Acta haetnat. 54: 306-311 (1975)
Acute Lymphoblastic Crisis in a Patient with Chronic Lymphatic Leukemia A. K lajman , A. Y aretzky , J. M anor and Z. Steiner Medical Department B and Immunological Laboratory, Meir Hospital, Kfar Saba, and Tel Aviv University Medical School, Tel Aviv
Key Words. B lymphocytes • Immunofluorescence • Lymphatic leukemia • Lym phoblastic crisis • Null cells • T lymphocytes Abstract. A case of chronic lymphatic leukemia terminating in a lymphoblastic crisis is described. The small lymphocytes were demonstrated to be B cells, they car ried immunoglobulins on their surface and formed EAC rosettes. The lymphoblasts had no immunoglobulins on their surface and only 18°/o of them formed EAC ro settes, none formed E rosettes. The lymphoblasts could be either immature B cells or Null cells.
Chronic lymphatic leukemia is rarely complicated by acute lympho blastic crisis. Acute lymphoblastic leukemia was reported during the course of chronic lymphatic leukemia in only 4 patients [1-3] and it has been suggested that in such cases there are two distinct and unrelated diseases [ 1].
This report describes a patient with B cell chronic lymphatic leukemia who died in acute lymphoblastic crisis.
A 58-year-old married woman was admitted to the hospital because of weakness and low-grade fever of 3 weeks’ duration. 15 years previously chronic lymphatic leukemia was diagnosed. She received no treatment, and was followed up in the out patient department. In the following years the number of leukocytes increased from 20,000 to 100,000 with 70-90% of the cells being small lymphocytes, with a few prelymphocytes. No blasts were observed. On admission, the physical examination
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Case Report
K lajman/Y aretzky/M anor/S teiner
307
revealed a well-nourished woman. There was widespread lymphadenopathy. The liv er was palpable 10 cm below the right cortal margin and the spleen 6 cm below the left border. Hemoglobin 11.0 g°/o. WBC 110,000 «1, with 38°/o mature small lymphocytes and 54°/o blast cells, Platelets 43,000 «1. The liver tests were normal. The bone marrow examinations on the day of admission revealed a heavy infiltration with lympho blasts which constituted 80°/o of the nucleated cells and 10% of the cells were small mature lymphocytes. The lymphoblasts (fig. 1) were large cells, 13—15,«m in diame ter with large vesicular nuclei and one or two nucleoli, the cytoplasm was often abundant and strongly basophilic. The diagnosis was made of acute lymphoblastic leukemia superimposed on chronic lymphatic leukemia. Treatment consisted of 150 mg of prednisone and 300 mg of allopurinol daily with weekly intravenous injections of 2 mg of vincris tine. After the fourth injection of vincristine, she suddenly developed paresis of both legs accompanied by severe paresthesias. She died 5 days later from gram-negative sepsis complicating a severe urinary tract infection.
Two ml of heparinized blood were mixed with an equal volume of physiological saline and carefully layered upon 3 ml Lymphoprep (Nyegaard & Co., Oslo, Nor way) in 12-ml test tubes. Centrifugation was performed for 30 min at room temper ature at exactly 400 g at the interface between blood and Lymphoprep [4], This re sulted in a band at the interface consisting of lymphoblasts, small lymphocytes and some monocytes. These cells were harvested with a Pasteur pipette and were washed 3 times with Hanks’ balanced salt solution (HBSS). The fractionation of lymphocy tic cells was done on a discontinuous albumin gradient [5]. The cell suspension was centrifuged at 4°C at 400 g for 10 min. The packed cells were resuspended in 9 parts of 33% bovine albumin solution in HBSS. One ml of the cell mixture was placed into the bottom of centrifuge tubes and carefully overlayered with 1.0-ml quantities of 29, 26, 23, and 0.5 ml of 10% albumin solutions. Centrifugation was carried out at 4 °C at 20,000 g for 30 min in a Sorval RC2-B centrifuge using HB4 rotor. Four discrete bands of cells, which were formed at the interface between al bumin solutions, were carefully harvested with a Pasteur pipette. In the uppermost A band 96% of the cells were blast cells; in the lowest D band 98% were small lym phocytes, and in the two intermediate bands both populations of cells were found. Blast cells from A band and lymphocytes from D band were tested separately for the presence of immunoglobulins on their surface and for the formation of E and EAC rosettes. The direct immunofluorescent method was employed for the study of membra ne-bound immunoglobulins [6], Fluorescein isothiocyanate-conjugated antiserum to human IgG, IgM and IgA (Hyland Laboratories) was used in the final dilution of 1:4. 500 lymphoid cells were counted.
