ICCS e-Newsletter CSI Winter 2012 Julia Almeida, MD PhD Department of Medicine and Cancer Research Center University of Salamanca Salamanca, Spain e-CSI – History and physical examination • A 77-year-old male with no significant past medical history was studied because of a lymphocytosis detected in a routine blood analysis • Patient was asymptomatic • Physical examination did not revealed any pathological sign (no organomegalies, no skin involvement) e-CSI – Peripheral blood cell counts CBC Normal range WBC: 14.6 x 109/l (4.5 – 10.8) RBC: 4.35 x 1012/l (4.0 – 5.4) Hgb: 13.0 g/dl (12.0 – 18.0) Hct: 38.3 % (35.0 – 52.0) MCV: 88.1 fl (80.0 – 99.0) MCH: 29.9 pg (27.0 – 32.0) MCHC: 33.9 g/dl (31.5 – 36.0) RDW: 14.3% (10.5 – 14.5) Plts: 346 x 109/l (150 – 450) e-CSI – CBC differential CBC differential (PB) % from WBC Absolute numbers (x109/l) Reference range (Absolute #) Neutrophils 27.2 3.97 1.4 - 6.5 x 109/l Monocytes 3.7 0.54 0.3 – 0.9 x 109/l Lymphocytes 67.8 9.90 1.2 – 3.5 x 109/l 1 0.15 0 – 0.5 x 109/l 0.3 0.04 0 – 0.1 x 109/l Eosinophils Basophils PB: Peripheral blood e-CSI – Biochemical parameters Parameter Value Normal range B2 microglobulin (mg/dl) 1.0 <2.5 mg/l LDH (IU/l) 340 < 460 IU/l e-CSI – Work-up and evaluation • Peripheral Blood in EDTA was received for evaluation of lymphocytosis • Flow cytometric immunophenotyping was performed on this sample, and the results from selected multiple-stained tubes are provided for review: e-CSI – Flow cytometric (FCM) studies Data acquisition was performed in a FACSCanto II (BDB); data analysis was done with the INFINICYT software (Cytognos SL) Sequential FCM strategy and combinations of fluorochrome MAb used: Step 1 (screening tube) Step 2 (T-cell clonality study) Step 3 (T-cell CLPD panel) Pac.B Pac.O FITC PE CD45 - CD8 CD56 Anti-sIgk Anti-sIgl PerCPCy5.5 PECY7 APC APCH7 CD4 CD19 CD20 CD3 - CD4 - TCR-Vb8 + TCR-Vb13.6 TCR-Vb13.1 + TCR-Vb13.6 CD3 - CD8 - CD4 CD4 CD4 CD4 CD4 CD45 CD45 CD45 CD45 CD45 CD7 CD27 CD5 CD57 cytPERF CD26 CD197 CD25 CD30 cytGRZ CD3 CD3 CD3 CD3 CD3 CD2 CD45RO HLADR CD16 CD28 CD45RA cytTCL1 CD11c CD94 CD8 CD8 CD8 CD8 CD8 cytPERF: cytoplasmic perforine; cytGRZ: cytoplasmic granzyme B e-CSI – Flow cytometric (FCM) studies Step 1: screening tube Exclusion of debris Display only CD3+ T cells Selection of T cells CD3+ gated T cells CD4+ gated T cells Refining selection of T cells CD4+ gated T cells CD4+ gated T cells 94% CD56+/CD4+ T cells 94% CD4+ T cells (CD4/CD8 ratio: 15.5) Most CD4+ T cells (94%) are CD56+. In addition, they show partial expression of CD8dim and higher SSC values in comparison to CD56- CD4+ T cells These cells represent around 67% of total leukocytes e-CSI – Flow cytometric (FCM) studies Step 1: screening tube Conclusion The lymphocytosis is at expense of CD4+ T cells showing cytotoxic-related markers: expression of CD56, partial expression of CD8dim and high SSC values (67% of all WBC; 9.78 x 109 cells/l) Are these expanded cells clonal? e-CSI – Flow cytometric (FCM) studies Step 2: assessment of T-cell clonality CD3+ live gate CD3+ live gate Selection of T cells CD3+ gated T cells Display only CD3+ T cells Refining selection of T cells Selection of CD4+ T cells CD4+ gated T cells Around 93% of CD4+ T cells express the same TCR-Vbeta region (TCR-Vb13.1+) This specific tube has been selected from the total panel of the TCR Vbeta Kit IOTest Beta Mark IM3497, which includes a total of 24 MAb against different TCR-Vb regions in a 8-tube format e-CSI – Flow cytometric (FCM) studies Step 2: assessment of T-cell clonality Conclusion YES, the expanded CD4+ T-cells are clonal, as they express the same TCR-Vbeta region assessed by FCM (TCR-Vb13.1+) e-CSI – Flow cytometric (FCM) studies Step 3: phenotypic characterization After applying the same gating strategy as previously shown to identify CD4+ T cells, then we proceed to characterize them: Step 3: T-cell CLPD panel TUBE1 Normal residual CD4+ T cells Pac.B Pac.O FITC PE PerCPCy5.5 PECY7 APC APCH7 CD4 CD45 CD7 CD26 CD3 CD2 CD28 CD8 Clonal CD4+ T cells Clonal CD4+ T cells are mostly CD7-, CD26- and CD28- and CD2hi e-CSI – Flow cytometric (FCM) studies Step 3: phenotypic characterization After applying the same gating strategy as previously shown to identify CD4+ T cells, then we proceed to characterize them: Step 3: T-cell CLPD panel TUBE2 Normal residual CD4+ T cells Pac.B Pac.O FITC PE PerCPCy5.5 PECY7 APC APCH7 CD4 CD45 CD27 CD197 CD3 CD45RO CD45RA CD8 Clonal CD4+ T cells Clonal CD4+ T cells show a typical phenotype of effector cells: CD45RA+ / CD197 (CCR7)- / CD27- / CD45RO-/+dim e-CSI – Flow cytometric (FCM) studies Step 3: phenotypic characterization After applying the same gating strategy as previously shown to identify CD4+ T cells, then we proceed to characterize them: Step 3: T-cell CLPD panel TUBE3 Normal residual CD4+ T cells Pac.B Pac.O FITC PE PerCPCy5.5 PECY7 APC APCH7 CD4 CD45 CD5 CD25 CD3 HLADR cytTCL1 CD8 Clonal CD4+ T cells Clonal CD4+ T cells are CD5+, CD8-/dim , cytTCL1- and HLADR+ heterogeneous e-CSI – Flow cytometric (FCM) studies Step 3: phenotypic characterization After applying the same gating strategy as previously shown to identify CD4+ T cells, then we proceed to characterize them: Step 3: T-cell CLPD panel TUBE4 Normal residual (+some clonal) CD4+ T cells Pac.B Pac.O FITC PE PerCPCy5.5 PECY7 APC APCH7 CD4 CD45 CD57 CD30 CD3 - CD11c CD8 Clonal CD4+ T cells 85% of total CD4+ T cells are CD57+. All CD4+ T cells are CD11c- and CD30- e-CSI – Flow cytometric (FCM) studies Step 3: phenotypic characterization After applying the same gating strategy as previously shown to identify CD4+ T cells, then we proceed to characterize them: Step 3: T-cell CLPD panel TUBE5 Pac.B Pac.O FITC PE PerCPCy5.5 PECY7 APC APCH7 CD4 CD45 cytPERF cytGRZ CD3 CD16 CD94 CD8 Clonal CD4+ T cells Normal residual CD4+ T cells Clonal CD4+ T cells express Perforine and Granzyme B at the cytoplasmic level and are mostly CD94- and CD16- Large Granular Lymphocytosis / Leukemia Large granular lymphocyte (LGL) leukemia is a wellrecognized disorder of clonal mature CD8+ T lymphocytes or less frequently natural killer cells; in addition, it has recently been shown that clonal LGL lymphocytosis / leukemia may also derive from CD4+ LGL T cells TCRab+/CD4+ Large Granular Lymphocytosis / Leukemia Clinical characteristics • These cases usually display an indolent clinical course – although rare cases associated with aggressive disease have also been reported – associated with a significantly lower frequency of cytopenias than CD8+ LGL leukemias • Accordingly, diagnosis is usually made from a lymphocytosis detected in a routine blood analysis (>80%) • However, these patients frequently (30%) show associated neoplasias (particularly B-cell chronic leukemias/lymphomas), so clinical outcome is determined by the associated tumor Lima et al, Am J Pathol 2003 TCRab+/CD4+ Large Granular Lymphocytosis / Leukemia Phenotypic characteristics of clonal cells T-cell related antigens: CD3+ TCRab+ CD4++ CD8-/+ CD5+ CD7-/+ CD2++ NK/cytotoxic-cell associated (Nka) markers: CD56+ CD57+ cyGranzyme B+ cyPerforine + CD11b-/+ CD11cCD16- CD94CD161- CD158aNKB1- Cytokine-receptors and activation-associated markers: CD25- CD122- CD38- HLADR+ CD28CD26- CD27CD62L- Maturation-associated antigens: CD197 (CCR7) - CD45RA+ CD45RO+ CD4+/NKa+/CD8-/+dim