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  Table of Contents    
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 54  |  Issue : 2  |  Page : 294-298
Immunophenotypic profile of plasma cell leukemia: A retrospective study in a reference cancer center in India and review of literature


1 Department of Pathology, Hematopathology Laboratory, Tata Memorial Center, Mumbai, India
2 Department of Biochemistry, Tata Memorial Center, Mumbai, India

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Date of Web Publication27-May-2011
 

   Abstract 

Background: Plasma cell leukemia (PCL) is a rare but aggressive subtype of plasma cell dyscrasia. It is known to present with highly variable morphological features and may mimic with other lymphoid neoplasms. Multicolor flow cytometry (MFC) with availability of newer markers is highly useful in the diagnosis of the plasma cell leukemia. We present an immunophenotypic profile in ten cases of PCL along with their clinical and laboratory findings. Materials and Methods: We retrospectively studied immunophenotypic profile of 10 cases of plasma cell leukemia (out of 4615 cases of hematolymphoid neoplasms) using five parameter, three color flow cytometric analysis. We also studied their clinical presentation and other laboratory findings. Results: Common clinical features at presentation were weakness, bone pain, anemia, thrombocytopenia and osteolytic lesions. Plasma cell population was identified on strong expression of CD38 and co-expression of CD38 and CD138. CD56 was expressed in 44% cases. CD19 and CD20 were negative in all cases. Surface light chain restriction was seen in 50% cases and in remaining 50% cases revealed cytoplasmic light chain restriction. CD117 was expressed in one out of two cases studied. Conclusions: MFC immunophenotyping is highly useful to differentiate Plasma cell leukemia from other chronic lymphoproliferative disorders with plasmacytoid morphology as well as from non-neoplastic reactive PC and co-expression of CD38 and CD138 is a best combination to identify the plasma cells by MFC.

Keywords: Immunophenotypic profile of plasma cell leukemia

How to cite this article:
Tembhare PR, Subramanian P G, Sehgal K, Yajamanam B, Kumar A, Gadge V, Inamdar N, Gujral S. Immunophenotypic profile of plasma cell leukemia: A retrospective study in a reference cancer center in India and review of literature. Indian J Pathol Microbiol 2011;54:294-8

How to cite this URL:
Tembhare PR, Subramanian P G, Sehgal K, Yajamanam B, Kumar A, Gadge V, Inamdar N, Gujral S. Immunophenotypic profile of plasma cell leukemia: A retrospective study in a reference cancer center in India and review of literature. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Dec 16];54:294-8. Available from: http://www.ijpmonline.org/text.asp?2011/54/2/294/81603



   Introduction Top


Plasma cell leukemia (PCL) is a rare, aggressive leukemic form of plasma cell dyscrasia (PCD) and is characterized by a rapid progression and extremely dismal prognosis. PCL represents less than 5% of PCD. [1] It is defined by a criteria of an absolute plasma cell (PC) count greater than 2x10 9 /L or a relative number greater than 20% of peripheral white blood cells. [1] It may be primary or secondary subtype. Primary PCL is a de novo neoplasm without pre-existence of multiple myeloma (MM), and accounts for about 60% cases; secondary PCL occurs as a terminal event in late stage multiple myeloma accounting for the remaining 40% of cases. [2] PCL has an aggressive clinical course and is resistant to chemotherapy with a median survival of 6-8 months. [3] However, drugs like bortezomib, cyclophosphamide and dexamethasone have been shown to be more effective for PCL. [2]

PCD are diagnosed based on clinical, radiological and laboratory parameters. Multiparametric flow cytometry is generally required in the differential diagnosis of unusual cases of PCD. However, availability of newer markers allows us to unequivocally identify plasma cells and also help to discriminate between normal and abnormal PCs. We present ten cases of PCL to illustrate the immunophenotypic profile of this disease.