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Methods
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K lajman/Y aretzky/M anor/Steiner
E and EAC rosettes were prepared with sheep red cells (SRC) using the method of Stjernsard el at. [7], with some modifications. E rosettes: SRC were stored in Alsever’s solution at 4 °C and used within the week of bleeding. Before use, the cells were washed twice and adjusted to a l°/o sus pension in HBSS. 0.25 ml (about 10°) lymphocytes were mixed with 0.25 of SRC and incubated at 37 °C for 15 min. The mixed cell suspension was spun at 200 g for 5 min and then incubated at 4 °C for 2 h. Most of the supernatant was sucked off and the pellet was resuspended by gentle rotation of the test tube. One drop of the cell suspension was mounted onto a glass slide covered by a coverslip and sealed with nail polish. EAC rosettes: 5 ml of a 5%> solution of SRC were incubated for 30 min at 37 °C with 5 ml amboceptor (rabbit anti-SRC) diluted 1:2,000 in PBS. The cells were washed 3 times and resuspended in 5 ml of PBS. 5 ml of human complement (fresh human serum) diluted 1:20 in PBS were added and the suspension was incubated for 30 min at 37 °C. The cells were washed 3 times and adjusted to 1%. Peripheral blood leukocytes and bone marrow cells were stained for periodic acid-Schiff (PAS) reaction [8], a-naphthyl-acetate esterase [9], naphthol-AS-Dchloracetate esterase [9], peroxidase [10] and acid and alkaline phosphatases [11].
Results Immunological studies are summarized in table I. 94% of small lym phocytes and none of the blast cells stained positively for surface immu noglobulins. 5.6% of small lymphocytes but no blast cells formed sponta neous E rosettes with SRBC. 42% of small lymphocytes (fig. 2) and 18% of blast cells formed EAC rosettes (fig. 3). Cytochemical studies: 20% of the blasts and all the small lymphocytes gave positive PAS reaction. Staining for peroxidase, acid and alkaline phosphatases, naphthol-AS-D-chloracetate esterase was negative in the blasts and in the small lymphocytes, while a-naphthyl-acetate esterase was weakly positive.
Surface Ig
Blasts, % Lymphocytes, %
0 94
Rosettes E
EAC
0 5.6
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Table /. The percentage of blasts and small lymphocytes which formed E and EAC rosettes and had Ig on their surface
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Fig. 1. Lymphoblasts in the bone marrow. May-Griinwald-Giemsa stain. X 1,000. Fig. 2. Small mature lymphocyte forming EAC rosette. Phase contrast microsco py. X 1,000. Fig. 3. Lymphoblast forming EAC rosette. Phase contrast microscopy. X 1,000.
The occurrence of acute lymphoblastic leukemia complicating chronic lymphatic leukemia is extremely rare and we could find only 4 well-docu mented cases in the literature [1-3]. Of special interest are the two cases reported by B rouet et al. [3], the lymphoblasts carried on their surface the same monoclonal IgM as the small lymphocytes. In both types of cells the surface IgM was proved to be synthesized in vitro. Moreover, in one case the IgM with anti-IgG antibody activity was found on the surface of small lymphocytes and lymphoblasts.
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Discussion
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Klajman/ Y aretzky/M anor/Steiner
Our patient was known to have been suffering from chronic lymphatic leukemia for 15 years before the onset of acute lymphoblastic leukemia. She received no treatment for the chronic leukemia. The small lympho cytes showed immunoglobulins on their surface and formed EAC rosettes characteristics of B lymphocytes. The blast cells had the morphology of lymphoblasts. Their positive PAS staining, negative peroxidase, acid and alkaline phosphatases and negative naphthyl-AS-D-chloroacetate esterase reactions were diagnostic of lymphoblasts. We could not demonstrate any immunoglobulins on their surface, but 18% of the blast cells formed EAC rosettes indicating the presence of receptor sites for C3. The lymphoblasts could be either primitive B blasts not yet mature enough to have devel oped immunoglobulins on their surface, although some of them had al ready receptors for C3, or Null lymphoblasts. Null lymphocytes are be lieved to form EAC rosettes, but they do not carry immunoglobulins on their surface. Ross et al. [12] reported that there was not always a good correlation between the presence of surface immunoglobulins and the ability of human leukemic lymphocytes to form EAC rosettes. Interest ingly enough, almost all the cases of acute lymphatic leukemia have been reported to be of T lymphocyte origin [13-15], the only exceptions being the case of G ajl P ecjalska et al. [16], who had no previous history of chronic lymphatic leukemia, and the two patients described by B rouet et al. [3], who supervened on B cell chronic lymphatic leukemia. It is there fore impossible to state whether in our case the small lymphocytes of chronic lymphatic leukemia and the lymphoblasts were derived from the same clone of cells, were two completely unrelated phenomena, or were induced by a common pathogenic factor.