T cells display relatively high FSC/SSC values and frequent dim reactivity for CD8, and show a phenotype of activated (CD7-/dim/CD2h/HLADR+) peripheral memory or effector (CD26-/CD27/CD28-/CCR7- with frequent coexpression of CD45RA and RO) cytotoxic (usually CD57+/CD56+ and granzyme B + /perforine + ) T cells in the absence of other Nka markers (i.e. CD16, CD94, CD161) Lima et al, Am J Pathol 2003 TCRab+/CD4+ Large Granular Lymphocytosis / Leukemia Analysis of the TCR-Vb repertoire by immunophenotype 45 Percentage of cases 40 Normal CD4+ T cells 35 30 Clonal CD4+ LGL T cells 25 20 15 10 5 vb23.1 vb22.1 vb21.3 vb20 vb18.1 vb17.1 vb16.1 vb14.1 vb13.6 vb13.1 vb12.2 vb11 vb9.1 vb8.1 vb7.1 vb6.7 vb6.1 vb5.3 vb5.2 vb5.1 vb3.1 vb2.1 vb1 0 TCRab+/CD4+ Large Granular Lymphocytosis / Leukemia have a restricted TCRVb repertoire with a preferential usage of a few TCR-Vb families; notably, in more than 40% of cases clonal cells are TCR-Vb 13.1+ Lima et al, Am J Pathol 2003 TCRab+/CD4+ Large Granular Lymphocytosis / Leukemia In addition to the restricted TCR-Vb repertoire, other evidences strongly support the fact of the existence of a common antigen-driven origin There is a clear association between the TCR-Vb repertoire and the HLA genotype: all TCR-Vb13.1+ cases are HLADR*0701 HLADR7/TCRVb13.1+ cases show a highly homogeneous and strikingly similar TCR (high homology in their CDR3) Garrido et al, Blood 2007 ¿What is the nature of the antigen? Clonal CD4+ LGL T cells show functional response to hCMV Rodriguez-Caballero et al, Blood 2008 TCRab+/CD4+ Large Granular Lymphocytosis / Leukemia Summary - Patients with CD4+/NKa+/CD8-/+dim T-LGL lymphocytosis / leukemia show an indolent course of the disease; however, they frequently have a second neoplasia and clinical outcome is usually determined by the associated tumor - Clonal CD4+/NKa+/CD8-/+dim T-cells show a typically activated, cytotoxic phenotype of effector T-LGL cells and a restricted TCR-Vb repertoire, with a preferential usage of a few TCR-Vb families - TCR-Vb13.1+ patients display a common HLA-DRB1*0701 genotype and clonal cells express identical motifs in their CDR3-TCR-V sequences, supporting a common antigen-driven origin - Clonal T cells usually display response to hCMV, suggesting the potential involvement of hCMV in the ontogeny of CD4+/NKa+/CD8-/+dim T-LGL lymphocytosis / leukemia TCRab+/CD4+ Large Granular Lymphocytosis / Leukemia References 1. Lima M, Almeida J, Dos Anjos Teixeira M, et al. TCRalphabeta+/CD4+ large granular lymphocytosis: a new clonal T-cell lymphoproliferative disorder. Am J Pathol. 2003 Aug;163(2):763-71. 2. Garrido P, Ruiz-Cabello F, Bárcena P, et al. Monoclonal TCR-Vbeta13.1+/CD4+/NKa+/CD8-/+dim T-LGL lymphocytosis: evidence for an antigen-driven chronic T-cell stimulation origin. Blood. 2007 Jun 1;109(11):4890-8. 3. Ghia P, Prato G, Stella S, Scielzo C, Geuna M, Caligaris-Cappio F. Age-dependent accumulation of monoclonal CD4+CD8+ double positive T lymphocytes in the peripheral blood of the elderly. Br J Haematol. 2007 Dec;139(5):780-90. 4. Rodríguez-Caballero A, García-Montero AC, Bárcena P, et al. Expanded cells in monoclonal TCRalphabeta+/CD4+/NKa+/CD8-/+dim T-LGL lymphocytosis recognize hCMV antigens. Blood. 2008 Dec 1;112(12):4609-16. 5. Olteanu H, Karandikar NJ, Eshoa C, Kroft SH. Laboratory findings in CD4(+) large granular lymphocytoses. Int J Lab Hematol. 2010 Feb;32(1 Pt 1):e9-16. 6. Sáez-Borderías A, Romo N, Ruiz-Cabello F, et al. Natural killer cell receptor expression reflects the role of human cytomegalovirus in the pathogenesis of a subset of CD4+ T-cell large granular lymphocytosis. Hum Immunol. 2011 Mar;72(3):226-8.