Alegretti, Ana Paula

Contin, Luis Carlos Zanandrea

Daudt, Liane Esteves

Farias, Mariela Granero

Pedrazzani, Fabiane Spagnol

Rigoni, Lisandra Della Costa

Revista Brasileira de Hematologia e Hemoterapia

Lume 5.8

rev bras hematol hemoter. 2 0 1 7;3  9(3):274–277www.rbhh.orgRevista Brasileira de Hematologia e HemoterapiaBrazilian Journal of Hematology and HemotherapyCase ReportFlow  cytometry  to  identify  bone-marrow  relapse  inblastic plasmacytoid  dendritic  cell  neoplasm:a case reportMariela Granero Fariasa,∗, Fabiane Spagnol Pedrazzania,Luis  Carlos Zanandrea Contina, Ana Paula Alegretti a,Lisandra  Della Costa Rigonia, Liane Esteves Daudta,ba Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazilb Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazila  r  t  i  c  l  e  i  n  f  oArticle history:Received 29 November 2016Accepted 17 April 2017Available online 16 May 2017cytoplasmic extensions similar to pseudopodia. The cellIntroductionBlastic plasmacytoid dendritic cell neoplasm (BPDCN) is arare acute leukemia subtype characterized by clonal expan-sion of dendritic-lineage cells.1 These cells are identifiedimmunophenotypically by weak CD45 expression and co-expression of the CD4 and CD56 antigens in the absence ofother lineage-specific markers.2,3 Previously known as blasticnatural killer (NK)-cell lymphoma or CD4+/CD56+ hematoder-mic  neoplasm, it is currently classified by the World HealthOrganization (WHO) as a distinct entity, under the acutemyeloid leukemia (AML) and related precursor neoplasmgroup.4Few studies have assessed the incidence of BPDCN inthe general population. The limited existing data suggestan extremely low overall incidence, representing 0.44% ofall hematological malignancies3,5 and 0.7% of cutaneous∗ Corresponding author at: Serviço de Patologia Clínica, Unidade de DiaRamiro Barcelos 2350, 90035-903 Porto Alegre, RS, Brazil.E-mail address: mgfarias@hcpa.edu.br (M.G. Farias).http://dx.doi.org/10.1016/j.bjhh.2017.04.0051516-8484/© 2017 Associação Brasileira de Hematologia, Hemoterapiaopen  access article under the CC BY-NC-ND license (http://creativecomlymphomas.6 BPDCN mostly affects men, with a 3:1 male-to-female ratio, and usually occurs in patients aged 60–70years7,8 although cases have been reported in children andyoung adults.9BPDCN is particularly difficult to diagnose because of itsclinical and biological heterogeneity that overlaps with otherclinical malignancies, and frequent lack of chromosomalabnormalities.5,10 On laboratory testing, the cell morphologycan be misleading, with a pseudolymphocytic appearance,abundant cytoplasm with a low nuclear-cytoplasmic ratio,strong basophilia, and no granulation. Microvacuoles are oftenvisible, possibly representing glycogen compounds inclined toform a “pearl necklace” on the nuclear membrane, as well as11,12gnóstico Personalizado, Hospital de Clínicas de Porto Alegre, Rualineage must be evaluated by flow cytometry immunopheno-typing, which identifies dendritic cells in their three stages ofdifferentiation.10 e Terapia Celular. Published by Elsevier Editora Ltda. This is anmons.org/licenses/by-nc-nd/4.0/).er. 2 0 1 7;3  9(3):274–277 275CtitiCtcweaaCs(tteeidscebcsfealcctaabisoeHaflrCA3ltwFigure 1 – Physical and morphologic features of blasticplasmacytoid dendritic cell neoplasm. Cutaneous lesionson the patient’s abdomen (A); morphology of leukemicblasts in the bone-marrow aspirate smear (B);anatomopathological study showing infiltration by blastrev bras hematol hemotA recent study showed that, according to their CD34 andD117 expressions, dendritic cells can be categorized intohree maturational stages: (1) in BPDCN, CD34 is expressedn some of the immature blasts; (2) intermediate cells are par-ially CD117-positive when the expression of CD34 is absentn blast cells; and (3) mature cells do not express CD34 orD117. These stages of maturation explain the variation inhe clinical presentation of BPDCN, as well as its laboratoryharacteristics.10The most differentiated stage is characterized by cellsith weak expression of CD45, no expression of CD34, co-xpression of CD4/CD56, presence of HLADR/CD123, andbsence of specific markers of myeloid, B and T lymphoid,nd NK cells.13,14 Co-expression of CD2, cytoplasmic CD3, CD5,D7, CD33, nTdT, CD79a, and/or CD117 can be common.13,15,16CD123 is the  chain of the interleukin-3 receptor, and is aensitive and specific marker of plasmacytoid dendritic cellspDC). However, although CD123 is currently the most impor-ant marker in the diagnosis of BPDCN, it is not unique tohe plasmacytoid dendritic cell lineage. CD4 and CD56 arexpressed in other hematological malignancies, and are