A retrospective study to assess the relative value of peripheral blood, bone marrow aspirate and biopsy morphology, immunohistochemical stains, and flow cytometric analysis in the diagnosis of chronic B cell lymphoproliferative neoplasms.

INTRODUCTION: The successful diagnosis of chronic B cell lymphoproliferative neoplasms (B-CLPN) requires the integration of multiple parameters, beginning with clinical information, CBC data, and morphology review. Immunophenotyping is essential and genetic testing may also be necessary. However, the relative value of each specimen or ancillary study in the diagnosis and classification has not been systematically established. We have performed a blinded retrospective review to assess what in our laboratory was the relative value of each specimen type and ancillary study in the diagnostic workup of B-CLPN. METHODS: A total of 185 cases of PB, BM, spleen and lymph nodes were analyzed for relative value of morphology, IHC, flow cytometry study in the diagnosis of B-CLPN. RESULTS: 'High yield' specimen was identified in most B-CLPN categories, which was highly predictive of the final WHO diagnosis. CONCLUSION: The goal of this retrospective study was to attempt to assess what was the relative value of morphology, immunophenotype, and molecular/cytogenetic study in various sites in the overall diagnostic process in our institution. We investigated the utility of the 'high yield' specimens in achieving the correct final diagnosis. In our study, some B-CLPNs notably splenic marginal zone lymphoma and hairy cell leukemia variant, required all studies for a 'best fit' type of diagnosis. In other cases, the morphology of a single specimen type was highly predictive of the final diagnosis, although confirmatory studies are recommended for definitive diagnosis.

Recombinant factor VIIa: unregulated continuous use in patients with bleeding and coagulopathy does not alter mortality and outcome.

Recombinant factor VIIa (rFVIIa) is used in patients with hemophilia who had developed inhibitors. A hemostatic effect has been demonstrated following the administration of rFVIIa in patients after trauma and bleeding. Currently, there is no widely accepted guideline for off-label rFVIIa usage in bleeding patients. We planned to review the rFVIIa utilization practice in our institution and develop policies and guidelines for future rFVIIa use. We acquired the medical records of 55 patients who received rFVIIa at our institution during 2003-2004. Patient charts were reviewed regarding their rFVIIa administration and indications, dose and frequency, cost, pre-rFVIIa blood component usage, utilization of hematology services and outcome were analyzed. Underlying liver disease with coagulopathy was the commonest (47%) indication for rFVIIa use. Recombinant FVIIa was successful (69%) in correcting laboratory parameters of coagulopathy, but did not alter outcome. Twenty-six of the 55 patients (47%) died during the same admission from their underlying diseases. Apart from two trauma patients, no one died from bleeding. We conclude that unregulated continuous administration of rFVIIa in bleeding/coagulopathic patients did not alter outcome. Closer monitoring of rFVIIa usage, including hematology consultation and enforcement of pre-rFVIIa blood component usage would optimize cost-effectiveness.

Detection and quantitation of apolipoprotein(a) mRNA in human liver and its relationship with plasma lipoprotein(a) concentration.

Northern blotting and hybridisation with specific probes was used to detect and quantitate apolipoprotein(a) (apo(a)) mRNA in total RNA isolated from 25 human liver samples. A total of 14 different transcripts were identified suggesting that there are at least 15 different alleles at the apo(a) locus including a probable null allele. Apo(a) mRNA sizes were linearly correlated with the electrophoretic mobility of plasma apo(a) glycoprotein isoforms, and differed, in many cases, by the equivalent of one Kringle 4 unit. To investigate the relationship between apo(a) mRNA size and its concentration in the liver, and between hepatic apo(a) mRNA concentration and plasma lipoprotein(a) (Lp(a)) levels, apo(a) mRNA was quantified by densitometric scanning of autoradiograms of Northern blots. Overall, there was a significant inverse correlation between apo(a) mRNA size and its concentration in the liver, despite a marked interindividual variability in the relative amounts of similar-sized transcripts. In each heterozygous individual, the difference in concentration between the two mRNA species was determined by the difference in size. However, there was not a significant relationship between hepatic apo(a) mRNA concentration and plasma Lp(a) levels in this group. These findings emphasise the importance of mechanisms other than the rate of transcription of the apo(a) gene in the regulation of Lp(a) synthesis.

