yr-1 is equivalent to historic loss rates since the 1970s, indicating that despite regionally accelerating relative sea level rise and purported eutrophication, salt marsh loss rates at Barnegat Bay remain steady. The main drivers of salt marsh loss are excavations for mosquito control (409 ha), edge erosion (303 ha) and ponding (240 ha). Upland migration of salt marsh did not completely mitigate these losses but accounted for a gain of 147 ha of tidal marsh habitat. The methodology presented herein yielded accurate salt marsh delineations (>90%) and trend detection (85%), outperforming low-resolution wetland delineations used in coastal management. This study demonstrates the suitability of high-resolution imagery for the detection of open water features. For the purposes of salt marsh change detection and the identification of change drivers, management and conservation agencies should make use of high-resolution imagery whenever feasible.

Tidal Flushing Rather Than Non-Point Source Nitrogen Pollution Drives Nutrient Dynamics in A Putatively Eutrophic Estuary

The effects of nonpoint source nutrients on estuaries can be difficult to pinpoint, with researchers often using indicator species, monitoring, and models to detect influence and change. Here, we made stable isotope measurements of nitrogen and carbon in sediment, water column particulates, primary producers, and consumers at 35 stations in the reportedly eutrophic Barnegat Bay (New Jersey) to assess N sources and processing pathways. Combined with water quality and hydrological data, our C and N isoscapes revealed four distinct geographic zones with diverging isotopic baselines, indicating variable nutrient sources and processing pathways. Overall, the carbon stable isotopes δ13C) reflected the terrestrial-marine gradient with the most depleted values in the urban and poorly flushed north of the estuary to the most enriched values in the salt marsh-dominated south. In contrast, the nitrogen stable isotope values δ15N) were most enriched near the oceanic inlets and were consistent with offshore δ15N values in particulate organic matter. Several biogeochemical processes likely alter δ15N, but the relatively lower δ15N values associated with the most urbanized area indicate that anthropogenic runoff is not a dominant N source to this area. Our findings stand in contrast to previous studies of similar estuaries, as δ15N signatures of biota in this system are inversely correlated to population density and nutrient concentrations. Further, our analyses of archival plant (Spartina sp., Phragmites australis) and shell (Geukensia demissa, Ilyanassa obsoleta) samples collected between 1880 and 2020 indicated that δ15N values have decreased over time, particularly in the consumers. Overall, we find that water quality issues appear to be most acute in the poorly flushed parts of Barnegat Bay and emphasize the important role that oceanic exchange plays in water quality and associated estuarine food webs in the lagoon.

Are Tidal Salt Marshes Exposed to Nutrient Pollution more Vulnerable to Sea Level Rise?

Over the past four decades, Long Island, NY, USA, has lost coastal wetlands at a rate of 4% per decade due to submergence. In this study, we examined relationships between the rate of tidal salt marsh loss and environmental factors, including marsh elevation, tidal range, and wastewater exposure through analysis of stable isotope ratios of marsh soils and biota. Our goal was to identify factors that increase vulnerability of marshes to sea level rise, with a specific emphasis on the potential role of poor water quality in hastening marsh loss. Our results suggest that wastewater exposure may accelerate loss of intertidal marsh, but does not negatively impact high tidal marsh resilience to sea level rise. And while marsh elevation and tidal range were statistically significant predictors of marsh loss, they similarly displayed opposite relationships among marsh zones. This study suggests that different functional zones of coastal salt marshes may not respond similarly to global change factors, and that elevation may be an important factor mediating eutrophication effects to coastal salt marshes.

Molecular pathology in the diagnosis and treatment of non-Hodgkin's lymphomas

The non-Hodgkin's lymphomas encompass a wide spectrum of hematologic neoplasms that exhibit different clinical and biological features. Lymphomas classically have been initially assessed based on their cytologic and histologic features. Morphology alone is often inadequate as similar appearing neoplasms may be immunophenotypically and molecularly heterogeneous. Molecular diagnostic methods can provide an additional level of testing that not only helps refine diagnoses but can provide prognostic information. New methods are being refined that may provide information to establish precise diagnostic profiles, provide targets for therapy and provide more sensitive methods for monitoring the success of treatment. Molecular methods will be increasingly utilized and eventually required as the accepted method of diagnosis and for monitoring the disease. Understanding of the molecular abnormality and the pathogenesis of the neoplasm hopefully will lead to therapeutic intervention aimed at the specific molecular defect or its product. The molecular pathology of the non-Hodgkin's lymphomas is discussed.

Kimura's disease: a case report

Kimura's disease is a rare, idiopathic condition that usually affects young men of Asian descent. The decrease is characterized by swelling and lesions in the head and neck region, with involvement of the subcutaneous soft tissue, major salivary glands, and lymph nodes. Patients almost always have eosinophilia and elevated serum immunoglobulin E levels. The diagnosis is established by biopsy. Kimura's disease is usually self-limiting. Its etiology is unknown but is thought to be a manifestation of an aberrant allergic response. In this paper, we describe the case of a 30-year-old patient who was diagnosed with Kimura's disease at our institution.

Detection of hepatitis C virus RNA sequences in B-cell non-Hodgkin lymphoma

Serologic testing shows that hepatitis C virus (HCV) may have a role in the pathogenesis of B-cell non-Hodgkin lymphomas (B-cell NHLs). We tried to demonstrate HCV RNA sequences in paraffin-embedded tissue from B-cell NHLs by reverse-transcription double polymerase chain reaction (RT-PCR) and Southern blotting. We studied 31 consecutive cases of B-cell NHLs; lymph nodes from 32 patients with diseases other than B-cell NHL were negative controls. Positive-strand HCV RNA was tested with primers for the 5' untranslated region. Replicative negative strand HCV RNA was tested with strand-specific RT-PCR for the 5' untranslated region. Immunohistochemical staining for HCV was done using an antibody to HCV core protein. Positive-strand HCV RNA was detected in 8 patients with B-cell NHL; negative-strand HCV RNA was detected in 6 of these cases, indicating viral replication. All control cases were negative for HCV RNA. Immunohistochemistry showed no staining of lymphoma cells for HCV core proteins in any case. HCV and B-cell NHLs may be associated. RT-PCR on paraffin-embedded lymphoma tissue is an alternative method of testing for HCV. The value of immunohistochemistry could not be ascertained. The exact role of HCV in the pathogenesis of B-cell NHL needs to be studied further.

