GrannyBarb and Art's

BLOODWORK and PATHOLOGY FROM

6 MONTH POST ABMT CHECK-UP

This page and the others like it, including the slides and the flow cytometry reports, have been added to Grannybarb's story by me of my own volition and with the knowledege of all my oncologist/hematologists and bone marrow transplant doctors. The images were created with the help of Gerald Marti, M.D., NIH, who hopes, as I do, that they will provide additional insight for professionals and patients who may be interested in the technical part of CLL. For those who are simply reading the story, please feel free to skip this part.

DANA FARBER CANCER INSTITUTE

BRIGHAM AND WOMEN'S HOSPITAL

TEACHING AFFILIATES OF THE HARVARD MEDICAL SCHOOL

PATIENT NAME             SEX       Age

LACKRITZ,BARBARA          F        59

PROCEDURE DATE  RECEIVED        REPORT DATE          HOSPITAL

01/26/98        01/27/98        02/03/98              DFCI       

PATHOLOGISTS DR. A.F. NINO
DR. T.J. WIECZOREK
DR. G.S. PINKUS

FINAL PATHOLOGIC DIAGNOSIS

BONE MARROW BIOPSY:

Variably cellular, overall moderately hypocellular marrow (70% fat). Less than 5% of the cellularity consists of nodular aggregates comprised of small lymphoid cells with round to irregular nuclei, indistinct nucleoli and scant cytoplasm, admixed with histiocytes, mast cells, and eosinophils. Immunoperoxidase studies performed on paraffin sections show that the aggregates are composed of a mixture of B (L26 positive) and T (CD3 positive) lymphocytes, plasma cells, histiocytes (KP1 positive) and mast cells (positive for mast cell tryptase). CD34 stain highlights small blood vessels/capillaries at the periphery of the aggregates Overall, the histologic and immunophenotypic findings suggest that the lymphoid aggregates are most likely reactive, and are unusual in their overall cell composition. These foci are not typical of those observed in mast cell disease. Erythroid elements moderately proportionally increased and include increased numbers of early forms. Myeloid elements are moderately proportionally decreased and include increased numbers of eosinophilic forms. Myeloblasts comprise less than 5% of the marrow cellularity. Megakaryocytes are mildly to moderately decreased, occur in occasional clusters and include occasional dysplastic forms. Scattered plasma cells are seen (non-diagnostic). Hemosiderin is present. Bone trabeculae exhibit osteoblastic activity. Giemsa stain examined for final diagnosis of bone marrow biopsy. The hypocellular, aspicular aspirate smear is insufficient for evaluation.

Flow cytometric analysis of disaggregated marrow cells reportedly shows no evidence of a B cell lymphoproliferative disorder.

FINAL PATHOLOGIC DIAGNOSIS

Features of involvement by chronic lymphocytic leukemia are not seen.

CLINICAL DATA

History: CLL, status post ABMT* six months ago.
* ABMT = autologous bone marrow transplant

TISSUE SUBMITTED: Bone marrow aspirate and biopsy.

GROSS DESCRIPTION

The specimen, labeled with the patient's name, number and "PLI", consists of a tan core of tissue, measuring 1.7 cm in length x 0.2 cm in diameter. It is fixed and decalcified in Zenker's acetic acid. A Wright-Giemsa stained bone marrow aspirate smear is received.

Micro: Bone marrow biopsy, ESS, 1 frag, 1 cass.

SLIDES

1 H&E 2 GIEMSA

IMPOX
CD5 CD3 CD20 KP1 CD34 Mast cell

SIGNED BY GERALDINE S. PINKUS, M.D. ON 02/03/98

By his/her signature above, the senior physician certifies that he/she personally conducted a gross and/or microscopic examination of the described specimen(s) and rendered or confirmed the diagnosis(es) related thereto.

Name of Patient: BARBARA LACKRITZ

January 26, 1998 CLINIC VISIT

Barbara Lackritz is a 59 year old woman who is status post 6 months following autologous bone marrow transplantation for her relapsed advanced stage CLL.

INTERVAL HISTORY: Barbara has had a rather eventful first 6 months following her transplant. She has been slow to engraft, required platelet red cell transfusions, subsequently introduction of Epogen with her red cell engraftment. The problem she had with losing her skin and nails continued after she returned to St. Louis, but eventually resolved. Barbara was back at work part time by 5 months post transplant and seems to be back to her very busy self. She has had no further recurrence of her chronic sinus problems that she had associated with her chronic lymphocytic leukemia Her appetite is good and she has been gaining weight recently. She denies upper respiratory tract symptoms, recent infections, chest pain, shortness of breath, nausea and vomiting, abdominal pain, change in bowel habits, bone pain and necrologic symptoms. All other systems are negative.

She remains on acyclovir 400 mg t.i.d. and inhaled pentamidine one monthly for PCP prophylaxis. She continues on folic acid and multivitamins.

PHYSICAL EXAMINATION: She appeared extremely well. weight 62 kilos, temperature 97.6, blood pressure 130/76. Pulse 86, respirations 20. Skin: unremarkable, without rash or lesion. Sclerae: anicteric. PERRL. Oropharynx: teeth and gums without lesions. Neck: supple without masses, normal thyroid gland. There was no cervical or supraclavicular axillary or inguinal lymphadenopathy. Chest: clear to percussion and auscultation. Cardiac: normal to palpation, S1, S2 normal without rubs or murmurs. Abdomen soft, contender, without masses and without hepatosplenomegaly. Extremities: no clubbing, cyanosis or edema. Neuro: intact cranial nerves and normal motor sensory exam.

