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HelpMayo Test ID HLLFH Hematologic Disorders, Leukemia/Lymphoma; Flow Hold, Varies
Ordering Guidance
For B-cell acute lymphoblastic leukemia minimal residual disease testing in either blood or bone marrow, order BALLM / B-Cell Lymphoblastic Leukemia Monitoring, Minimal Residual Disease Detection, Flow Cytometry, Varies.
For bone marrow specimens being evaluated for possible involvement by a myelodysplastic syndrome (MDS) or a myelodysplastic/myeloproliferative neoplasm (MDS/MPN) including chronic myelomonocytic leukemia (CMML), order MYEFL / Myelodysplastic Syndrome by Flow Cytometry, Bone Marrow.
Bronchoalveolar lavage specimens submitted for evaluation for leukemia or lymphoma are appropriate to send for this test.
This test is not appropriate for and cannot support diagnosis of sarcoidosis, hypersensitivity pneumonitis, interstitial lung diseases, or differentiating between pulmonary tuberculosis and sarcoidosis (requests for CD4/CD8 ratios). Specimens sent for these purposes will be rejected.
This test is not intended for products of conception (POC) specimens. For POC specimens see CMAPC / Chromosomal Microarray, Autopsy, Products of Conception, or Stillbirth.
Additional Testing Requirements
For bone marrow testing, if cytogenetic tests are desired along with this test request, an additional specimen should be submitted. It is important that the specimen be obtained, processed, and transported according to instructions for the other test.
Shipping Instructions
Specimen must arrive within 4 days of collection.
Necessary Information
The following information is required:
1. Pertinent clinical history, including reason for testing or clinical indication/morphologic suspicion
2. Specimen source
3. For tissue specimens:
-Tissue type
-Location
-Pathology/diagnostic report, including the client surgical pathology case number
Specimen Required
Due to specimen stability, spinal fluid is not appropriate for this test.
Submit only 1 of the following specimens:
Specimen Type: Whole blood
Container/Tube:
Preferred: Yellow top (ACD solution A or B)
Acceptable: Lavender top (EDTA) or Green top (sodium heparin)
Specimen Volume: 10 mL
Slides: If possible, include 5- to 10-unstained blood smears, must be labeled with two unique identifiers.
Collection Instructions:
1. Send whole blood specimen in original tube. Do not aliquot.
2. Label specimen as blood.
Specimen Stability Information: Ambient ≤4 days/Refrigerated ≤4 days
Specimen Type: Bone marrow
Container/Tube:
Preferred: Yellow top (ACD solution A or B)
Acceptable: Lavender top (EDTA) or green top (sodium heparin)
Specimen Volume: 1 to 5 mL
Slides: If possible, include 5- to 10-unstained bone marrow aspirate smears, which must be labeled with two unique identifiers
Collection Instructions:
1. Submission of bilateral specimens is not required.
2. Send bone marrow specimen in original tube. Do not aliquot.
3. Label specimen as bone marrow.
Specimen Stability Information: Ambient ≤4 days/Refrigerated ≤4 days
Specimen Type: Fluid
Sources: Serous effusions, pleural, pericardial, or abdominal (peritoneal fluid)
Container/Tube: Body fluid container
Specimen Volume: 20 mL
Collection Instructions:
1. If possible, fluids should be anticoagulated with heparin (1 U/mL of fluid).
2. Label specimen with fluid type.
Specimen Stability Information: Refrigerated/Ambient ≤4 days
Additional Information: The volume of fluid necessary to phenotype the lymphocytes or blasts in serous effusions depends upon the cell count in the specimen. Usually, 20 mL of pleural or peritoneal fluid is sufficient. Smaller volumes can be used if there is a high cell count.