1 Me P hedran, P. and H eath , C. W.: Acute leukemia occurring during chronic lymphatic leukemia. Blood 35: 7-12 (1970). 2 Boggs , D. R.; W introbe , M. M., and C artwright , G. E.: The acute leukemias; analysis of 322 cases and review of literature. Medicine 41: 163-225 (1962). 3 Brouet , J. C.; P roud ’H omme, J. L.; S eligmann , M., and Bernard, J.: Blast cells with monoclonal surface immunoglobulin in two cases of acute blast crisis su pervening on chronic lymphatic leukemia. Br. med. J. iv: 23-24 (1973). 4 B6 yum , A.: Separation of leukocytes from blood and bone marrow. Scand. J. clin. Lab. Invest., suppl. 97, pp. 31-50 (1968).
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References
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311
Prof. A. K lajman, Medical Department B, Meir Hospital, Kfar Saba (Israel)
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5 R aidt, D. J.; M ishell , R. L, and D utton , R. W.: Cellular events in the immune response. J. exp. Med. 128: 681-688 (1968). 6 Sen L. and Borella L.: Expression of cell surface markers on T and B lym phocytes after long term chemotherapy of acute leukemia. Cell Immunol. 9: 84-89 (1973). 7 Stjernsard Y.; J ondal M.; V anky F.; W igzell H. and Sealy R.: Lympho penia and change in distribution of human B and T lymphocytes in peripheral blood. Lancet i: 1352-1356 (1972). 8 H ayhoe, F. G. Y.; Q uaglino , D., and F lemans, R. Y.: Consecutive use of Romanowsky and periodic-acid-Schiff techniques in study of blood and bone mar row cells. Br. J. Haemat. 6: 23 (1960). 9 R ozenszajn, L.; L eibovich , M.; Shoham, D„ and E pstein , Y.: The esterase ac tivity in megaloblasts, leukemic and normal hemopoietic cells. Br. J. Haemat. 14: 105-110 (1968). 10 O sgood, E. and A shworth , C. M.: In C artwright Diagnostic laboratory hae matology; 2nd ed., p. 91 (Grune & Stratton, 1958). 11 R ozenszajn, L.; M arshak, G., and E frati, P.: Acid phosphatase activity in nor mal human blood and bone marrow cells, a demonstration of azo dye method. Acta haemat. 30: 310-316 (1963). 12 Ross, G. D.; R abeluno , E. M.; P olley , M. Y., and G rey , H. M.: Combined studies of complement receptor and surface immunoglobulin-bearing cells and sheep erythrocyte rosette forming cells in normal and leukemic human lympho cytes. J. clin. Invest. 52: 377-385 (1973). 13 Borella, L. and Sen , L.: T-cell surface markers on lymphoblasts from acute lymphatic leukemia. J. Immun. I l l : 1257-1260 (1973). 14 C hin , A. H.; Saiki, Y. H.; T rujillo , Y. M., and W illiams, R. C.: Peripheral blood T and B lymphocytes in patients with lymphoma and acute leukemia. Clin. Immunol. Immunopath. 1: 499-510 (1973). 15 K ersey, J. H.; Sabad, A., and G ajl P ecjalska, K. J.: Acute lymphoblastic leuke mia cells with T lymphocyte markers. Science 182: 1355-1357 (1973). 16 G ajl P ecjalska, K. J.; Bloomfield , C. D.; N esbit, M. E., and K ersey , Y. H.: B-cell markers on lymphoblasts in acute lymphoblastic leukemia. Clin. exp. Im munol. 17: 561-569 (1974).