Morphology and classification of acute myeloid leukemias

The morphology and classification of AML are discussed. In addition to routine morphology and cytochemistry, however, it is now necessary to use newer modalities of immunocytochemistry or flow cytometry to confirm a diagnosis. These latter are essential for the diagnosis of the newer described entities of AML with minimal differentiation (FAB-M0) and acute megakaryoblastic leukemia (FAB-M7). Cytogenetics and fluorescent-in-situ-hybridization techniques are also very important for diagnosis as in FAB-M3 (promyelocytic leukemia) but also for detecting those myeloid leukemias that are associated with a favorable or unfavorable response.

der(1)t(1;19)(p12;p11): a new nonrandom chromosomal abnormality in myelodysplastic syndrome

The der(1)t(1;19)(p12;p11) has not been previously reported in myelodysplastic syndrome (MDS). Fluorescence in situ hybridization (FISH) using chromosome 1- and chromosome 19-specific probes, performed on the bone marrow (BM) cells of this patient confirmed the initial karyotype, i.e., 47,XY,+der(1)t(1;19)(p12;p11).

Refractory T cell acute lymphoblastic leukemia with unusual karyotype and interesting immunophenotype

Karyotype, immunophenotype, and molecular studies are important in the evaluation of Acute Lymphocytic Leukemia as these data provide diagnostic as well as prognostic information. We present a case of acute lymphoblastic leukemia with unusual cytogenetics, 45,XY,i(7q),der(9)t(3;9)(q12;p22),del(12)(p12), :der(18)t(3;18)(p14;q22),-3. This karyotype is hypodiploid, showing loss of chromosome 3, a very rare occurrence. Hypodiploidy and translocations are suggestive of a poor clinical outcome. Cytogenetics also showed a chromosome 12p deletion which has been implicated in the oncogenesis of some acute leukemias. Immunophenotype by flow cytometry was positive for CD7 and CD10, T, and precursor B cell markers respectively. Given the specificity of CD7 for T cell processes, it was felt that the flow cytometry was more suggestive of a T cell process. Gene rearrangement studies showing a T cell receptor rearrangement helped confirm the T cell lineage of this malignancy. Hypodiploidy and T cell phenotype are indicators of poor prognosis. Interestingly this patient was refractory to two conventional chemotherapeutic protocols and finally responded to an unconventional protocol of high dose Ara C, etopside, and L asparaginase.

The Tulane University Medical Center/Columbia partnership: opportunities and challenges for pathology

A joint venture between the largest health-care corporation in the country (Columbia/HCA) and Tulane University Hospital/Clinic was established about 1 year ago. Early indications are that the partnership is successful and mutually beneficial. For Tulane University Medical Center, the joint venture provides financial stability and support for academic centers of excellence. Tulane University Hospital/Clinic will become the referral center for complicated cases from the regional Columbia hospitals. The Tulane University Hospital laboratories are positioned to become the regional referral laboratory for esoteric testing. For the pathologists of the regional Columbia hospitals, the opportunity beckons to form a group of equal partners that will contract with Columbia to provide laboratory services at Columbia hospitals and to consolidate the laboratories in the New Orleans division. Columbia has brought corporate expertise, capital, and opportunities for cost-saving economies of scale to the partnership. Quality and cost-effectiveness of patients care will be emphasized as will research on clinical outcomes. This model of corporate/academic partnership represents a new option for academic medical centers around the country as they respond to the rapid changes in the health-care environment.

Clinical use of B- and T-cell gene rearrangement analysis in hematopoietic disorders

The clinical application of B- and T-cell gene rearrangement analysis is discussed relative to diagnostic problems in specific lymphoproliferative disorders. This article reviews the use of the Southern blot hybridization technique for B- and T-cell gene rearrangement detection in the analysis of various hematopoietic lesions. Several case studies are presented and analyzed.

The automated white blood cell differential. A current perspective

The white blood cell differential count represents a major portion of the workload in the hematology laboratory. The traditional procedure whereby a technologist examines a Romanowsky-stained blood film and classifies 100 cells is both labor intensive and imprecise. To significantly improve the precision, the technologist would have to count and classify at least 1000 cells, which is obviously impractical in terms of time and efficiency. Until the availability of the automated hematology instruments, it was not possible to obtain a differential count that could be regarded as statistically significant. Automation is therefore necessary and desirable for both economic and clinical reasons. Automation can also provide a number of instrument-derived parameters tha have attained diagnostic significance in their own right. Analytic and technologic advances have occurred with every generation of hematology instruments. As the means of analysis becomes more sophisticated, additional categories of cells may be expected to be classified, and current categories may be more accurately and precisely defined. It is hoped this will lead to even greater clinical utility, as well as provide quality assurance and assessment methods that need to be developed similar to other procedures in the clinical laboratory.

Basaloid squamous cell carcinoma of the head and neck: a clinicopathologic and flow cytometric study of 10 new cases with review of the English literature

INTRODUCTION

We describe the clinicopathologic and flow cytometric features of 10 cases of basaloid squamous cell carcinoma (BSCC) of the head and neck to determine if DNA ploidy is a useful prognostic indicator. We also provide a review of 80 cases previously reported in the English language literature.

MATERIALS AND METHODS

The 10 cases were obtained from the surgical pathology files of Presbyterian University Hospital and The Eye and Ear Institute, Pittsburgh, PA (1987-1991). In all 10 cases, the microscopic slides and clinical data were reviewed. Flow cytometry was performed using the Hedley technique and formalin-fixed, paraffin-embedded tissue.