Specimen Type: Tissue
Supplies: Hank's Solution (T132)
Container/Tube: Sterile container with 15 mL of tissue culture medium (eg, Hank's balanced salt solution, RPMI, or equivalent)
Specimen Volume: 5 mm(3) or larger biopsy
Collection Instructions:
1. Send intact specimen (do not mince)
2. Specimen cannot be fixed.
Specimen Stability Information: Ambient ≤4 days/Refrigerated ≤4 days
Useful For
Evaluating lymphocytoses of undetermined etiology
Identifying B- and T-cell lymphoproliferative disorders involving blood and bone marrow
Distinguishing acute lymphoblastic leukemia (ALL) from acute myeloid leukemia (AML)
Immunologic subtyping of acute leukemias
Distinguishing reactive lymphocytes and lymphoid hyperplasia from malignant lymphoma
Distinguishing between malignant lymphoma and acute leukemia
Phenotypic subclassification of B- and T-cell chronic lymphoproliferative disorders, including chronic lymphocytic leukemia, mantle cell lymphoma, and hairy cell leukemia
Recognizing AML with minimal morphologic or cytochemical evidence of differentiation
Recognizing monoclonal plasma cells
This test is not intended for detection of minimal residual disease below 5% blasts.
Additional Tests
| Test ID | Reporting Name | Available Separately | Always Performed |
|---|---|---|---|
| ADD1 | Flow Cytometry, Cell Surface, Addl | No, (Bill Only) | Yes |
| FIRST | Flow Cytometry, Cell Surface, First | No, (Bill Only) | Yes |
Reflex Tests
| Test ID | Reporting Name | Available Separately | Always Performed |
|---|---|---|---|
| FCIMS | Flow Cytometry Interp, 9-15 Markers | No, (Bill Only) | No |
| FCINS | Flow Cytometry Interp,16 or greater | No, (Bill Only) | No |
| FCINT | Flow Cytometry Interp, 2-8 Markers | No, (Bill Only) | No |
| AMLMF | AML, Specified FISH | Yes | No |
Testing Algorithm
This test is designed to delay the start of leukemia/lymphoma immunophenotyping until the preliminary assessment is completed. Specimens are held in the laboratory until noon (12 p.m. Central time) 2 days after the collection date. For testing to be canceled, the client must call 800-533-1710. The testing process will be initiated and fully charged if no notification is received within this time period. To expedite the beginning of testing, call 800-533-1710.
The testing process begins with a screening panel. The panel will be charged based on the number of markers tested (FIRST for first marker, ADD1 for each additional marker). The interpretation will be based on markers tested in increments of 2 to 8, 9 to 15, or 16 and greater. In addition, reflex testing may occur to fully characterize a disease state or clarify any abnormalities from the screening test. Reflex tests will be performed at an additional charge for each marker tested (FIRST if applicable, ADD1 if applicable).
In addition to reflexing flow cytometric panels, AMLF / Acute Myeloid Leukemia (AML), FISH, Varies testing for PML::RARA translocation t(15;17),may be added by the Mayo Clinic pathologist to exclude acute promyelocytic leukemia if there is morphologic suspicion and/or blasts and promyelocytes are CD34 and HLA-DR-negative.
The triage panel is initially performed on peripheral blood, bone marrow, and fluid samples to evaluate for monotypic B cells by kappa and lambda immunoglobulin light chain expression, increased numbers of blasts by CD34 and CD45 expression along with side scatter gating, and increased plasma cells by CD45 expression and side scatter gating. The triage panel also includes antibodies to assess the number of CD3-positive T cells and CD16-positive/CD3-negative natural killer (NK) cells present. This triage panel also determines if there is an increase in the number of T cells that aberrantly coexpress CD16, an immunophenotypic feature of T-cell granular lymphocytic leukemia.
The tissue triage panel is initially performed on tissue specimens to evaluate for monotypic B cells by kappa and lambda immunoglobulin light chain expression, CD5,CD10,CD19,CD20, and CD23. Increased numbers of blasts and plasma cells are identified by CD45 expression along with side scatter gating. The panel can also evaluate T cells with CD3, CD5, and CD7. Additionally, viability is assessed on all tissue specimens using 7-AAD (7-amino actinomycin d) exclusion.
This testing, together with the provided clinical history and morphologic review is used to determine what, if any, additional testing is needed for disease diagnosis or classification. If additional testing is required, it will be added per algorithm to fully characterize a disease state with a charge per unique antibody tested.