Acute Lymphoblastic Crisis in a Patient with Chronic Lymphatic Leukemia A. K lajman , A. Y aretzky , J. M anor and Z. Steiner Medical Department B and Immunological Laboratory, Meir Hospital, Kfar Saba, and Tel Aviv University Medical School, Tel Aviv
Key Words. B lymphocytes • Immunofluorescence • Lymphatic leukemia • Lym phoblastic crisis • Null cells • T lymphocytes Abstract. A case of chronic lymphatic leukemia terminating in a lymphoblastic crisis is described. The small lymphocytes were demonstrated to be B cells, they car ried immunoglobulins on their surface and formed EAC rosettes. The lymphoblasts had no immunoglobulins on their surface and only 18°/o of them formed EAC ro settes, none formed E rosettes. The lymphoblasts could be either immature B cells or Null cells.
Chronic lymphatic leukemia is rarely complicated by acute lympho blastic crisis. Acute lymphoblastic leukemia was reported during the course of chronic lymphatic leukemia in only 4 patients [1-3] and it has been suggested that in such cases there are two distinct and unrelated diseases [ 1].
This report describes a patient with B cell chronic lymphatic leukemia who died in acute lymphoblastic crisis.
A 58-year-old married woman was admitted to the hospital because of weakness and low-grade fever of 3 weeks’ duration. 15 years previously chronic lymphatic leukemia was diagnosed. She received no treatment, and was followed up in the out patient department. In the following years the number of leukocytes increased from 20,000 to 100,000 with 70-90% of the cells being small lymphocytes, with a few prelymphocytes. No blasts were observed. On admission, the physical examination
Downloaded by: King's College London 137.73.144.138 - 1/21/2019 2:34:20 AM
Case Report
K lajman/Y aretzky/M anor/S teiner
307
revealed a well-nourished woman. There was widespread lymphadenopathy. The liv er was palpable 10 cm below the right cortal margin and the spleen 6 cm below the left border. Hemoglobin 11.0 g°/o. WBC 110,000 «1, with 38°/o mature small lymphocytes and 54°/o blast cells, Platelets 43,000 «1. The liver tests were normal. The bone marrow examinations on the day of admission revealed a heavy infiltration with lympho blasts which constituted 80°/o of the nucleated cells and 10% of the cells were small mature lymphocytes. The lymphoblasts (fig. 1) were large cells, 13—15,«m in diame ter with large vesicular nuclei and one or two nucleoli, the cytoplasm was often abundant and strongly basophilic. The diagnosis was made of acute lymphoblastic leukemia superimposed on chronic lymphatic leukemia. Treatment consisted of 150 mg of prednisone and 300 mg of allopurinol daily with weekly intravenous injections of 2 mg of vincris tine. After the fourth injection of vincristine, she suddenly developed paresis of both legs accompanied by severe paresthesias. She died 5 days later from gram-negative sepsis complicating a severe urinary tract infection.
Two ml of heparinized blood were mixed with an equal volume of physiological saline and carefully layered upon 3 ml Lymphoprep (Nyegaard & Co., Oslo, Nor way) in 12-ml test tubes. Centrifugation was performed for 30 min at room temper ature at exactly 400 g at the interface between blood and Lymphoprep [4], This re sulted in a band at the interface consisting of lymphoblasts, small lymphocytes and some monocytes. These cells were harvested with a Pasteur pipette and were washed 3 times with Hanks’ balanced salt solution (HBSS). The fractionation of lymphocy tic cells was done on a discontinuous albumin gradient [5]. The cell suspension was centrifuged at 4°C at 400 g for 10 min. The packed cells were resuspended in 9 parts of 33% bovine albumin solution in HBSS. One ml of the cell mixture was placed into the bottom of centrifuge tubes and carefully overlayered with 1.0-ml quantities of 29, 26, 23, and 0.5 ml of 10% albumin solutions. Centrifugation was carried out at 4 °C at 20,000 g for 30 min in a Sorval RC2-B centrifuge using HB4 rotor. Four discrete bands of cells, which were formed at the interface between al bumin solutions, were carefully harvested with a Pasteur pipette. In the uppermost A band 96% of the cells were blast cells; in the lowest D band 98% were small lym phocytes, and in the two intermediate bands both populations of cells were found. Blast cells from A band and lymphocytes from D band were tested separately for the presence of immunoglobulins on their surface and for the formation of E and EAC rosettes. The direct immunofluorescent method was employed for the study of membra ne-bound immunoglobulins [6], Fluorescein isothiocyanate-conjugated antiserum to human IgG, IgM and IgA (Hyland Laboratories) was used in the final dilution of 1:4. 500 lymphoid cells were counted.