   Materials and Methods Top


We reviewed an immunophenotypic profile of ten cases of PCL (six primary PCL and four secondary PCL) presented to our laboratory out of 4615 cases of hematolymphoid neoplasms, over a period of six years, from 2003 to 2009 [Table 1]. We received peripheral blood (PB) samples in all and bone marrow aspirate (BMA) in 2 cases. The PB and BMA smears were stained with Wright's stain for morphologic evaluation. For flow cytometric immunophenotyping (FCI), the cells were stained within 24 hours of collection using a whole blood lyse wash technique. [3] Panel of directly conjugated monoclonal antibodies comprised of CD45 (HI30-FITC), CD3 (UCHT1-FITC, PE), CD5 (UCHT2-FITC), CD10 (H1 10A-PE.Cy5), CD11c (B-ly6-PE), CD19 (H1B1.9- PE.Cy5), CD20 (2H7- PE.Cy5), CD22 (HIB22-PE), CD23 (M-L233-PE), CD25(M-A251-FITC), CD38 (HIT2-FITC, PE), CD56 (B159-PE.Cy5), CD79b (SN8-PE), CD103 (LF61-FITC), CD138 (Mi15-FITC, PE), FMC7 (fmc7-FITC), Kappa (G20-193-FITC), Lambda (JDC12-PE), IgD (11-26c.2a-PE) and IgM (G20-127-FITC) (Becton Dickinson, San Jose, CA). CD117 (YB5.B8- PE.Cy5) was done in two cases only. Intracytoplasmic evaluation of Kappa and Lambda light chains (LC) was done in cases where surface expression was negative, using 1% formalin (fixative) and 0.05% saponin (permeabilizing agent). [4] Five parameter three color immunophenotyping was performed using a FACS Caliber (Becton Dickinson, San Jose, CA). Minimum 10,000 events were acquired using low side scatter versus low to high forward scatter gating. Data (collected in list mode) was analyzed with CellQuestpro software (Becton Dickinson) as shown in [Figure 1]. Other clinical, hematological and biochemical parameters were correlated [Table 2].
Figure 1: Flow cytometric analysis of a representative case of plasma cell leukemia. Plasma cells are isolated on their light scattering characteristics in side light scatter against forward light scatter dot plot (plot a) using R-1 gate which is applied to all other dot plots. Dual expression of CD38 and CD138 (plot c) confirms that events in R-1 gate are predominantly consist of plasma cells. Normal B and T lymphocytes included in R-1 gate are used as internal negative controls. Gated plasma cells are negative for CD19 (plot b), CD22 (plot d), CD3 (plot e), CD10 (plot f) and show surface lambda light chain restriction (plot i) which confirms their abnormal and monoclonal nature. Plasma cells are negative for CD56, surface kappa light chain, Ig D and IgM (plot g, j and k respectively)

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Table 1: Clinical details of plasma cell leukemia patients

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Table 2: Haematology and biochemistry laboratory data of plasma cell leukemia cases

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   Results Top


Clinical Features

Common complaints were asthenia, loss of weight, bone pain and fever. Five patients had hepatosplenomegaly. Osteolytic lesions were detected in all cases, commonly involving the skull, spine, and mandible bones [Table 1]. Radiological details were not available in one case.

Laboratory Findings

Leukocytosis (median; 44.75 x 10 9 /L, range; 30.7-133 x 10 9 /L), and anemia (median; 78g/L, range of hemoglobin; 52-82g/L), were seen in all cases. Thrombocytopenia (median; 94 x 10 9 /L, range of platelets; 5-136 x 10 9 /L) was seen in eight cases. In two cases platelet counts were normal (180 and 384 x10 9 /L). On manual differential count in PB smear, the PC percentage was more than 20% (range; 27-97%) in all cases except one case (12%), in which an absolute count of the plasma cells was > 2000 cell/μl [Table 1]. High resolution serum protein electrophoresis (SPE) on 1% agarose gel was available in six cases out of which five cases revealed monoclonal protein (M) band [Table 2] and one case showed hypogammaglobulinemia. In five cases high levels of serum IgG level was detected by nephelometric methods. Bence Jones proteins done by an automated analyzer were examined in three cases and were positive in one case. Biochemical investigations revealed hypercalcemia (60%), high serum creatinine (50%) and blood urea levels (90%) [Table 2].

