Diagnostic Discrepancies in Haematological Malignancies - A Casebook of Teamwork and Techniques

1. Sandra Birdsall Haematology, Cardiff Part 2 written option by Casebook

2. Why I choose a Casebook? • Easiest to undertake independently • No additional resources needed • Used retrospective data rather than prospective planning • Proposal was accurate • All information required easily available • Quickest

3. Contents • Index • Introduction • Cases • Conclusion • Materials and methods • Schematic Diagram of locations of the FISH Probe sets used in this casebook • Acknowledgements • References

4. Diagnostic Discrepancies in Haematological Malignancies –The Benefits of Multidisciplinary Teamwork • 2-3 hours to collect data • 4-5 hours to collect images • Around 3 weeks to write • Further 2-3 weeks to tidy up • 2 days type corrections and write report (longer to think what needed doing)‏

5. Plan • Cases, that demonstrated diagnostic discrepancies between different diagnostic modalities used in leukaemia’s and lymphomas. • I performed either the conventional or molecular cytogenetic analysis. • Molecular, morphological, immunophenotypic and immunohistochemical testing was carried out in different laboratories (indicated in the text). • included false positive and false negative RT-PCR and DNA-PCR, false negative G-banded analysis and FISH, and false positive and false negative immunohistochemistry. • Discussed possible conclusions and further testing undertaken in order to establish the correct diagnosis. • presented relevant literature to provide evidence of the relative sensitivities of techniques used. • Role of cytogenetic technologies in the future of pathological diagnosis

6. Cases 1-4 • Case 1: Probable False Negative RT-PCR for an Inverted Chromosome 16. • PCR –ve • Cyto and FISH +ve • Case 2: False Negative Conventional Cytogenetic and FISH Studies in a Philadelphia Positive ALL • PCR +ve • Cyto and FISH –ve cultured BM, FISH +ve BM smear • Case 3 – Possible False Positive RT-PCR for the BCR/ABL Gene Rearrangement • Cyto near-haploid FISH BCR-ABL –ve • PCR +ve • Case 4: Probable False Positive RT-PCR for the BCR/ABL Gene Rearrangement in a Childhood ALL. • Cyto Normal FISH –ve • PCR +ve

7. Cases 5-8 • Case 5: Probable False Negative DNA-PCR for an IGH/BCL2 gene rearrangement • Cyto and FISH +ve • PCR -ve • Case 6: Probable False Positive DNA PCR for an IGH/CCND1 gene rearrangement • Cyto (+3, +18) and FISH –ve • PCR +ve • Case 7: False Negative Immunohistochemistry for an IGH/CCND1 gene rearrangement • Cyclin D1 –ve • FISH +ve • Case 8: Potential false +ve diagnosis of Burkitt lymphoma by histopathological studies • ICC – Burkitt • FISH – transformed follicular

8. Assessor’s feedback after 4 months • 2 assessor’s grade B • 1st assessor – 2 pages corrections • 2nd assessor – 5 pages corrections • Some very minor points • Errors in references • Units missing of blood counts • Images miss-aligned with label • Other needed more work • Increase length of conclusion • Include costings

9. Obvious points I forgot • Index • Full materials and methods • My contribution within the casebook • I put it in the accompanying form only • Diagrams of FISH probe locations • Which cultures were used for analysis

10. Resubmission • Included list of the changes I had made • Addressed each point by each examiner • Resubmitted • No feedback for several months • Entered for Viva before acceptance came through