PROCEDURE NOTE

After receiving informed permission, the patient was placed in the prone position. The left iliac crest was prepped and anesthetized with 1% Xylocaine. Bone marrow aspirate and biopsy were performed with minimal discomfort to the patient without complications. Samples were sent for histology, cytogenetics, immunocytometry and PCR analysis.

LABORATORY DATA: WBC 3.7, hemoglobin 8.9, hematocrit 27.3. MCV 104, platelets 49, Differential 65 neutrophils, 17 lymphs, 14 monos. BUN 22, creatinine 1. LDH mildly elevated at 896. Liver function tests otherwise within normal limits. Bone marrow biopsy revealed a variably cellular overall moderately hypercellular marrow. Less than 5% of the cellularity consisted of nodular aggregates of small lymphoid cells. Immunoperoxidase studies revealed the aggregates are comprised of a mixture of B and T lymphocytes, plasma cells, histiocytes and fibrous cells. Myeloid cells were moderately proportionately decreased. Megakaryocytes are mildly to moderately decreased. Immunophenotype of disaggregated marrow cells showed no evidence of a B Cell proliferative disorder. It is our impression that there are no diagnostic features of involvement by CLL.

NAME: LACKRITZ, BARBARA B   59Y   SEX: F

HEMATOLOGY - COUNTS and DIFFS

---FOOTNOTES---
P15 15 MIN POST PLTX

PAGE 1

PAGE 2

NAME: LACKRITZ,BARBARA B AGE: 59Y SEX: F

HEMATOLOGY - COUNTS & DIFFS

---FOOTNOTES---

• TOXG = TOXIC GRANULATION
• WNL = WITHIN NORMAL LIMITS
• (a) FEW OVALOCYTES
• (b) MODERATE ANISOCYTOSIS
• (c)FEW ANISOCYTOSIS
• (d) SLIGHT ANISOCYTOSIS
• (e) SLIGHT HYPOCHRONIA
• (f) SLIGHT POLYCHROMASIA
• (g) MODERATE POIKILOCYTOSIS
• (h) SLIGHT POIKILOCYTOSIS
• (i) SLIGHT BASOPHILIC STIPPLING
• (j) MODERATE OVALOCYTES
• (k) FEW TEARDROP CELLS
• (l) FEW FRAGMENTS

Page 2

02/05/98

DANA-FARBER CANCER INSTITUTE CUMULATIVE REPORT

NAME: LACKRITZ,BARBARA B   AGE: 59Y   SEX: F

BONE MARROW AND SPECIAL STAINS

        DATE:   01/26/98
        TIME:   NORMAL  UNITS       +1156
        
        BLAST           %               0
        PROMYELOCYTE    %               0
        MYELOID         %               0
        RYTROID         %               0
        LYMPHOID        %               0
        TOTAL CELLS COUNTED             0
        EGAKARYOCYTE                    NONE NOTED
        BONE MARROW SITE                PLI
        ASP CELLULARITY                 ?HYPO/DIL
        BONE MARROW COGENT              (m)
                                        (n)

LACKRITZ,BARBARA B CONTINUED PAGE 3

NAME: LACKRITZ,BARBARA B   AGE: 59Y    SEX: F

CHEMISTRY - ROUTINE

---FOOTNOTES---

• CRD RESULT CHEC E D
• CRDP RESULT CHECKED AND PHONED

LACKRITZ,BARBARA B CONTINUED PAGE 4

NAME: LACKRITZ,BARBARA B AGE: 59Y SEX: F

BLOOD COMPONENT LAB--TESTS

        
	DATE:               		     06/09/97
      TINE:   NORMAL       
        
      ABO/Rh TYPE                      	A POS
      ANTIBODY SCREEN                  	NEGATIVE
      RPR                              	NONREACTIVE
                                       	MGH1
        

BLOOD COMPONENT LAB - EIA TESTS

DATE:                           06/09/97
        TIME:           NORMAL          1000
        
        HBSAG (SURFACE AG)              NEGATIVE
                                        MGH1
        HBCAB (CORE AB) NEG             NEGATIVE
                                        MGH1
        HCV AB (HEP C AB)               NEGATIVE
                                        MGH1

---FOOTNOTES---

MGH1 TEST PERFORMED AT MGH

LACKRITZ,BARBARA B CONTINUED PAGE 5

06/26/98 REC: NOT RECEIVED PHYS: GRIBBEN,JOHN

BONE MARROW DIFF PENDING

        F5402 COLL: 06/26/98    REC: 06/26/98  PHYS: GRIBBEN,JOHN

        PCR 

        F5400 COLL: 06/26/98       REC: 06/26/98  PHYS: GRIBBEN,JOHN

        CBC
        WBC COUNT               4.5          [4.8-10.8]  K/UL
        RBC COUNT               4.68         [4.20-5.40] M/UL
        tEMOGLOBIN             14.9          [12.0-16.0] GM/DL
        HEMATOCRIT             47.3          [37-47]     %
        MCV                   101.2          [82-92]     FL
        MCH                    31.8          [27-32]     PG
        MCHC                   31.4          [33-37]     %
        PLATELET               76            [130-400]   K/UL