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Methods
308
K lajman/Y aretzky/M anor/Steiner
E and EAC rosettes were prepared with sheep red cells (SRC) using the method of Stjernsard el at. [7], with some modifications. E rosettes: SRC were stored in Alsever’s solution at 4 °C and used within the week of bleeding. Before use, the cells were washed twice and adjusted to a l°/o sus pension in HBSS. 0.25 ml (about 10°) lymphocytes were mixed with 0.25 of SRC and incubated at 37 °C for 15 min. The mixed cell suspension was spun at 200 g for 5 min and then incubated at 4 °C for 2 h. Most of the supernatant was sucked off and the pellet was resuspended by gentle rotation of the test tube. One drop of the cell suspension was mounted onto a glass slide covered by a coverslip and sealed with nail polish. EAC rosettes: 5 ml of a 5%> solution of SRC were incubated for 30 min at 37 °C with 5 ml amboceptor (rabbit anti-SRC) diluted 1:2,000 in PBS. The cells were washed 3 times and resuspended in 5 ml of PBS. 5 ml of human complement (fresh human serum) diluted 1:20 in PBS were added and the suspension was incubated for 30 min at 37 °C. The cells were washed 3 times and adjusted to 1%. Peripheral blood leukocytes and bone marrow cells were stained for periodic acid-Schiff (PAS) reaction [8], a-naphthyl-acetate esterase [9], naphthol-AS-Dchloracetate esterase [9], peroxidase [10] and acid and alkaline phosphatases [11].
Results Immunological studies are summarized in table I. 94% of small lym phocytes and none of the blast cells stained positively for surface immu noglobulins. 5.6% of small lymphocytes but no blast cells formed sponta neous E rosettes with SRBC. 42% of small lymphocytes (fig. 2) and 18% of blast cells formed EAC rosettes (fig. 3). Cytochemical studies: 20% of the blasts and all the small lymphocytes gave positive PAS reaction. Staining for peroxidase, acid and alkaline phosphatases, naphthol-AS-D-chloracetate esterase was negative in the blasts and in the small lymphocytes, while a-naphthyl-acetate esterase was weakly positive.
Surface Ig
Blasts, % Lymphocytes, %
0 94
Rosettes E
EAC
0 5.6
18 42 Downloaded by: King's College London 137.73.144.138 - 1/21/2019 2:34:20 AM
Table /. The percentage of blasts and small lymphocytes which formed E and EAC rosettes and had Ig on their surface
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Fig. 1. Lymphoblasts in the bone marrow. May-Griinwald-Giemsa stain. X 1,000. Fig. 2. Small mature lymphocyte forming EAC rosette. Phase contrast microsco py. X 1,000. Fig. 3. Lymphoblast forming EAC rosette. Phase contrast microscopy. X 1,000.
The occurrence of acute lymphoblastic leukemia complicating chronic lymphatic leukemia is extremely rare and we could find only 4 well-docu mented cases in the literature [1-3]. Of special interest are the two cases reported by B rouet et al. [3], the lymphoblasts carried on their surface the same monoclonal IgM as the small lymphocytes. In both types of cells the surface IgM was proved to be synthesized in vitro. Moreover, in one case the IgM with anti-IgG antibody activity was found on the surface of small lymphocytes and lymphoblasts.
Downloaded by: King's College London 137.73.144.138 - 1/21/2019 2:34:20 AM
Discussion
310
Klajman/ Y aretzky/M anor/Steiner
Our patient was known to have been suffering from chronic lymphatic leukemia for 15 years before the onset of acute lymphoblastic leukemia. She received no treatment for the chronic leukemia. The small lympho cytes showed immunoglobulins on their surface and formed EAC rosettes characteristics of B lymphocytes. The blast cells had the morphology of lymphoblasts. Their positive PAS staining, negative peroxidase, acid and alkaline phosphatases and negative naphthyl-AS-D-chloroacetate esterase reactions were diagnostic of lymphoblasts. We could not demonstrate any immunoglobulins on their surface, but 18% of the blast cells formed EAC rosettes indicating the presence of receptor sites for C3. The lymphoblasts could be either primitive B blasts not yet mature enough to have devel oped immunoglobulins on their surface, although some of them had al ready receptors for C3, or Null lymphoblasts. Null lymphocytes are be lieved to form EAC rosettes, but they do not carry immunoglobulins on their surface. Ross et al. [12] reported that there was not always a good correlation between the presence of surface immunoglobulins and the ability of human leukemic lymphocytes to form EAC rosettes. Interest ingly enough, almost all the cases of acute lymphatic leukemia have been reported to be of T lymphocyte origin [13-15], the only exceptions being the case of G ajl P ecjalska et al. [16], who had no previous history of chronic lymphatic leukemia, and the two patients described by B rouet et al. [3], who supervened on B cell chronic lymphatic leukemia. It is there fore impossible to state whether in our case the small lymphocytes of chronic lymphatic leukemia and the lymphoblasts were derived from the same clone of cells, were two completely unrelated phenomena, or were induced by a common pathogenic factor.
