Test Id : LCMS

The testing process begins with a screening panel. The screening 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, acute myeloid leukemia (AML) fluorescence in situ hybridization (FISH) 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 or if blasts and promyelocytes are CD34-negative and HLA-DR-negative.

The triage panel is initially performed to evaluate for monotypic B cells by kappa and lambda immunoglobulin light chain expression, increased numbers of blast cells 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.

This panel, 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 the algorithm to fully characterize a disease state with a charge per unique antibody tested.

If no abnormalities are detected by the initial triage 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, 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 Myeloid Leukemia: Testing Algorithm

-Acute Myeloid Leukemia: Relapsed with Previous Remission Testing Algorithm

-Acute Promyelocytic Leukemia: Guideline to Diagnosis and Follow-up

-Mast Cell Disorder: Diagnostic Algorithm, Bone Marrow

-Acute Leukemias of Ambiguous Lineage Testing Algorithm

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.

This test is appropriate for hematopoietic specimens only. For solid tissue specimens, order LLPT / Leukemia/Lymphoma Immunophenotyping, Flow Cytometry, Tissue.

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 product of conception (POC) specimens. For POC specimens see CMAPC / Chromosomal Microarray, Autopsy, Products of Conception, or Stillbirth.

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.

Specimen must arrive within 4 days of collection.

The following information is required:

1. Pertinent clinical history including reason for testing or clinical indication/morphologic suspicion.

2. Specimen source

3. For spinal fluid specimens: spinal fluid cell and differential counts are required

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: 6 mL

Slides: If possible, include 5 to 10 unstained blood smears 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 < or =4 days/Refrigerated < or =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 < or =4 days/Refrigerated < or =4 days

Specimen Type: Fluid

Sources: Serous effusions, pleural fluid, pericardial fluid, abdominal (peritoneal) fluid

Container/Tube: Body fluid container

Specimen Volume: 20 mL

Collection Instructions:

1. If possible, fluids other than spinal fluid should be anticoagulated with heparin (1 U/mL of fluid).

2. Label specimen with fluid type.

Specimen Stability Information: Refrigerated < or =4 days/Ambient < or =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: Spinal fluid

Container/Tube: Sterile vial

Specimen Volume: 1 to 1.5 mL

Collection Instructions:

1. An original cytospin preparation (preferably unstained) should be included with the spinal fluid specimen so correlative morphologic evaluation can occur.

2.. Label specimen as spinal fluid.

Specimen Stability Information: Refrigerated < or =4 days/Ambient < or =4 days

Additional Information: The volume of fluid necessary to phenotype the lymphocytes or blasts in spinal fluid depends upon the cell count in the specimen. A cell count should be determined and submitted with the specimen. Usually 1 to 1.5 mL of spinal fluid is sufficient. Smaller volumes can be used if there is a high cell count. If cell count is <10 cells/mcL, a larger volume of spinal fluid may be required. When cell counts drop below 5 cells/mcL, the immunophenotypic analysis may not be successful.

• Hematopathology Patient Information
• Bone Marrow Staging for Known or Suspected Malignant Lymphoma Algorithm
• Acute Promyelocytic Leukemia: Guideline to Diagnosis and Follow-up
• Acute Leukemias of Ambiguous Lineage Testing Algorithm
• Acute Myeloid Leukemia: Testing Algorithm
• Acute Myeloid Leukemia: Relapsed with Previous Remission Algorithm
• Mast Cell Disorder: Diagnostic Algorithm, Bone Marrow

1. Hematopathology Patient Information (T676)

2. If not ordering electronically, complete, print, and send 1 of the following forms with the specimen:

-Hematopathology/Cytogenetics Test Request (T726)

-Benign Hematology Test Request (T755)

Blood: 3 mL

Bone marrow: 0.5mL

Spinal fluid: 1 mL

Fluid from serous effusions: 5 mL

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.

The testing process begins with a screening panel. The screening 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, acute myeloid leukemia (AML) fluorescence in situ hybridization (FISH) 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 or if blasts and promyelocytes are CD34-negative and HLA-DR-negative.

The triage panel is initially performed to evaluate for monotypic B cells by kappa and lambda immunoglobulin light chain expression, increased numbers of blast cells 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.

This panel, 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 the algorithm to fully characterize a disease state with a charge per unique antibody tested.

If no abnormalities are detected by the initial triage 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, 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 Myeloid Leukemia: Testing Algorithm

-Acute Myeloid Leukemia: Relapsed with Previous Remission Testing Algorithm

-Acute Promyelocytic Leukemia: Guideline to Diagnosis and Follow-up

-Mast Cell Disorder: Diagnostic Algorithm, Bone Marrow

-Acute Leukemias of Ambiguous Lineage Testing Algorithm

Diagnostic hematopathology has become an increasingly complex subspecialty, particularly with neoplastic disorders of blood and bone marrow. While morphologic assessment of blood smears, bone marrow smears, and tissue sections remains the cornerstone of lymphoma and leukemia diagnosis and classification, immunophenotyping is a very valuable and important complementary tool.

Immunophenotyping hematopoietic specimens can help resolve many differential diagnostic problems posed by the clinical or morphologic features.

This test is appropriate for hematopoietic specimens only.

An interpretive report will be provided.

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 for every case.

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.

Specimens will be initially triaged to determine which, if any, of the immunophenotyping panels should be performed.

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. doi:10.1016/j.leukres.2010.03.020

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. doi:10.1002/cyto.b.21768

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. doi:10.1111/bjh.13303

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. doi:10.1080/10428194.2017.1410885

6. Morice WG, Kimlinger T, Katzmann JA, et al: Flow cytometric assessment of TCR-Vbeta 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. doi:10.1309/3A32-DTVM-H640-M2QA

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. doi:10.1002/cyto.b.21782

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

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, CD117.

(Keren D, McCoy JP, Carey J. Flow Cytometry in Clinical Diagnosis. 4th ed. American Society for Clinical Pathology; 2007; Betters DM: Use of flow cytometry in clinical practice. J Adv Pract Oncol. 2015;6[5]:435-440. doi:10.6004/jadpro.2015.6.5.4)

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• Prospective clients should contact their account representative. For assistance, contact Customer Service.

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.

88184-Flow cytometry; first cell surface, cytoplasmic or nuclear marker x 1

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)