RESULTS

The mean age of patients with BSCC was 64 years (range, 49 to 75 years). Tumor involved the base of tongue (n = 5), hypopharynx-epiglottis (n = 3), and tonsil (n = 1). One case presented with cervical lymph node metastasis from an unknown primary site. Histologically, BSCC showed a biphasic pattern with basaloid-squamous elements, comedonecrosis, stromal hyalinization, surface dysplasia, and an in situ and/or invasive squamous cell carcinoma component. Flow cytometry revealed six diploid and four aneuploid tumors. Five of six patients with diploid and all four patients with aneuploid tumors developed early regional and/or distant metastases. Of the two patients who died of disease, one had a diploid and the other an aneuploid tumor.

CONCLUSION

Our study reaffirms the predilection of BSCC for the base of tongue, pyriform sinus, and supraglottic larynx, and its aggressive biologic behavior with a high incidence of cervical lymph node metastasis (64%), distant spread (44%), and death from disease (38% mortality at 17 months median follow-up). However, in contrast to previous reports, tumor ploidy by flow cytometry provided no additional prognostic information beyond that supplied by routine histologic evaluation.

A new procedure for cell lineage determination in acute leukemias. Myeloperoxidase mRNA detection

Determination of cell lineage in acute leukemias is essential for diagnosis and treatment. Detection of myeloperoxidase (MPO) mRNA establishes myeloid lineage of leukemic blasts that may be too primitive to be identified as myeloblasts based on morphology, cytochemistry, or immunophenotype. A highly specific and sensitive new procedure for MPO mRNA detection has been developed using HL-60 cells. It involves a microprocedure for total cellular RNA extraction, reverse transcription, and specific amplification of target sequences in the resulting MPO cDNA, by the polymerase chain reaction. Specific primers are designed to amplify an 89-base pair (bp) sequence from the signal peptide, 179 and 318-bp sequences from the start and end, respectively, of the heavy-chain sequence, and a 255-bp sequence overlapping the proregion and light chain. The correct-size amplification products, detected electrophoretically, demonstrate MPO mRNA expression in the leukemic cells analyzed. The sensitivity of this new procedure was evaluated on serial concentrations of HL-60 cells and was found to be 10-10(4) cells depending on the MPO cDNA amplified sequence. No amplification products were obtained using peripheral blood lymphocytes as a negative cellular control. The specificity of the procedure is demonstrated by Southern blotting and hybridization with 32P-labeled oligonucleotide probes specific for each of the amplified sequences. An additional advantage of this procedure is availability of results in 8-24 h, compared with 1-2 weeks for conventional RNA methods.

DNA content in fresh versus paraffin-embedded tissue. Flow cytometric analysis of 100 tumors

DNA ploidy analysis was determined on 100 consecutive tumors from a wide variety of sites using both fresh and paraffin-embedded tissue on the same specimen. The correlation coefficient (r) value between the methods was 0.85. Aneuploidy was detected by both methods in 51/100 (51%) of the cases. Fresh tissue analysis yielded 10 additional cases (overall 61% aneuploidy) not detected on corresponding paraffin-embedded sections, whereas paraffin-embedded analysis detected 4 additional cases (overall 55% aneuploidy) not revealed by fresh tissue analysis. Fresh tissue analysis produced lower coefficients of variation and resulted in a cleaner preparation with less cellular debris. Fresh tissue analysis was also superior to paraffin for the detection of hypodiploid, near-diploid and multiple peaks. Analysis of paraffin-embedded material allows examination of archival tissue and provides a more rapid means of long-term follow-up and statistical correlations for prognostic studies. Although the overall correlation of both methodologies for DNA analysis showed a minimal variation in results, in our experience fresh tissue analysis has an advantage and is preferable, when available, for ploidy analysis.

Morphological diagnosis of parvovirus B19 infection. A cytopathic effect easily recognized in air-dried, formalin-fixed bone marrow smears stained with hematoxylin-eosin or Wright-Giemsa

Readily identifiable intranuclear inclusions characterize parvovirus B19 cytopathic effect in formalin-fixed, paraffin-embedded material. Such inclusions are not apparent in air-dried smears of bone marrow aspirates. Brief formalin fixation of bone marrow smears, followed by either hematoxylin-eosin or Wright-Giemsa staining, permitted easy detection of parvovirus B19 inclusions in material from a renal transplant recipient with parvovirus B19 infection documented serologically and by electron microscopy. Formalin fixation of bone marrow and peripheral blood smears before hematoxylin-eosin or Wright-Giemsa staining may simplify the morphological diagnosis of parvovirus B19 infection.

Atypical (7;19) translocation in acute myelomonocytic leukemia

Chromosome studies were carried out after a 24-hour harvest of unstimulated bone marrow aspirate cell cultures from a 75-year-old male with a clinical diagnosis of acute myelomonocytic leukemia (FAB M4). Analysis of nine cells after trypsin-Giemsa banding (GTG) revealed two cell lines with a mosaic chromosome pattern, 46,XY/46,XY,t(7;19)(q22;p13.3). A review of the recent literature reveals one case of childhood ALL with a 46,XY/46,XY,t(7;19)(q11;q13) chromosome pattern [1] and a 46,XY,t(3q;11q),t(7q;19p),t(15;17)(q26;q22) in one patient with ANLL (FAB M3) [2]. The t(7;19)(q22;p13.3) seen in our case has not been reported as the sole specific clonal chromosome rearrangement in myeloid neoplasia. Interestingly, the plasminogen activator inhibitor type I, multi-drug resistance, and erythropoietin genes are located at band 7q22 and the insulin receptor gene is located at band 19p13.3. Both sites contain fragile site loci. The possible role of these fragile sites, genes, or other genes in the rearrangement can only be surmised.

Warfarin and the international normalized ratio: reducing interlaboratory effects

In North America, the dose of warfarin has been unintentionally increased during the past two decades because of failure to recognize the effect on the anticoagulation test of less sensitive tissue thromboplastins. Although there still is some controversy, the suggested dose of warfarin has now been adjusted downward to reduce the risk of bleeding. These revised dosing recommendations incorporate the international normalized ratio (INR), which takes into account the source of thromboplastin. However, there is considerable variability in the sensitivities of thromboplastin from manufacturer to manufacturer and lot to lot. Therefore, prothrombin times (PTs) are not comparable from laboratory to laboratory without knowing the sensitivity of the thromboplastin. Unless laboratories adopt a standardized tissue thromboplastin, the PT should be reported as an INR.

