PMC4578553_01
(A) Peripheral blood smear showing example of circulating blasts (100x) (B) Bone marrow aspirate (100x) with many circulating heterogeneous blasts. The majority were medium to large sized with intermediate to fine chromatin with one or more prominent nucleoli and moderate amount of light blue cytoplasm. Some showed azurophilic granules, cytoplasmic blebs and or cytoplasmic vacuolation. Others were smaller with scant cytoplasm, more condensed chromatin and less prominent to inconspicuous nucleoli.
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The differential count showed 13% segmented neutrophils, 48% lymphocytes, 2% monocytes, 1% metamyelocytes, 2% myelocytes, and 34% blasts (Fig. 1A). Others were smaller with scant cytoplasm, more condensed chromatin, and less prominent to inconspicuous nucleoli (Fig. 1B).
Flow cytometric dot plots: B-lymphoblasts cluster in green color gated (K) on CD45 comprises 60% of total expressing CD19, CD34, CD10, cCD79a, HLADR, and partial Tdt with aberrant expression of CD33 and CD13. T-lymphoblast cluster in blue color gated (G) comprise 19% of the total expressing cCD3, CD7, CD5, CD2, and CD1a; lymphocytes gated (E).
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Two distinct populations of blasts were identified on CD45 vs SSC plot (Fig. 2). The immunophenotype of these blasts was consistent with B-lymphoblast. The other immature population comprising approximately 19% of total cells expressed CD45 (moderate) and T-cell markers, including cCD3, CD7, CD5, CD2, and CD1a. This population was negative for surface CD3, TdT, CD34, B, and myeloid markers (Fig. 2).
(A) G-banding karyotype showing 46, XY, t(9;22)(q34;q11.2) [22]. (B) Showing a representative cell from minor clone with 80-88, XXYY, -9[5], t(9;22)(q34;q11.2)[20], -11[6], -13[3], -14[3], -15[2], -18[2], -20[6], -21[3], -22, +der(22) t(9;22)[20][cp20].
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The main clone with 46, XY with reciprocal t(9;22)(q34;q11.2) in 22/42 cells (Fig. 3A). The subclone was a near tetraploid (80-88 chromosomes) with multiple structural and numeric abnormalities, including double Ph+ chromosome (Fig. 3B).
Patterns of BCR/ABL gene rearrangements involving the m-bcr breakpoint (p190 BCR/ABL) as revealed by FISH analysis of interphase-cultured BM nuclei cells showing two different patterns: nuclei with two fusions (typical m-BCR/ABL gene rearrangements) and nuclei with three fusions, including an extra signal corresponding to supernumerary Ph chromosome, in addition to the two fusion signals typical of m-BCR gene rearrangements.
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A second abnormal clone was also detected with a triple fusion pattern (double fusion signal of the minor (m)-BCR/ABL1 rearrangement plus a third extra fusion signal corresponding to the presence of supernumerary Ph chromosome) in 16% of the cells analyzed (Fig. 4).
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