1 Me P hedran, P. and H eath , C. W.: Acute leukemia occurring during chronic lymphatic leukemia. Blood 35: 7-12 (1970). 2 Boggs , D. R.; W introbe , M. M., and C artwright , G. E.: The acute leukemias; analysis of 322 cases and review of literature. Medicine 41: 163-225 (1962). 3 Brouet , J. C.; P roud ’H omme, J. L.; S eligmann , M., and Bernard, J.: Blast cells with monoclonal surface immunoglobulin in two cases of acute blast crisis su pervening on chronic lymphatic leukemia. Br. med. J. iv: 23-24 (1973). 4 B6 yum , A.: Separation of leukocytes from blood and bone marrow. Scand. J. clin. Lab. Invest., suppl. 97, pp. 31-50 (1968).
Downloaded by: King's College London 137.73.144.138 - 1/21/2019 2:34:20 AM
References
Lymphoblastic Crisis in Lymphatic Leukemia
311
Prof. A. K lajman, Medical Department B, Meir Hospital, Kfar Saba (Israel)
Downloaded by: King's College London 137.73.144.138 - 1/21/2019 2:34:20 AM
5 R aidt, D. J.; M ishell , R. L, and D utton , R. W.: Cellular events in the immune response. J. exp. Med. 128: 681-688 (1968). 6 Sen L. and Borella L.: Expression of cell surface markers on T and B lym phocytes after long term chemotherapy of acute leukemia. Cell Immunol. 9: 84-89 (1973). 7 Stjernsard Y.; J ondal M.; V anky F.; W igzell H. and Sealy R.: Lympho penia and change in distribution of human B and T lymphocytes in peripheral blood. Lancet i: 1352-1356 (1972). 8 H ayhoe, F. G. Y.; Q uaglino , D., and F lemans, R. Y.: Consecutive use of Romanowsky and periodic-acid-Schiff techniques in study of blood and bone mar row cells. Br. J. Haemat. 6: 23 (1960). 9 R ozenszajn, L.; L eibovich , M.; Shoham, D„ and E pstein , Y.: The esterase ac tivity in megaloblasts, leukemic and normal hemopoietic cells. Br. J. Haemat. 14: 105-110 (1968). 10 O sgood, E. and A shworth , C. M.: In C artwright Diagnostic laboratory hae matology; 2nd ed., p. 91 (Grune & Stratton, 1958). 11 R ozenszajn, L.; M arshak, G., and E frati, P.: Acid phosphatase activity in nor mal human blood and bone marrow cells, a demonstration of azo dye method. Acta haemat. 30: 310-316 (1963). 12 Ross, G. D.; R abeluno , E. M.; P olley , M. Y., and G rey , H. M.: Combined studies of complement receptor and surface immunoglobulin-bearing cells and sheep erythrocyte rosette forming cells in normal and leukemic human lympho cytes. J. clin. Invest. 52: 377-385 (1973). 13 Borella, L. and Sen , L.: T-cell surface markers on lymphoblasts from acute lymphatic leukemia. J. Immun. I l l : 1257-1260 (1973). 14 C hin , A. H.; Saiki, Y. H.; T rujillo , Y. M., and W illiams, R. C.: Peripheral blood T and B lymphocytes in patients with lymphoma and acute leukemia. Clin. Immunol. Immunopath. 1: 499-510 (1973). 15 K ersey, J. H.; Sabad, A., and G ajl P ecjalska, K. J.: Acute lymphoblastic leuke mia cells with T lymphocyte markers. Science 182: 1355-1357 (1973). 16 G ajl P ecjalska, K. J.; Bloomfield , C. D.; N esbit, M. E., and K ersey , Y. H.: B-cell markers on lymphoblasts in acute lymphoblastic leukemia. Clin. exp. Im munol. 17: 561-569 (1974).