Detection of rearrangement of immunoglobulin heavy chain and T-cell receptor beta chain in leukemic cells by restricted polymerase chain reaction

Rearrangement of the immunoglobulin heavy chain and of the T-cell receptor beta subunit was analyzed by using restricted polymerase chain reaction (PCR). To differentiate between the germline configuration and the rearranged genome in a DNA sample extracted from lymphocytes, we compared the ratio of the amplified products. The intensity of amplification of the intron region (JHF) upstream of the first joining region was compared to the intensity of joining region 6 of the immunoglobulin heavy chain. The number of the amplification cycles in the PCR was designated in such a way that the ratio of JHF/JH6 was less than one in the rearranged configuration. As the concentration of clonal B-lymphocytes with the rearranged genome in the sample increased the amplification of the JHF intron proportionally decreased. We used the same approach for the two constant regions of the T-cell receptor beta chain. As one of the intron regions of the constant sequence became depleted by rearrangement so the amplification of the particular region decreased. Therefore, the absence or decreased concentration of a particular product of amplification indicated deletion and thus rearrangement of the genome in the leukemic B- or T-lymphocytes. The threshold of detection of cells with the rearranged genome on a photograph of agarose gel loaded with the particular amplified regions and staining with the ethidium bromide is less than 10% by densitometric tracing and 25-50% by visual evaluation. This novel approach allows the detection of the rearranged DNA sequences in a 2 day span. Hence, it can serve as a diagnostic tool for the identification of clonal expansion of lymphocytes in acute leukemias and lymphomas in particular and for the detection of deleted genomic regions in general.

Down's syndrome and mixed acute leukemia in infants

The routine use of panels of monoclonal antibodies has been complementary to the French-American-British (FAB) leukemia classification, and has unmasked the occurrence of mixed acute leukemia (myeloid-lymphoid). It is widely accepted that children with Down's syndrome (DS) have a high incidence of acute leukemia. There is an extensive body of literature emphasizing the cytogenetic findings in these children. However, information as to the immunophenotype is often limited to the lymphoid surface determinants. The authors report two children with DS whose leukemic blasts were studied with a panel of 17 monoclonal antibodies (myeloid, lymphoid, and megakaryocytic) by flow cytometric examination and were classified as biphenotypic acute leukemia. The blast population coexpressed myeloid and T-cell surface markers. The lymphoid origin was ruled out on the basis of negative terminal deoxynucleotidyl transferase and molecular analysis demonstrating germline configuration for the JH and beta TCR genes.

Granulocytopenia in cancer patients treated in a phase I trial with recombinant human tumor necrosis factor

We have examined the effect of recombinant human tumor necrosis factor (TNF) upon granulocyte kinetics in cancer patients in a phase I clinical trial. TNF was given to each patient intravenously over 2 h at varying doses. A marked drop in the total white blood cell count, absolute polymorphonuclear leukocyte (PMN) count, and absolute monocyte count occurred reproducibly at 30 min after TNF initiation. Also noted was a drop in the absolute lymphocyte and eosinophil counts, both of which reached their nadir at approximately 4 h. A marked increase in immature PMN leukocytes (bands) was noted beginning at 1 h. These changes were statistically significant. Statistically significant increases in hemoglobin and hematocrit occurred at the 30 min time point but subsequently decreased to approximately 90% of pretreatment baseline. Additionally, the platelet count decreased, reaching its nadir approximately 6 h after TNF initiation. In four serial studies in patients on the highest dose of TNF, the granulocyte adhesion protein CD11b was shown to increase on the surface of the PMN leukocytes by as early as 7-15 min after initiation of TNF infusion. In each of these, expression of CD11b antigen increased prior to the disappearance of PMN leukocytes from the peripheral circulation. A similar finding was obtained for monocytes. This work indicates that within 30 min of intravenous infusion of TNF, mature granulocytes and monocytes have left the peripheral circulation. This is followed by an apparent bone marrow response indicated by an outpouring of bands. The initial granulocyte and monocyte emigration from the peripheral circulation is preceded at highest-dose TNF by increased cell surface expression of CD11b for both cell types, suggesting a causal relationship between these temporally linked events.

Size and frequency of the DNA fragments in the rearranged immunoglobulin heavy chain joining regions in the lymphocytic leukemias

Four distinct groups of DNA fragments produced by the rearrangement of the joining regions of the immunoglobulin heavy chain gene were found after hydrolysis of the leukemic DNA with the EcoR I restriction enzyme. Three fragments were smaller than the genomic fragment (16 kb) and their average sizes were 9.6, 11.2, and 13.7 kb. The largest fragment was 18.7 kb. The fragment groups 2 and 3 (11.2 and 13.7 kb) were found in 65 per cent of the cases. There was no correlation between the fragment groups and the acute or chronic lymphocytic leukemia or B-cell lymphoma.

Diagnostic value of DNA analysis in effusions by flow cytometry and image analysis. A prospective study on 102 patients as compared with cytologic examination

One hundred twenty-six effusion samples from 102 patients were examined by cytology and flow cytometry (FCM). Overall, there was an 84% correlation between cytologic and FCM results. Of the 36 malignant cases determined by cytologic examination, FCM revealed an aneuploid peak in 20 (56%). Image analysis (IA) performed on the malignant cytologic cases with a diploid flow pattern detected two additional aneuploid peaks. In addition, FCM indicated three aneuploid cases in which cytologic characteristics were initially interpreted as benign (false negative). Aneuploidy was therefore detected in 64% of the malignant effusion specimens by FCM and IA. Twenty-three of the total of 24 aneuploid cases detected by FCM were associated with malignancy (predictive value = 96%). The one nonmalignant case was that of hemorrhagic pancreatitis with infected pseudocyst. FCM is an excellent tool when moderate to large numbers of tumor cells are present, whereas use of IA is advantageous for specimens containing smaller numbers of malignant cells because these can be directly analyzed. When an aneuploid peak is present, a diagnosis of malignancy must be suspected, and, if the initial cytologic screen is negative, a critical review of the cytology slides is justified. In those cases with an equivocal atypical cytology report and an abnormal cytometric histogram, additional investigation is warranted. In some malignancies the tumor cells will be diploid (in this study 36%) and neither FCM nor IA will add to tumor detection, leaving cytologic examination as the definitive technique.