Immunophenotypic Characteristics

[Table 3] The PC population was identified on the moderate to strong expression of CD38 and co-expression of CD38 and CD138. CD56 expression was seen in four out of nine cases studied (44 %). CD117 was expressed in one out of two cases studied. Surface light chain restriction was observed in five (50%) cases (k - 2 cases and λ - 3 cases). In remaining five cases, cytoplasmic light chain restriction (LCR) was found (k - 2 cases and λ - 3 cases). Surface IgM expression was studied in eight cases and only one case (1.25%) has shown positivity. CD19, CD20 and CD22 were negative in all cases. Other markers which including CD45, CD5, CD10, CD11c, CD23, CD25, CD79b, and CD103 were consistently negative in all cases.
Table 3: Immunophenotypic profile of all cases of plasma cell leukemia

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   Discussion Top


Advancement in cytomation technology permits more specific and sensitive evaluations of PC populations. PCL being an uncommon entity, there is a paucity of published literature related to its immunophenotypic spectrum. [5],[6],[7],[8],[9],[10] The PC are morphologically easy to identify in BM, however, they are often missed on PB smear examination owing to is resemblance to plasmacytoid lymphocytes, monocytoid cells [11] or erythroid precursors and rarely hairy cells [12] . Rarely PCL can also be misdiagnosed as acute leukemia. [11],[12],[13] In addition, a few PC may be seen in peripheral circulation in various inflammatory conditions. [14] In cases of MM where PC in peripheral blood may not meet the criteria (number and / or percentage of PC) for PCL, however PB monoclonal PC may predict the survival in patients with MM independently. [15]

An important component of a reproducible and sensitive immunophenotypic analysis of PC is the identification of an accurate gating strategy. A variety of approaches based on CD38, CD138 (syndecan-1) and/or CD45 expression are being used. Majority of centers report a gating strategy using combined CD38, CD138 and light scatter characteristics. [16],[17] Combined use of CD38, CD138 and CD45 together with light scatter characteristics has been recommended by European Myeloma Network. [18] In the present study, we have analyzed immunophenotypic features of ten cases of PCL along with other laboratory data presented over a period of six years. We used light scatter (forward scatter vs side scatter) characteristics for gating of the PCs and co-expression of CD38 and CD138 for identification of plasma cells [Figure 1]. Neoplastic PCs traditionally have been identified by their strong CD38 and negative or dim CD45 expression pattern on FCM. [19],[20] With the introduction of specific monoclonal antibody for PC (CD138), it has been shown that strong CD38 and negative or dim CD45 gating alone might fail to identify myeloma composed largely or partly of CD45+ PCs. [21],[22] CD38 is a nonspecific marker that can be detected on hematopoietic stem cells, myeloid cells and lymphocytes. Neoplastic PCs typically express CD38 at a lower intensity than normal PCs and might be indistinguishable from contaminating T or B cells. Thus, PC immunophenotyping is best determined by multiparameter FC using at least a 3-color assay that includes CD138 in the analysis. [23]

Normal PC usually express CD19 which is absent in neoplastic PCs in contrast to it CD20 is usually negative in normal PCs and have been shown to be positive 30% cases of MM. [18] However, due to rarity of disease, enough literature regarding the expression of CD19 in PCL is not available. Garc΄a-Sanz R et al. [23] and Linden MD et al. [5] have reported expression of CD20 in 50% cases in a study of 26 cases and 3 out of 4 cases of primary PCL respectively. He also suggested expression of CD20 as a poor prognostic factor. [23] In our study, all ten cases were negative for CD19 as well as CD20. Lack of CD20 expression in cases of primary PCL in our study may represent the Indian profile of PCL however more extensive study is needed to come to a conclusion.

CD56 antigen, which has been considered to have an important role in anchoring PCs to the BM stroma, [23] is not expressed by normal PCs. However, most of the myeloma cells aberrantly express CD56. [17] Pellat-Deceunynck et al.[24] have reported that the malignant cells of PCL (primary or secondary) do not express or weakly express CD56 in contrast to patients with MM. [17],[19] Lack of CD56 expression might be associated with more aggressive disease and extramedullary dissemination. [17] Four out of seven cases (56%) were negative for CD56 expression (which included three patients with past history of MM). CD117 (c-kit) is expressed by 30% cases of PCD. Within PC lineage the c-kit antigen is found to be restricted to the neoplastic population and thus has been considered as a 'tumour-associated marker' for monitoring minimal residual disease and may be a valuable marker in the use of tyrosine kinase selective inhibitors. [25],[26] In our study, one out of two cases studied revealed CD117 expression.

