Cytometry Part B (Clinical Cytometry) 88B:348–351 (2015)
Brief Communication
Aberrant NK Cell Associated Marker (CD56 and CD57) Expression in Chronic Lymphocytic Leukemia Pranav Dorwal,* Simmi Mehra, Amit Pande, Dharmendra Jain, G. Smeeta, Ritesh Sachdev, and Vimarsh Raina Department of Pathology and Laboratory Medicine, Medanta the Medicity, Gurgaon, Haryana 122 001, India
Background: Chronic lymphocytic leukemia (CLL) is one of the commonest leukemias that has been reported extensively throughout the literature. The characteristic phenotype includes co-expression of CD5 and CD23, along with dim expression of light chain and CD22/CD79b, with lack of FMC7. The immunophenotypic scoring system given by Matutes has been used to differentiate CLL from non-CLL chronic lymphoproliferative disorders. Various aberrancies have been described in CLL cases, including abnormal (dim or bright) expression of B cell markers and lineage infidel T cell, myelomonocytic, or rarely Natural killer (NK) cells markers. However, the aberrant co-expression of CD56 and CD57 has not yet been reported. Method and Results: We hereby report a case of 62-year female with a typical CLL phenotype and Matutes score of 5, showing the expression of CD56 and CD57. Conclusion: This entity may represent a rare subtype of CLL which needs to be studied more extensively for its prognostic implications. This is the first report of CLL with aberrant CD56 and CD57 C 2015 International Clinical Cytometry Society expression. V Key terms: CLL; CD56; CD57; flow cytometry
How to cite this article: Dorwal P, Mehra S, Pande A, Jain D, Smeeta G, Sachdev R and Raina V. Aberrant NK Cell Associated Marker (CD56 and CD57) Expression in Chronic Lymphocytic Leukemia. Cytometry Part B 2015; 88B: 348–351.
Chronic lymphocytic leukemia (B-CLL) is one of the commonest leukemias that usually affect the elderly. The prognosis and the management of CLL usually depend on the staging of the disease based on the Binet or Rai score (1,2). A classical CLL phenotype is that of B cells (CD191) expressing CD5 and CD23, with dim light chain expression (kappa or lambda) along with dim expression of CD22/CD79b and lack of FMC7, as was described by Matutes et al. vide the Matutes’ scores (3). A few modifications in the scoring system have recently been recommended by K€ ohnke et al, with the inclusion of CD200 (4). CD56 and CD57 are known to be markers for Natural killer (NK) cells, with CD56 (along with CD16) being a lineage marker for NK cells. CD57 is not usually found in the fetal NK cells, however its expression increases with age (5). There have been multiple reports of expression of T cell associated markers on the B-CLL cells with variable prognostic significance (6). We hereby report a case, first of its kind, of CLL (with Matutes’ score of 5) with
C 2015 International Clinical Cytometry Society V
the aberrant expression of NK cell associated antigens (CD56 and CD57). A 65-year-old female was admitted with complaints of fever, weakness, and reduced appetite. She was a known case of rheumatoid arthritis which was diagnosed a few years back and was treated with steroids. On peripheral smear examination, the total WBC count of the patient was 114,000/cmm (reference range: 4,000–10,000), with 80% lymphoid cells. The hemoglobin of the patient was 10.8 g/dl (reference range: 12.0 – 15.0 g/dl), while the platelet count was 185,000/cmm (reference range: 150,000–400,000/cmm). The lymphoid *Correspondence to: Dr. Pranav Dorwal, Associate Consultant, Department of Pathology and Laboratory Medicine, Medanta The Medicity, Gurgaon 122001, India. E-mail: [email protected] Received 18 November 2014; Revised 25 March 2015; Accepted 20 May 2015 Published online 6 July 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cyto.b.21254
CLL WITH CD56 AND CD57 EXPRESSION
FIG. 1. Microphotograph of the peripheral smear showing presence of small cells with scanty to moderate cytoplasm and condensed chromatin. No nucleoli or cleaving seen. A smudge cells is also identified. The morphology was suggestive of chronic lymphoproliferative disorder (1003, oil immersion, Giemsa stained). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