Automated differentials in the hematology laboratory

The white blood cell differential continues to be one of the most widely performed clinical laboratory procedures. However, its clinical usefulness is affected by sampling error and, to some extent, by classification criteria. It is also labor intensive and expensive to perform. Automated leukocyte differential instrumentation addresses many of the sources of error that occur with the manual differential. Current state-of-the-art instrumentation will give results that equal or exceed the routine manual differential. Because these instruments also examine red blood cell and platelet parameters, as well as providing white blood cell information, they can better screen for significant abnormalities as well as greatly reduce the expensive and time-consuming manual differential procedures.

Quality control in flow cytometry for diagnostic pathology. I. Cell surface phenotyping and general laboratory procedures

Flow cytometric analyses have become commonplace in the clinical laboratory for determining cell lineage and for quantitation of cells bearing a given phenotype. Because these assays are being conducted to support diagnoses or assist in determining therapy, it is crucial to ensure that these tests are highly accurate and reproducible within a laboratory and among laboratories involved in similar endeavors. This quality assurance has been slow evolving in clinical flow cytometry for a variety of reasons: the exquisite sensitivity and delicacy of the instrumentation that recognize previously undetectable variations in staining; the constant improvement of the hardware and software; the rapid development of new techniques and reagents of clinical interest; and the failure of any existing specialty or subspecialty to encompass all aspects of flow cytometry. This article provides an overview of quality assurance necessary for the flow cytometric analysis of cell surface markers. Practical experience, published studies, and suggested guidelines from accreditation agencies have been combined to develop the text.

Posttransplant mediastinal Burkitt-like lymphoma. Diagnosis by cytologic and flow cytometric analysis of pleural fluid

Cytologic and flow cytometric (FCM) analyses of pleural fluids established the diagnosis of a Burkitt-like posttransplant lymphoma with a unique mediastinal presentation. FCM analysis of pleural fluid specimens was especially helpful in determining the cell lineage.

Multiple lineage reactivity in childhood leukemia

The leukemia cells from 63 children with acute leukemia were evaluated by flow cytometry with a panel of monoclonal antibodies that included lymphoid and myeloid lineage-specific antigens. Surface markers from patients with acute lyphocytic leukemia (ALL) did not correlate with their FAB classification except for L3 leukemia. Myeloid leukemias of FAB class M1-M4 were positive for CD13 and CD33, whereas CD14 and MY8 were only detected in FAB class M4 leukemia. Mixed leukemias were subclassified as intralineage (B+T+) or interlineage (B+ or T+/M+). Interlineage leukemias represented 5.6% of ALLs, and all patients are alive after treatment with ALL protocols. Interlineage mixed leukemias represent 7.9% of all leukemias occurring in 3.7% of ALLs and 33% of acute myeloid leukemias (AMLs). All children with mixed interlineage leukemias are alive after treatment with the protocol for the dominant leukemia; however, follow-up periods are too short to predict final outcome. The high proportion of mixed interlineage leukemias in AMLs supports Greaves' theory of lineage promiscuity, that is, there is a normal period of hematopoietic development when individual cells co-express multiple lineage antigens on the cell surface.

Three infants with acute megakaryoblastic leukemia simulating metastatic tumor

The diagnosis of acute megakaryoblastic leukemia (AMKL) (M7, French-American-British [FAB] classification) has rarely been made in children due, in part, to its pleomorphic morphology and ability to mimic other malignancies common in the pediatric age group. Three infants are described who had thrombocytopenia and the classical criteria of metastatic solid tumor in the bone marrow: patchy infiltration by cohesive clusters of cells with high nuclear cytoplasmic ratio and myelofibrosis in the bone marrow biopsy infiltrated area. This finding prompted clinical evaluation for solid tumor. The megakaryocytic lineage was ascertained by immunocytochemical studies and/or electron microscopic examinations of the bone marrow aspirates. The blasts in all three patients showed cytogenetic abnormalities that also were demonstrated by quantitative DNA analysis. None of the infants had Down's syndrome. Two of the patients are alive; one is off of therapy and the other is in remission. The third patient was transferred to another institution and lost to follow-up. Two children had wheezing that disappeared in remission. It is proposed that the clinical symptoms may be due to a substance produced, stored, or released by the leukemic cells.

Immunophenotyping in the classification of acute leukemia in adults. Interpretation of multiple lineage reactivity

Fifty-nine adult patients with acute leukemia were classified using a combination of the French-American-British (FAB) criteria and characterization by immunophenotyping using flow cytometric study. The authors identified 51 patients with acute myeloblastic leukemia and eight with acute lymphoblastic leukemia. This procedure permitted lineage assignment in leukemias that otherwise might have been unclassifiable. In addition, the authors demonstrated that the leukemic blasts of 29% of patients with myeloblastic disease exhibited one or more T-cell antigens on their surface. The use of immunophenotyping has greatly enhanced the authors' ability to correctly identify the lineage of acute leukemias. The data, however, must be interpreted with caution with respect to diagnosing acute mixed lineage leukemias and must be integrated with the morphologic and cytochemical evaluation of traditional classification schemes. The possible significance of T-cell markers in myeloblastic leukemia is discussed.