In addition to aberrant immunophenotypic expression (CD20, CD56, CD117) in a majority of PCL/multiple myeloma, restricted expression (intracytoplasmic as well as surface) of kappa/lambda light chains also helped in defining monoclonality of the disease. [14] In our study, the cases showing cytoplasmic and surface LCR were equal for kappa as well as lambda light chains.

Few attempts have been made to differentiate PCL from MM based on immunophenotypic characteristics, however have been inconclusive. [18],[24] However the phenotypic characteristics do help in prognosticating the disease, since CD56 antigen expression has been associated with a good prognosis [24] while the CD20 antigen has been associated with a shorter survival. [23]

In conclusion, FCI is useful to differentiate PCL from other chronic lymphoproliferative disorders with plasmacytoid morphology as well as from non-neoplastic reactive PC. Co-expression of CD38 and CD138 is a best tool to identify the PCs in FCI. Surface LCR or cytoplasmic LCR (especially in Surface LCR negative cases) is a useful way to confirm the plasma cell clonality. Inclusion of antibodies against antigens like CD19, CD20, CD56, and CD117 in the panel not only helps to diagnose their aberrant expression by PCL but also helps in prediction of prognosis.

 
   References Top

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2.Kim SJ, Kim J, Cho Y, Seo BK, Kim BS. Combination chemotherapy with bortezomib, cyclophosphamide and dexamethasone may be effective for plasma cell leukemia. Jpn J Clin Oncol 2007;37:382-4.  Back to cited text no. 2
    
3.Menéndez P, Redondo O, Rodriguez A, Lopez-Berges MC, Ercilla G, López A, et al. Comparison between a lyse-and-then-wash method and a lyse-non-wash techn0ique for the enumeration of CD34+ hematopoietic progenitor cells. Cytometry 1998;34:264-71.  Back to cited text no. 3
    
4.Jacob MC, Favre M, Bensa JC. Membrane cell permeabilization with saponin and multiparametric analysis by flow cytometry. Cytometry 1991;12:550-8.  Back to cited text no. 4
    
5.Linden MD, Fishleder AJ, Tubbs RR, Park H. Immunophenotypic spectrum of plasma cell leukemia. Cancer 1989;63:859-62.  Back to cited text no. 5
    
6.Shimazaki C, Gotoh H, Ashihara E, Oku N, Inaba T, Murakami S, et al. Immunophenotype and DNA content of myeloma cells in primary plasma cell leukemia. Am J Hematol 1992;39:159-62.  Back to cited text no. 6
    
7.Costello R, Sainty D, Bouabdallah R, Fermand JP, Delmer A, Diviné M, et al. Primary plasma cell leukaemia: a report of 18 cases. Leuk Res 2001;25:103-7.  Back to cited text no. 7
    
8.Johnson MR, Del Carpio-Jayo D, Lin P, Giralt S, Anderlini P, Champlin RE, et al. Primary plasma cell leukemia: morphologic, immunophenotypic, and cytogenetic features of 4 cases treated with chemotherapy and stem cell transplantation. Ann Diagn Pathol 2006;10:263-8.  Back to cited text no. 8
    
9.Rawstron AC, Owen RG, Davies FE, Johnson RJ, Jones RA, Richards SJ, et al. Circulating plasma cells in multiple myeloma: characterization and correlation with disease stage. Br J Haematol 1997;97:46-55.  Back to cited text no. 9
    
10.Colovic M, Jankovic G, Suvajdzic N, Miliæ N, Dordeviæ V, Jankoviæ S. Thirty patients with primary plasma cell leukemia: a single center experience. Med Oncol 2008;25:154-60.  Back to cited text no. 10
    
11.Eclache V, Lusina D, Lejeune F, Casassus P, Smadja N, Lortholary P. Plasma cell leukaemia mimicking acute monocytic leukaemia in the course of multiple myeloma. Nouv Rev Fr Hematol 1993;35:419-22.  Back to cited text no. 11
    
12.Tanioka F, Tamashima S, Shimizu S, Kobayashi H, Kobayashi Y, Sugimura H. A case of primary plasma cell leukemia with hairy-cell morphology and lambda-type Bence-Jones protein immunohistochemical and molecular analysis. Jpn J Clin Oncol 2003;33:232-7.   Back to cited text no. 12
    