notnough to establish diagnosis.17,18Clinically, this disease manifests with isolated cutaneousnvolvement in the form of single or multiple lesions, and,espite initial indolent behavior, it is characterized by aggres-ive, rapid systemic dissemination.19,20 Many patients haveytopenia, particularly thrombocytopenia, as a result ofxtremely variable rates of dendritic-cell infiltration of theone marrow. Although there is an initial response to systemichemotherapy, the disease relapses as a matter of course, andurvival ranges from 12 to 14 months.19Currently, there is no consensus as to the ideal treatmentor BPDCN.1,21 Retrospective studies have evaluated differ-nt treatment strategies, including multi-agent chemotherapyccording to established protocols for acute lymphoblasticeukemia (ALL) or acute myeloid leukemia (AML), while a fewases have been submitted to allogeneic hematopoietic stemell transplantation (HSCT).1,21 The neoplastic cells are ini-ially sensitive to chemotherapy agents which are typicallyctive against lymphoblasts, such as steroids, vincristine, andsparaginase. Therefore, it is recommended that ALL protocolse followed, with subsequent HSCT when appropriate.1,20 It ismportant to highlight that the effectiveness of this proceduretill needs to be investigated by clinical studies, and the rolef transplantation has yet to be defined.1 The Martín-Martínt al. study demonstrated that this strategy (ALL therapy plusSCT) was associated with the best prognosis.10Within this context, the aim of this paper is to report case of this rare, difficult-to-diagnose neoplasm in whichow cytometry immunophenotyping contributed to the cor-ect identification of leukemic cell lineage.ase  report 51-year-old previously healthy female presented with a-month history of progressively disseminating cutaneousesions, with no defined diagnosis and no clinical responseo topical treatments. Immunohistochemistry skin biopsyas performed and revealed blast-appearing cells, positivecells (C).for CD45 and CD123, and negative for TCL1 related to theCD3 and CD20 antigens, indicating BPDCN. Bone marrowaspiration and biopsy did not show bone-marrow involve-ment at the time of diagnosis. Treatment was performedwith cytarabine and daunorubicin (7 + 3 protocol – induction,re-induction, and three consolidations). Three months aftercompleting high-dose cytarabine maintenance, a cutaneousrelapse was detected (Figure 1A) with central nervous sys-tem (CNS) involvement. At this time, bone marrow biopsyidentified 80% immature cells with lymphoblast appearance(Figure 1B) and an anatomopathological study revealed diffuseinfiltration by blast cells of lymphoid origin (Figure 1C). Bonemarrow immunophenotyping by flow cytometry (Figure 2)using the FACSCanto II system (Becton Dickinson, San Jose,CA, USA) showed 62% of cells with expression of the antigensCD4, HLADR, CD38, weak and heterogeneous CD56 expression,276  rev bras hematol hemoter. 2 0 1 7;3  9(3):274–27701 11 11E1 1E11E2 1E21E3 1E31E4 1E411E11E21E31E41E1 1E11E2 1E21E3 1E31E4 1E4 1 1E1 1E2 1E3 1E4SSC-A Exp-SSC LowSSC-A Exp-SSC LowSSC-A Exp-SSC Low20090050030020010000 0100 100200 200300 300500 500900 900400FSC-A  linearCD 123 APC-A:APC-A LOGA CD 123 APC-A:APC-A LOG CD56 PE-A:PE-A LOGARITHMCD38 APC-A:APC-A LOGARITHMCD4 PE-A:PE-A LOGARITHMHLADR FITC-A:FITC-A LOGCD45 APC-A:APC-A LOGA CD34 PerCP-A:PerCP-A LOG600 800 10001 11E1 1E11E2 1E21E3 1E31E4 1E4Figure 2 – Immunophenotyping by flow cytometry of a bone-marrow aspirate sample, showing the main markers thatidentify and characterize plasmacytoid dendritic blast cells.strong and homogeneous CD123 and weak CD45 expression.There was no expression of CD34 or markers of lymphoid B(cCD79a, CD19), lymphoid T (CD7, CD3, CD5, CD2), NK (CD11b,CD16), or myeloid cells (cMPO, CD13, CD15, CD64, CD65) sug-gesting BPDCL. The patient began a HyperCVAD regimen(cyclophosphamide, vincristine, doxorubicin and dexametha-sone) and underwent allogeneic HSCT. The post-transplantcourse was complicated by septic shock and hemorrhagicalveolitis, and the patient died 18 days after HSCT.DiscussionBPDCN is rare, aggressive, and difficult to diagnose. Knowl-edge about this condition has been improving in recent yearsbecause of the increasing number of reported cases and a bet-ter comprehension of its biological characteristics.22 Given theclinical and biological heterogeneity of this neoplasm, correctidentification and classification require the experience of theclinician and histopathologist, as well as appropriate diagnos-tic tests.Diagnosis of BPDCN by flow cytometry may be challengingin some cases because of the different maturational stagesor because cells do