If no abnormalities are detected by the initial panel, no further flow cytometric assessment will be performed unless otherwise indicated by specific features of the clinical presentation or prior laboratory results.
In addition to reflexing flow cytometric panels, fluorescence in situ hybridization (FISH), molecular testing or cytochemical stains may be recommended by the Mayo Clinic pathologist to facilitate diagnosis. They will contact the referring provider or pathologist to confirm the addition of these tests.
The following algorithms are available:
-Bone Marrow Staging for Known or Suspected Malignant Lymphoma Algorithm
-Acute Promyelocytic Leukemia: Guideline to Diagnosis and Follow-up
Special Instructions
Method Name
Immunophenotyping
Reporting Name
Heme Leukemia/Lymphoma; Flow Hold VSpecimen Type
VariesSpecimen Minimum Volume
Blood: 3 mL
Bone Marrow: 0.5 mL
Fluid: 5 mL
Tissue: 1 mm(3) or larger biopsy
Specimen Stability Information
| Specimen Type | Temperature | Time | Special Container |
|---|---|---|---|
| Varies | Varies | ||
Reject Due To
| Gross hemolysis | Reject |
| Fixed, paraffin-embedded, or minced tissue | Reject |
Clinical Information
Immunophenotyping hematopoietic specimens can help resolve many differential diagnostic problems posed by the clinical or morphologic features.
Reference Values
An interpretive report will be provided.
Interpretation
This test will be processed as a laboratory consultation. An interpretation of the immunophenotypic findings and correlation with the morphologic features will be provided by a hematopathologist.
Report will include a morphologic description, a summary of the procedure, the percent positivity of selected antigens, and an interpretive conclusion based on the correlation of the clinical history with the morphologic features and immunophenotypic results.
Cautions
Specimens will be initially screened to determine which, if any, of the immunophenotyping panels should be performed.
Viability will be assessed in all tissue specimens. Cases in which the viability is low (<50%) are prone to false-negative results and, therefore, must be interpreted with caution. In cases with viability less than 50%, testing will be attempted but may not be interpretable. Fine-needle aspiration and small biopsy specimens have a higher frequency of low cell counts and poor viability, which may be uninterpretable.
Clinical Reference
1. Jevremovic D, Dronca RS, Morice WG, et al. CD5+ B-cell lymphoproliferative disorders: Beyond chronic lymphocytic leukemia and mantle cell lymphoma. Leuk Res. 2010;34(9):1235-1238
2. Hanson CA. Acute leukemias and myelodysplastic syndromes. In: McClatchey KD, ed. Clinical Laboratory Medicine. Williams and Wilkins; 1994:939-969
3. Jevremovic D, Olteanu H. Flow cytometry applications in the diagnosis of T/NK-Cell lymphoproliferative disorders. Cytometry B Clin Cytom. 2019;96(2):99-115
4. Rosado FG, Morice WG, He R, Howard MT, Timm M, McPhail ED. Immunophenotypic features by multiparameter flow cytometry can help distinguish low grade B-cell lymphomas with plasmacytic differentiation from plasma cell proliferative disorders with an unrelated clonal B-cell process. Br J Haematol. 2015;169(3):368-376
5. Shi M, Ternus JA, Ketterling RP, et al. Immunophenotypic and laboratory features of t(11;14)(q13;q32)-positive plasma cell neoplasms. Leuk Lymphoma. 2018;59(8):1913-1919
6. Morice WG, Kimlinger T, Katzmann JA, et al. Flow cytometric assessment of TCR-V-beta expression in the evaluation of peripheral blood involvement by T-cell lymphoproliferative disorders: a comparison with conventional T-cell immunophenotyping and molecular genetic techniques. Am J Clin Pathol. 2004;121(3):373-383
7. Shi M, Jevremovic D, Otteson GE, Timm MM, Olteanu H, Horna P. Single antibody detection of T-Cell receptor alpha beta clonality by flow cytometry rapidly identifies mature T-Cell neoplasms and monotypic small CD8-positive subsets of uncertain significance. Cytometry B Clin Cytom. 2020;98(1):99-107
8. Jevremovic D, Olteanu H. Flow cytometry applications in the diagnosis of T/NK-cell lymphoproliferative disorders. Cytometry B Clin Cytom. 2019;96(2):99-115
Method Description
Flow cytometric immunophenotyping of peripheral blood, bone marrow, and body fluids is performed using the following antibodies:
Triage Panel: CD3, CD10, CD16, CD19, CD34, CD45, and kappa and lambda immunoglobulin light chains.