13.Tripathy K, Gouda KP, Chakrabarty S, Das AK, Mohanty R. Plasma cell leukemia masquerading as ALL-L3--a case report. Indian J Pathol Microbiol 2005;48:221-3.  Back to cited text no. 13
    
14.Toma VA, Retief FP, Potgieter GM, Anderson JD. Plasma cell leukaemia. Diagnostic problems in our experience with 11 cases. Acta Haematol 1980;63:136-45.  Back to cited text no. 14
    
15.Witzig TE, Gertz MA, Lust JA, Kyle RA, O'Fallon WM, Greipp PR. Peripheral blood monoclonal plasma cells as a predictor of survival in patients with multiple myeloma. Blood 1996;88:1780-7.  Back to cited text no. 15
    
16.Pérez-Andrés M, Santiago M, Almeida J, Mateo G, Porwit-MacDonald A, Bjorklund E, et al. Immunophenotypic approach to the identification and characterization of clonal plasma cells from patients with monoclonal gammopathies. J Biol Regul Homeost Agents 2004;18:392-8.  Back to cited text no. 16
    
17.Lin P, Owens R, Tricot G, Wilson CS. Flow cytometric immunophenotypic analysis of 306 cases of multiple myeloma. Am J Clin Pathol 2004;121:482-8.  Back to cited text no. 17
    
18.Rawstron AC, Orfao A, Beksac M, Bezdickova L, Brooimans RA, Bumbea H, et al. Report of the European Myeloma Network on multiparametric flow cytometry in multiple myeloma and related disorders. Haematologica 2008;93:431-8.  Back to cited text no. 18
    
19.Harada H, Kawano MM, Huang N, Harada Y, Iwato K, Tanabe O, et al. Phenotypic difference of normal plasma cells from mature myeloma cells. Blood 1993;81:2658-63.  Back to cited text no. 19
    
20.Weisberger J, Wu CD, Liu Z, Wong JY, Melamed MR, Darzynkiewicz Z, et al. Differential diagnosis of malignant lymphomas and related disorders by specific pattern of expression of immunophenotypic markers revealed by multiparameter flow cytometry (Review). Int J Oncol 2000;17:1165-77.  Back to cited text no. 20
    
21.Almeida J, Orfao A, Ocqueteau M, Mateo G, Corral M, Caballero MD, et al. High-sensitive immunophenotyping and DNA ploidy studies for the investigation of minimal residual disease in multiple myeloma. Br J Haematol 1999;107:121-31.  Back to cited text no. 21
    
22.Witzig TE, Kimlinger T, Stenson M, Therneau T. Syndecan-1 expression on malignant cells from the blood and marrow of patients with plasma cell proliferative disorders and B-cell chronic lymphocytic leukemia. Leuk Lymphoma 1998;31:167-75.  Back to cited text no. 22
    
23.Garcia-Sanz R, Orfao A, Gonzalez M, Tabernero MD, Bladé J, Moro MJ, et al. Primary plasma cell leukemia: clinical, immunophenotypic, DNA ploidy, and cytogenetic characteristics. Blood 1999;93:1032-7.  Back to cited text no. 23
    
24.Pellat-Deceunynck C, Barille S, Jego G, Puthier D, Robillard N, Pineau D, et al. The absence of CD56 (NCAM) on malignant plasma cells is a hallmark of plasma cell leukemia and of a special subset of multiple myeloma. Leukemia 1998;12:1977-82.  Back to cited text no. 24
    
25.Ocqueteau M, Orfao A, Garcia-Sanz R, Almeida J, Gonzalez M, San Miguel JF, et al. Expression of the CD117 antigen (c-Kit) on normal and myelomatous plasma cells. Br J Haematol 1996;95:489-93.  Back to cited text no. 25
    
26.Li J, Luo SK, Zhang GC, Hong WD, Tong XZ. Expression of CD117 antigen on multiple myeloma and its significance. Ai Zheng 2004;23:951-4.  Back to cited text no. 26
    

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Correspondence Address:
Sumeet Gujral
Department of Pathology, Hematopathology Laboratory, Tata Memorial Center, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.81603

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