Microgranular promyelocytic leukemia: a multiparameter examination

Six cases of microgranular variant acute promyelocytic leukemia (M3v) were studied by use of a multiparameter approach including morphology, cytochemistry, flow cytochemistry, flow cytometry, cytogenetics, and gene rearrangement. Three of six cases demonstrated both myeloid and monocytoid associated surface markers by flow cytometry. One of six cases had strong alpha-naphthyl-butyrate esterase (alpha-NBE) activity in addition to myeloperoxidase activity. There was no correlation between percentage of positive monocytoid surface markers and intensity of cytoplasmic alpha-NBE activity. Four of six cases also had a T-cell-associated surface antigen. Further studies indicated that the T-cell markers appeared to be on the promyelocytes and that the T-B receptor gene was not rearranged. Similarly, cytogenetics studies indicated only one clonal abnormality t(15q+; 17q-). Whether these cases represent true "lineage infidelity" remains to be answered. Future important studies are needed on normal hematopoietic progenitor cells at early stages of development and childhood to study lineage-specific characteristics and to determine whether co-expression normally exists during early development.

Detection of the ras p21 gene product in human leukemias by flow cytometry

To date, the detection of oncogene products in human neoplasms has relied primarily upon immunoblot analysis of specimen homogenates. Herein are reported the results of a study using flow cytometry to evaluate the expression of the ras p21 gene product in both fresh and cryopreserved specimens of human acute leukemias. Cell lines known to express ras p21 were used as positive controls and normal peripheral blood was used as a negative control. Intensity of staining for ras p21 (Ip21) was expressed as the ratio of the peak channel numbers of the peak generated by staining with anti-ras p21 to the peak obtained by staining with an isotype control. Using this method, 21 out of 32 clinical specimens of acute leukemia were found to express ras p21 in elevated amounts compared to normal peripheral blood. Flow cytometry appears to be a practical method for routine screening of clinical specimens for the expression of oncogene products on individual cells rather than cell homogenates.

Regulation of total leukocyte, neutrophil and lymphocyte concentrations in human blood by major effectors

Commingling analysis of total leukocyte, neutrophil and lymphocyte concentrations in human blood suggested the effect of major regulatory factors affecting each type of white blood cells. Our results showed two distributions for the total leukocyte and lymphocyte concentrations. The values of the low and high phenotypes were 5.8 and 8.4 x 10(9)/l of total leukocytes and 2.0 and 4.6 x 10(9)/l of total lymphocytes. On the other hand, the neutrophil concentration in blood is probably regulated by equally penetrant factors. The means of the three phenotypes were 2.6, 4.2 and 6.5 x 10(9)/l. The evidence of two or three phenotypes, although consistent with the effect of a single-factor hypothesis (genetic or environmental), must be confirmed by segregation analysis of families.

The bone marrow in nutritional deficiencies

The overwhelming majority of nutritional deficiencies that affect the bone marrow and blood are due to the lack of vitamin B12, folic acid, or iron or combinations thereof. The two vitamins are closely related in DNA synthesis, whereas iron is the most abundant heavy metal in the body and is chiefly utilized for hemoglobin synthesis. Concomitant conditions of vitamin B12 and/or folate deficiency along with iron deficiency are not infrequent, and one type of anemia may mask the other. It is important to establish the correct diagnoses, as therapy directed at the wrong deficiency may hide the real deficiency with disastrous results. Specific diagnostic tests are now available to determine definitive diagnoses, and specific therapy is readily available to restore and maintain a normal nutrient status.

Use of the Technicon H-1 in the characterization of leukemias

The Technicon H-1 is a hematology analyzer that performs a complete blood cell count and white blood cell differential using both cytochemistry and flow technology. Two white blood cell cytograms are produced based on peroxidase activity and nuclear characteristics of the cells. Ninety cases of leukemia were studied. The 25 cases of acute lymphocytic leukemia (ALL) could be distinguished from the 39 cases of acute nonlymphocytic leukemia as the lymphocyte percentage was greater than 50% in the ALL cases and the mean peroxidase index value was 0 in 80% of the cases. The ALL cases and the chronic lymphocytic leukemia cases also had different cytogram patterns. Subtypes of acute nonlymphocytic leukemia could not be absolutely distinguished, although promyelocytic leukemias (M3) had characteristic cytograms and a monocyte percentage above 15% suggested a monocytic component (M4 or M5). Chronic myelogenous leukemia likewise seemed to have a recognizable pattern. Since a sample takes only 60 s to process, information is readily available. The unique data available from this instrument should provide a significant advancement in the automated hematology field.

Effect of simulated altitude erythrocythemia in women on hemoglobin flow rate during exercise

The effect of simulated altitude erythrocythemia on hemoglobin flow rate and maximal O2 uptake (VO2max) was determined for nine women sea-level residents. Test conditions included normoxia and normobaric hypoxia (16% O2-84% N2). Cycle tests were performed under normoxia (T1-N) and hypoxia (T1-H) at prereinfusion control and under hypoxia 48 h after a placebo infusion (T2-H) and 48 h after autologous infusion of 334 ml of erythrocytes (T3-H). Hematocrit (38.1-44.9%) and hemoglobin concentration (12.7-14.7 g.dl-1) increased from control to postreinfusion. At peak exercise, VO2max decreased from T1-N (2.40 l.min-1) to T1-H (2.15 l.min-1) then increased at T3-H (2.37 l.min-1). Maximal arterial-mixed venous O2 difference decreased from T1-N to T1-H and increased at T3-H. Cardiac output (Q), stroke volume, heart rate, and total peripheral resistance during maximal exercise were unchanged from T1-N through T3-H. Hemoglobin flow rate (Hb flow) at maximum did not change from T1-N to T1-H but increased at T3-H. When compared with submaximal values for T1-N, VO2 was unchanged at T1-H and T3-H; Q increased at T1-H and decreased at T3-H; arterial-mixed venous O2 difference decreased at T1-H and increased at T3-H; Hb flow did not change at T1-N but increased at T3-H. For young women, simulated altitude erythrocythemia increased peak Hb flow and decreased physiological altitude (227.8 m) but did not affect maximum cardiac output (Qmax).