not exhibit the distinctive profile dueto either the absence of the main markers or the presenceof additional markers indicative of other lineages.10,13 Theadvantage of flow cytometry in the diagnosis of BPDCN isthat it is a quantitative and qualitative method, in addition tobeing more  sensitive and specific, as it not only demonstratesantigen co-expression but also shows the density of each anti-gen quantitatively. This technique also has better ability todetect numerous antigens simultaneously, including some notroutinely tested by immunohistochemistry.12,23Expression of CD123 is typical of BPDCN, but this markercan be found in basophils and in many  cases of acute leukemiaof other lineages.24 Intensity of expression of this antigen canvary during dendritic cell maturation, although strong, homo-geneous expression is an important indicator of differentiatedplasmacytoid dendritic origin; therefore, it must be evaluatedtogether with other markers.13It is important to distinguish BPDCN from other malignan-cies that express CD4 and CD56, such as aggressive NK-cellleukemia/lymphoma, nasal NK-cell lymphoma, and AML,which can feature aberrant expressions of these markers andcutaneous involvement.25We  reported the case of BPDCN in a female patient with anindolent clinical presentation, cutaneous and CNS infiltration,no initial bone marrow involvement, and no response to AMLtreatment. During relapse, a high percentage of plasmacytoiddendritic-lineage cells was identified in the bone marrow byflow cytometry. The patient died 18 days after HSCT.We emphasize the importance of performing flow cytom-etry with a panel of monoclonal antibodies suitable toidentify BPDCN, especially in patients presenting with lesionsand neoplastic cells showing morphological characteristicsindicative of the lymphoid lineage. This technique can estab-lish the correct diagnosis and define the most appropriatetreatment.25er. 2 0FHCTr111111111122222rev bras hematol hemotundingCPA Research and Event Promotion Fund (FIPE-HCPA).onflicts  of  interesthe authors declare no conflicts of interest. e  f  e  r  e  n  c  e  s1. Pagano L, Valentini CG, Pulsoni A, Fisogni S, Carluccio P,Mannelli F, et al. Blastic plasmacytoid dendritic cell neoplasmwith leukemic presentation: an Italian multicenter study.Haematologica. 2013;98(2):239–46.2. Jacob MC, Chaperot L, Mossuz P, Feuillard J, Valensi F, LerouxD, et al. CD4+ CD56+ lineage negative malignancies: a newentity developed from malignant early plasmacytoiddendritic cells. Haematologica. 2003;88(8):941–55.3. Bueno C, Almeida J, Lucio P, Marco J. Incidence andcharacteristics of CD4+/HLA DRhi dendritic cell malignancies.Haematologica. 2004;89(1):58–69.4. Facchetti F, Jones DM, Petrella T. Blastic plasmacytoiddendritic cells neoplasm. In: Swerdlow SH, Campo E, HarrisNL, Jaffe ES, Pileri SA, Stein H, Thiele J, Vardiman JW,  editors.WHO classification of tumours of haematopoietic andlymphoid tissues. 4th ed. Lyon, France: IARC Press; 2008. p.146–7. World Health Organization Classification of Tumours,vol. 2.5. Riaz W,  Zhang L, Horna P, Sokol L. Blastic plasmacytoiddendritic cell neoplasm: update on molecular biology,diagnosis, and therapy. Cancer Control. 2014;21(4):279–89.6. Ng AP, Lade S, Rutherford T, McCormack C, Prince HM,Westerman DA. Primary cutaneous CD4+/CD56+hematodermic neoplasm (blastic NK-cell lymphoma): areport of five cases. Haematologica. 2006;91(1):143–4.7. Garnache-Ottou F, Feuillard J, Saas P. Plasmacytoid dendriticcell  leukaemia/lymphoma: towards a well defined entity? Br JHaematol. 2007;136(4):539–48.8. Facchetti F, Ungari M, Marocolo D, Lonardi S, Vermi W.  Blasticplasmacytoid dendritic cell neoplasm. Haematol Meet Rep.2009;3(3):1–3.9. Feuillard J, Jacob MC, Valensi F, Maynadié M, Gressin R,Chaperot L, et al. Clinical and biologic features ofCD4(+)CD56(+) malignancies. Blood. 2002;99(5):1556–63.0. Martín-Martín L, López A, Vidriales B, Caballero MD,Rodrigues AS, Ferreira SI, et al. Classification and clinicalbehavior of blastic plasmacytoid dendritic cell neoplasmsaccording to their maturation associated immunophenotypicprofile. Oncotarget. 2015;6(22):19204–16.2 1 7;3  9(3):274–277 2771. Jegalian AG, Buxbaum NP, Facchetti F, Raffeld M, Pittaluga S,Wayne  AS, et al. 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Flow cytometry to identify bone-marrow relapse in blastic plasmacytoid dendritic cell neoplasm : a case report

Universidade Federal do Rio Grande do Sul

Flow cytometry to identify bone-marrow relapse in blastic plasmacytoid dendritic cell neoplasm : a case report

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Universidade Federal do Rio Grande do Sul