Flow cytometric immunophenotyping of tissues is performed using the following antibodies:
Tissue Panel: CD3, CD5, CD7, CD10, CD19, CD20, CD23, CD45, 7-AAD, and kappa and lambda immunoglobulin light chains.
Possible Additional Panels: Performed per algorithmic approach
-B-cell Panel: CD5, CD11c, CD19, CD20, CD22, CD23, CD38, CD45, CD103, CD200 and kappa and lambda immunoglobulin light chains
-T-cell Panel: CD2, CD3, CD4, CD5, CD7, CD8, CD45, TRBC1, and gamma/delta
-Sezary Panel: CD2, CD3, CD4, CD5, CD7, CD8, CD26, CD45, and TRBC1.
-Killer-cell Immunoglobulin-like Receptor Panel: CD3, CD8, CD16, CD56, CD57, CD94, CD158a, CD158b, CD158e (p70) and NKG2a
Acute Panel: CD2, CD7, CD13, CD15, CD16, CD33, CD34, CD36, CD38, CD45, CD56, CD64, CD117 and HLA-DR
B-cell ALL,: CD10, CD19, CD20, CD22, CD24, CD34, CD38, CD45, CD58, and CD66c
Myeloperoxidase (MPO)/terminal deoxynucleotidyl transferase (TdT) (MPO/TdT) Panel: cytoplasmic CD3, CD13, cytoplasmic CD22, CD34, CD45, cytoplasmic CD79a, nuclear TDT, and cytoplasmic MPO
Plasma Cell Panel: CD19, CD38, CD45, CD138, and cytoplasmic kappa and lambda immunoglobulin light chains
Mast Cell Panel (bone marrow only): CD2, CD25, CD69, and CD117.(Keren P, McCoy JP, Carey J, eds. Flow Cytometry in Clinical Diagnosis. 4th ed. ASCP Press; 2007; Betters DM: Use of flow cytometry in clinical practice. J Adv Pract Oncol. 2015;6[5]:435-440)
Day(s) Performed
Monday through Saturday
Report Available
2 to 4 daysSpecimen Retention Time
Remaining blood/bone marrow: -14 days; Remaining fluid/tissue: -7 daysPerforming Laboratory
Mayo Clinic Laboratories in Rochester
Test Classification
This test was developed using an analyte specific reagent. Its performance characteristics were determined by Mayo Clinic in a manner consistent with CLIA requirements. This test has not been cleared or approved by the US Food and Drug Administration.CPT Code Information
88184-Flow cytometry; first cell surface, cytoplasmic or nuclear marker
88185-Flow cytometry; additional cell surface, cytoplasmic or nuclear marker (each)
88187-Flow Cytometry Interpretation, 2 to 8 Markers (if appropriate)
88188-Flow Cytometry Interpretation, 9 to 15 Markers (if appropriate)
88189-Flow Cytometry Interpretation, 16 or More Markers (if appropriate)
LOINC Code Information
| Test ID | Test Order Name | Order LOINC Value |
|---|---|---|
| HLLFH | Heme Leukemia/Lymphoma; Flow Hold V | In Process |
| Result ID | Test Result Name | Result LOINC Value |
|---|---|---|
| CK075 | Final Diagnosis | 34574-4 |
| CK076 | Special Studies | 30954-2 |
| CK077 | Microscopic Description | 22635-7 |
| CK078 | Flow Cytometry Testing | No LOINC Needed |