Detection and quantitation of low density lipoprotein (LDL) receptors in human liver by ligand blotting, immunoblotting, and radioimmunoassay. LDL receptor protein content is correlated with plasma LDL cholesterol concentration.

Low density lipoprotein (LDL) receptor activity has been detected and identified in human liver samples by ligand blotting with biotinylated lipoproteins and by immunoblotting with a monoclonal antibody raised against the bovine adrenal LDL receptor. The molecular weight of the human liver LDL receptor, approximately 132,000 on nonreduced polyacrylamide gels, is identical to that of LDL receptors detected in normal human skin fibroblasts by the same methods. LDL receptor-dependent binding activity in human liver samples has been semi-quantitated by integrating the areas under the peaks after scanning photographs of ligand blots, and receptor protein determined by radioimmunoassay with purified bovine adrenal LDL receptor protein as the standard. There was a highly significant correlation between the values obtained by each method for seven different liver samples (r = 0.948). The LDL receptor protein content of liver membranes from 10 subjects as determined by radioimmunoassay was inversely related to the plasma LDL cholesterol concentration (r = 0.663, p = 0.05) but not to other plasma lipid values, including total plasma cholesterol, high density lipoprotein cholesterol, or plasma triglyceride concentrations.

Difference in saturable binding of low density lipoprotein to liver membranes from normocholesterolemic subjects and patients with heterozygous familial hypercholesterolemia.

To investigate the possible role of the low density lipoprotein (LDL) receptor in the catabolism of LDL by the human liver, the binding of 125I-labeled LDL to membrane fractions prepared from human liver biopsies was determined. Biopsy samples taken for routine histology were obtained from seven patients with heterozygous familial hypercholesterolemia, one with non-familial hypercholesterolemia, and seven normocholesterolemic subjects. LDL was bound by the membranes from normal subjects in a saturable manner that was inhibited by 56% in the presence of excess LDL. Binding of LDL was also inhibited by modification of the lipoproteins with 1,2-cyclohexanedione. The amount of 125I-labeled LDL bound to membranes from familial hypercholesterolemic livers that could be displaced with excess LDL was significantly less than that bound by normocholesterolemic membranes. These observations suggest that LDL receptors are expressed in normal human liver and are defective in the livers of familial hypercholesterolemic patients.

The effect of partial ileal bypass on receptor-mediated uptake and catabolism of low density lipoprotein in the rhesus monkey.

The fractional rates of catabolism (FCR) of 125I-labelled low-density lipoprotein (LDL) and 131I-labelled LDL coupled with 1,2-cyclohexanedione (LDL-CHD) were determined before and 6 weeks after partial ileal bypass in three Rhesus monkeys. Receptor-mediated catabolism, determined as the difference between the FCRs of 125I-LDL and 131I-LDL-CHD, increased significantly after partial ileal bypass. Analysis of tissue distribution of radioactivity in one monkey, killed at the conclusion of a third turnover study 6 months after partial ileal bypass, suggested that the liver was the main tissue site of accumulation of LDL, and that uptake had occurred mainly via a receptor-mediated mechanism. It is concluded that partial ileal bypass stimulates receptor-mediated LDL catabolism in the Rhesus monkey as in man, and that this increase is probably mediated via hepatic LDL receptors.

Serum cholesterol levels in patients with familial hypercholesterolemia confirmed by tissue culture.

Sixty-two subjects from 23 families were evaluated by serum lipid analyses and tissue culture biochemistry in skin fibroblasts. In 53 cases from 19 families with proven familial hypercholesterolemia (FHC), fibroblast cultures were successful. In 45 of these cases (85%) the clinical diagnosis of hyper- or normocholesterolemia was in accordance with the tissue culture findings. Four patients 2-38 years old, had hypercholesterolemia but normal tissue culture results. Four patients, 18-44 years old, had normal serum cholesterol levels for their age and sex, but were heterozygotes according to tissue culture results. In the remaining four families only the propositus had hypercholesterolemia. All members of the families including the propositus had normal tissue culture determinations indicating that not all cases of idiopathic hypercholesterolemia are due to the Goldstein-Brown mechanism of defective LDL receptor function.