Flow cytometry in the diagnosis of acute leukemia

Fifty cases of acute leukemia were analyzed by means of flow cytometry. The results obtained were correlated with morphology and routine cytochemistries. The panel selected was useful in classifying an acute leukemia as acute lymphocytic (ALL) or acute nonlymphocytic (ANLL), which is of primary importance for therapeutic considerations. Common ALL (CALLA) (J5) was a good marker for classifying the leukemia as ALL. Monoclonal antibodies (MoAbs) T1 and/or T11 further delineated the lymphoid leukemia as T-cell ALL while MoAbs B4 or B1 delineated the lymphoid leukemia as non-T-cell ALL. Eighteen cases of ALL were diagnosed and consisted of five cases of T-cell ALL and 13 cases of non-T-cell ALL. Both the T-cell ALL cases and non-T-cell ALL cases were found to be heterogeneous and could be further subgrouped by phenotypic expression with additional MoAbs in the panel. A monoclonal antibody panel consisting of My4, My7, My9, Mo1, and Mo2 was useful in characterizing an acute leukemia as ANLL. This panel was less useful in distinguishing myeloid from monocytic subtypes although My4, Mo1, or Mo2 when present, appeared to favor a monocytic component. Of interest, a case of biclonal leukemia with two distinct blast populations on the flow cytogram was discovered. Morphology alone was successful in diagnosing ALL from ANLL in 35 cases (70%). It was not useful in distinguishing non-T-ALL cases from T-ALL cases. The ambiguous cases could be resolved by cytometric means. Flow cytometry has much to offer as a diagnostic aid in the evaluation of acute leukemia.

Immunogold staining in bone marrow aspirate for the study of surface markers in acute lymphoblastic leukemia

The diagnostic value of phenotyping acute lymphoblastic leukemia (ALL) of childhood using the immunogold staining method (IGS) was assessed in 34 consecutive new ALL patients seen at Children's Hospital of Pittsburgh during a 14-month period. IGS proved to have considerable value in the diagnosis and classification of ALL. It allowed a sharp and clear identification of surface antigens, documented surface antigen heterogeneity in normal and abnormal cells, and provided a permanent record. The combination with cytochemistries allowed further cytoplasmic identification and correlation. This method does not require sophisticated equipment and can be performed in any laboratory, thus enabling results from different institutions to be more readily compared.

Biclonal IgM gammopathy in chronic lymphocytic leukemia

The association of chronic lymphocytic leukemia (CLL) with serum paraproteinemia (ie, monoclonal immunoglobulin production and secretion) is well known. We, however, could find only three previous reports of CLL where multiple serum paraproteins were encountered. We describe a case of biclonal gammopathy in CLL, involving IgM/kappa and IgM/lambda, with each paraprotein reaching serum levels of approximately 10 g/L (1 g/dL). Using immunohistochemical techniques, we identified two morphologically similar lymphocyte populations, which could be stained for either mu and kappa or mu and lambda. The peripheral blood contained a majority of mu/kappa-containing cells (kappa/lambda = 17.5:1), while the bone marrow only contained a modest excess of cells staining for mu/kappa (kappa/lambda = 2.4:1). The clinical significance and prognosis of biclonal IgM gammopathies is uncertain, since so few cases have been reported. Our patient has now been followed up for more than four years.

Simultaneous evaluation of terminal deoxynucleotidyl transferase and myeloperoxidase in acute leukemias using an immunocytochemical method

The classification of acute leukemia is important for the selection of optimal therapy. Classification often rests on morphologic, cytochemical, and immunologic criteria, and the marker enzyme terminal deoxynucleotidyl transferase (TdT) has been considered to be a reliable indicator of lymphoblastic leukemias. Because TdT-positive cells sometimes are seen in leukemias otherwise identified as myeloblastic, the authors evaluated blasts identified as myeloid by the presence of myeloperoxidase (MPO) for the simultaneous expression of TdT. The blasts in the bone marrow aspirate or peripheral blood of unselected patients with hematologic malignancies were evaluated and 60 cases are shown. The French-American-British system and, in some patients, cytochemical and immunologic studies were used to classify the leukemias. The authors demonstrated that blasts simultaneously contained MPO and TdT in 29% of patients with acute myeloblastic leukemia and 3% of patients with acute lymphocytic leukemia (ALL). This finding supports the hypothesis that TdT is an expression of cell primitivity rather than a marker for lymphoblastic cells.

Search for eosinopenia in hospitalized patients with normal blood leukocyte concentration

Hospitalized patients were studied prospectively in an attempt to determine whether idiopathic eosinopenia in the absence of other major changes in blood cells is rare or is more frequent than is commonly recognized. Strict criteria for eosinopenia were used; patients with more than 10.0 X 10(9)/liter total leukocyte count, or less than 4.0, as well as those with any form of hematologic cancer, or those receiving any form of cancer chemotherapy, were excluded from the study. With those criteria and exclusions, only 24 patients with eosinopenia were found among 24,300. Twenty were receiving some form of adrenal glucocorticosteroid (steroid) and of the other four, three had serious organic diseases for which they were receiving various drugs. The remaining patient, whose primary problem was depression, could have had drug-induced eosinopenia. Thus, unexpected eosinopenia appears to be a very rare event or syndrome. A normal range for eosinophils was defined from studies of 740 medical students, which was 0.015 to 0.65 X 10(9)/liter and was quite similar to previously reported values. The effect of acute or chronic steroid administration on eosinophils in normal human subjects was studied. Confirming studies reported for man and many other mammals, eosinopenia developed promptly, but disappeared within hours unless repeated doses were given. Literature on various types of eosinopenia was reviewed.

Multiple myeloma in two young postpartum women

Multiple myeloma is an uncommon disease before age 30 years. We recently encountered two cases of myeloma in women, aged 29 and 30 years, respectively. Aside from their young age, another unusual feature of these cases was that each woman had been pregnant and had a normal delivery, three and four months prior to diagnosis. A literature search revealed only 35 reported cases of multiple myeloma at or before the age of 30 years. Of these, only 14 were thought to be clear-cut or highly suggestive of myeloma by the authors. The relationship of multiple myeloma and pregnancy is discussed. Although the number of cases is small, the occurrence of myeloma in the younger individual does not appear to impart a worse prognosis or survival.