cells were small, with scant to moderate cytoplasm and condensed chromatin. No nucleoli or nuclear clefting was observed. Smudge cells were also identified (Fig. 1). A morphological diagnosis of chronic lymphoproliferative disorder was made and immunophenotyping suggested. Meanwhile, the radiological examination revealed hepatosplenomegaly with presence of multiple abdominal lymph nodes. Multiparametric immunophenotyping was performed on the BD FACSVerse, dual laser, six-color, flow cytometer (BD Biosciences, San Jose, CA). A comprehensive lymphoproliferative disorder panel was put-up comprising of B-cell, T-cell, and NK-cell markers, that included CD19 (APC-H7), CD20 (PerCP Cy5.5), CD10 (APC), CD5 (PE-Cy7), CD23 (PE), FMC7 (FITC), CD22 (PE), CD200 (PerCP Cy5.5), CD103 (FITC), CD38 (APC), CD4 (FITC), CD8 (APC), CD7 (PE), CD3 (PerCP Cy5.5), CD56 (PECy7), CD57 (APC), CD45 (APC-H7), kappa (PE) and lambda (FITC) (BD Biosciences, San Jose, CA). We have recently included CD200 in our panel, after it was reported to be useful in differentiation of mature B-cell neoplasms (7). The tubes that were put were: FMC7/ CD23/CD20/CD5/CD38/CD19, CD103/CD22/CD138/ CD11c/–/CD19, lambda/kappa/CD200/–/CD10/CD19, CD4/CD7/CD3/CD5/CD8/CD45, and CD16/–/CD3/ CD56/CD57/CD45. Two unlabeled tubes containing only the back bone markers (CD19 and CD45) were also put. The BD FACSuite software (v1.0.5.3841) (BD Biosciences, San Jose, CA), was used for acquisition and analysis. The gating was performed using CD19-SSC and CD45-SSC plots. The quadrant markers were put-up using the unlabeled tubes. We have a cut-off of 20% for reporting a marker as positive or negative (8,9). The intensity of expression was categorized as dim, moder-
Cytometry Part B: Clinical Cytometry
349
ate or strong based on the expression compared to the negative control. The analysis revealed a prominent population in the mature lymphocyte region, constituting around 78% of the acquired events. Most of these cells were B cells (CD191), which were gated and analyzed further. These showed the typical phenotype of CLL with the co-expression of CD5 and CD23 along with dim expression of kappa and CD22, and lack of FMC7 expression (Fig. 2). There was dim and partial expression of CD10. These gated cells were also negative CD103. The Matutes’ score was 5 and there was also expression of CD200. CD38 which is a prognostic marker in CLL was also expressed. Interestingly, there was also expression of NK cell associated antigens, i.e., CD56 and CD57. There was no expression of any T cell marker, namely CD4, CD8, or CD3 (surface or cytoplasmic). The bone marrow biopsy showed replacement of marrow by B cells expressing CD20 and being negative for CD3 and Cyclin D1 (Dako, Denmark). The Ki67 was also found to be low (
Brief Communication
Aberrant NK Cell Associated Marker (CD56 and CD57) Expression in Chronic Lymphocytic Leukemia Pranav Dorwal,* Simmi Mehra, Amit Pande, Dharmendra Jain, G. Smeeta, Ritesh Sachdev, and Vimarsh Raina Department of Pathology and Laboratory Medicine, Medanta the Medicity, Gurgaon, Haryana 122 001, India
Background: Chronic lymphocytic leukemia (CLL) is one of the commonest leukemias that has been reported extensively throughout the literature. The characteristic phenotype includes co-expression of CD5 and CD23, along with dim expression of light chain and CD22/CD79b, with lack of FMC7. The immunophenotypic scoring system given by Matutes has been used to differentiate CLL from non-CLL chronic lymphoproliferative disorders. Various aberrancies have been described in CLL cases, including abnormal (dim or bright) expression of B cell markers and lineage infidel T cell, myelomonocytic, or rarely Natural killer (NK) cells markers. However, the aberrant co-expression of CD56 and CD57 has not yet been reported. Method and Results: We hereby report a case of 62-year female with a typical CLL phenotype and Matutes score of 5, showing the expression of CD56 and CD57. Conclusion: This entity may represent a rare subtype of CLL which needs to be studied more extensively for its prognostic implications. This is the first report of CLL with aberrant CD56 and CD57 C 2015 International Clinical Cytometry Society expression. V Key terms: CLL; CD56; CD57; flow cytometry
How to cite this article: Dorwal P, Mehra S, Pande A, Jain D, Smeeta G, Sachdev R and Raina V. Aberrant NK Cell Associated Marker (CD56 and CD57) Expression in Chronic Lymphocytic Leukemia. Cytometry Part B 2015; 88B: 348–351.
Chronic lymphocytic leukemia (B-CLL) is one of the commonest leukemias that usually affect the elderly. The prognosis and the management of CLL usually depend on the staging of the disease based on the Binet or Rai score (1,2). A classical CLL phenotype is that of B cells (CD191) expressing CD5 and CD23, with dim light chain expression (kappa or lambda) along with dim expression of CD22/CD79b and lack of FMC7, as was described by Matutes et al. vide the Matutes’ scores (3). A few modifications in the scoring system have recently been recommended by K€ ohnke et al, with the inclusion of CD200 (4). CD56 and CD57 are known to be markers for Natural killer (NK) cells, with CD56 (along with CD16) being a lineage marker for NK cells. CD57 is not usually found in the fetal NK cells, however its expression increases with age (5). There have been multiple reports of expression of T cell associated markers on the B-CLL cells with variable prognostic significance (6). We hereby report a case, first of its kind, of CLL (with Matutes’ score of 5) with
C 2015 International Clinical Cytometry Society V
the aberrant expression of NK cell associated antigens (CD56 and CD57). A 65-year-old female was admitted with complaints of fever, weakness, and reduced appetite. She was a known case of rheumatoid arthritis which was diagnosed a few years back and was treated with steroids. On peripheral smear examination, the total WBC count of the patient was 114,000/cmm (reference range: 4,000–10,000), with 80% lymphoid cells. The hemoglobin of the patient was 10.8 g/dl (reference range: 12.0 – 15.0 g/dl), while the platelet count was 185,000/cmm (reference range: 150,000–400,000/cmm). The lymphoid *Correspondence to: Dr. Pranav Dorwal, Associate Consultant, Department of Pathology and Laboratory Medicine, Medanta The Medicity, Gurgaon 122001, India. E-mail: [email protected] Received 18 November 2014; Revised 25 March 2015; Accepted 20 May 2015 Published online 6 July 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cyto.b.21254
CLL WITH CD56 AND CD57 EXPRESSION
FIG. 1. Microphotograph of the peripheral smear showing presence of small cells with scanty to moderate cytoplasm and condensed chromatin. No nucleoli or cleaving seen. A smudge cells is also identified. The morphology was suggestive of chronic lymphoproliferative disorder (1003, oil immersion, Giemsa stained). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
cells were small, with scant to moderate cytoplasm and condensed chromatin. No nucleoli or nuclear clefting was observed. Smudge cells were also identified (Fig. 1). A morphological diagnosis of chronic lymphoproliferative disorder was made and immunophenotyping suggested. Meanwhile, the radiological examination revealed hepatosplenomegaly with presence of multiple abdominal lymph nodes. Multiparametric immunophenotyping was performed on the BD FACSVerse, dual laser, six-color, flow cytometer (BD Biosciences, San Jose, CA). A comprehensive lymphoproliferative disorder panel was put-up comprising of B-cell, T-cell, and NK-cell markers, that included CD19 (APC-H7), CD20 (PerCP Cy5.5), CD10 (APC), CD5 (PE-Cy7), CD23 (PE), FMC7 (FITC), CD22 (PE), CD200 (PerCP Cy5.5), CD103 (FITC), CD38 (APC), CD4 (FITC), CD8 (APC), CD7 (PE), CD3 (PerCP Cy5.5), CD56 (PECy7), CD57 (APC), CD45 (APC-H7), kappa (PE) and lambda (FITC) (BD Biosciences, San Jose, CA). We have recently included CD200 in our panel, after it was reported to be useful in differentiation of mature B-cell neoplasms (7). The tubes that were put were: FMC7/ CD23/CD20/CD5/CD38/CD19, CD103/CD22/CD138/ CD11c/–/CD19, lambda/kappa/CD200/–/CD10/CD19, CD4/CD7/CD3/CD5/CD8/CD45, and CD16/–/CD3/ CD56/CD57/CD45. Two unlabeled tubes containing only the back bone markers (CD19 and CD45) were also put. The BD FACSuite software (v1.0.5.3841) (BD Biosciences, San Jose, CA), was used for acquisition and analysis. The gating was performed using CD19-SSC and CD45-SSC plots. The quadrant markers were put-up using the unlabeled tubes. We have a cut-off of 20% for reporting a marker as positive or negative (8,9). The intensity of expression was categorized as dim, moder-
Cytometry Part B: Clinical Cytometry
349
ate or strong based on the expression compared to the negative control. The analysis revealed a prominent population in the mature lymphocyte region, constituting around 78% of the acquired events. Most of these cells were B cells (CD191), which were gated and analyzed further. These showed the typical phenotype of CLL with the co-expression of CD5 and CD23 along with dim expression of kappa and CD22, and lack of FMC7 expression (Fig. 2). There was dim and partial expression of CD10. These gated cells were also negative CD103. The Matutes’ score was 5 and there was also expression of CD200. CD38 which is a prognostic marker in CLL was also expressed. Interestingly, there was also expression of NK cell associated antigens, i.e., CD56 and CD57. There was no expression of any T cell marker, namely CD4, CD8, or CD3 (surface or cytoplasmic). The bone marrow biopsy showed replacement of marrow by B cells expressing CD20 and being negative for CD3 and Cyclin D1 (Dako, Denmark). The Ki67 was also found to be low (