Investigation of cell size and nuclear clefts as prognostic parameters in chronic lymphocytic leukemia

The importance of the size and morphology of peripheral blood lymphocytes has been controversial as prognostic indicators in chronic lymphocytic leukemia (CLL). This study was initiated to specifically examine cell size and morphology with respect to presence or absence of nuclear clefts and the relative importance to survival. Eighty-seven cases of CLL that had not been previously treated were examined. Cleaved cells were considered present in significant numbers when they exceeded 5% of the circulating lymphocytes. Prognosis was not statistically significant when cell size and nuclear clefts were examined individually and in combination. This study confirms that clinical staging is the significant prognostic predictor irrespective of cell size and/or nuclear configuration.

Terminal deoxynucleotidyl transferase activity in acute leukemia: a study of 100 cases comparing an immunoperoxidase (PAP) vs immunofluorescent method

A comparison between the immunofluorescent (IF) method for terminal deoxynucleotidyl transferase (TdT) activity and the immunoperoxidase (IP) method by peroxidase-anti-peroxidase (PAP) technique was done for 100 cases of acute leukemia. For the acute lymphoblastic leukemias (ALL) there was agreement in 93% of the cases. However, the IP method detected 51/55 (93%) TdT+ cases versus 47/55 (85%) by the IF method. For the acute nonlymphocytic leukemias (ANLL), there was an agreement in 89% of the cases. The IP method detected 8/36 (22%) TdT-positive cases while IF detected 4/36 (11%) positive cases. If a figure of 10% TdT+ cells is considered significant in the marrow of the ANLLs, then the IP method would detect eight additional cases for a total of 16/36 (44%) TdT+ cases. This latter figure questions the ability of the IP TdT assay as a single test adequately to determine the lineage of a cell line. It may be rather that TdT is a marker that is expressed in a stem cell.

Morphometric study of megakaryocytes size and prognosis in adults with acute non-lymphocytic leukemia

Morphometric analysis of megakaryocyte cellular and nuclear size in bone marrow biopsies of 28 cases of acute non-lymphocytic leukemia at diagnosis and 15 controls was performed. Median megakaryocyte cell diameter, median area, and perimeter were less than 95% control range (less than 18.5 microns, less than 263 microns2, less than 64 microns) in 5/5 of induction failures. Attainment of complete remission was significantly greater in those with median megakaryocyte diameter greater than or equal to 18.5 microns (p less than 0.01), median area greater than or equal to 263 microns (p less than 0.001) and perimeter greater than or equal to 64 microns (p less than 0.001). Prolonged complete remission was correlated with normal megakaryocyte size with the median megakaryocyte area, median diameter, and perimeter within or greater than the reference range (greater than or equal to 18.5 microns, greater than or equal to 263 microns2, greater than or equal to 64 microns, p less than 0.05) in 6/7 cases with continuous remissions greater than 3 yr. Measurements of megakaryocyte size may be useful in predicting induction failure and possibly the likelihood of prolonged complete remission in adults.

Phagocytic macrophages in the bone marrow biopsies of children with Hodgkin's disease

Phagocytic macrophages in bone marrow aspirates have been described as normal and are frequently observed in autoimmune disorders. They are rarely seen in bone marrow biopsies. We observed phagocytosis of leukocytes and nuclear debris by macrophages in the bone marrow biopsies in 20 of 26 children with Hodgkin's disease before therapy. In contrast, phagocytic activity was present in only 1 of 16 children with solid tumors and 4 of 17 children receiving chemotherapy for neoplasia other than Hodgkin's disease. In all groups the marrow was not directly involved by tumor. The presence of macrophage activity did not correlate with clinical stage or histological type of Hodgkin's disease or with the peripheral blood count. Its increased frequency in patients with Hodgkin's disease may reflect abnormal macrophage function in those patients.

Prolymphocytic transformation of chronic lymphocytic leukemia. A report of three cases and review of the literature

Three cases of prolymphocytic transformation of chronic lymphocytic leukemia (PLL-trs CLL) are described, and a review of the literature yields 15 additional cases. PLL-trs CLL may be recognized when two populations of cells are present and the number of prolymphocytes are greater than 15% admixed with the small round lymphocytes of CLL. Surface immunoglobulin intensity appears to be greater on the prolymphocytes than on the small lymphocyte in the same case, suggesting a clonal differentiation. At the time of transformation, the spleen is generally larger than at the time of diagnosis of CLL, and lymphadenopathy is variable. Transformation is thought to be associated with increasing refractoriness to treatment and shorter survival, although most of the deaths occurred in clinical Stages III and IV, known to have a poor prognosis. Similar features between PLL-trs CLL and so-called de novo PLL also suggest an evolutionary process. However, additional morphologic and immunologic studies in transforming CLL cases are necessary to answer this question.

Occurrence of three cases of carcinoma in individuals with Crohn's disease treated with metronidazole

Controversy exists regarding the safety of metronidazole. Experimental studies have suggested both a carcinogenic and mutagenic effect in animals. In women treated with metronidazole for trichomoniasis which involves low dosages and short time periods, no carcinogenic effect was noted. Metronidazole is also used in the treatment of Crohn's disease which involves larger dosages over longer periods of time. The authors have recently encountered three individuals with Crohn's disease who were treated with large doses of metronidazole and who developed a malignancy [breast (two) and cholangiocarcinoma] at a rather young age (32, 31, and 27 years, respectively). Whereas this association based on three cases is not per se incriminatory or even suggestive, nevertheless, the cases are unusual and we urge prospective and long-term follow-up studies on individuals being treated with large doses of metronidazole over prolonged periods of time. Metronidazole (Flagyl) was introduced into The United States in the 1960's for the treatment of trichomoniasis (1). The conditions for which this drug is indicated and has been used have expanded to include such diverse entities as amebiasis (2), brain abscess (3), and Crohn's disease (4). A controversy exists regarding the safety of this drug (5, 6). Experimental studies have shown that metronidazole is both carcinogenic and mutagenic (7-9). However, a recent study (10) cited lack of evidence for a carcinogenic effect with the use of metronidazole in women treated for trichomoniasis. In the past 1 1/2 years we have encountered three unusual cases involving individuals who were treated with large doses of metronidazole for Crohn's disease and who developed a malignant neoplasm at a relatively young age. The features of these three cases are the subject of this report.