Robetorye, Ryan S.

Abstract Abstract 4743 Background: BMBX procedures are traditionally performed by physicians, NPs, or PAs using a manual method. It is uncommon for nurses to perform these procedures, and even more rare for nurses to perform them using non-traditional techniques, such as the battery-powered system (OnControl, Vidacare, Shavano, TX). In this study, we report our nurse-led BMBX team experience using OnControl to collect diagnostic BMBX samples. Patient care and safety, team satisfaction, and specimen quality were evaluated. Methods: A team of nurses trained to perform BMBX procedures on sedated and non-sedated patients completed 94 procedures using OnControl and established SOPs. All nurses completed a questionnaire aimed at assessing the patient experience during and after the procedure and overall nurse satisfaction with OnControl. Specimen quality was graded by 3 physicians and compared to 25 specimens obtained by the same nursing team using traditional methods. Bone core specimens were graded based on core length and the presence/absence of artifacts. Biopsies had to be >1 cm or >1.5 cm to qualify good or excellent, respectively. Aspirates were similarly evaluated taking into account the presence/absence of spicules on stained smears. Results: Patient Care & Safety: The majority (86.2%) of patients who underwent a BMBX procedure during the study were outpatients, and minimal sedation was used in 94.7%. Most patients (76.6%) had a prior BMBX using the traditional method. In 94 patients evaluated, pre-procedure pain was 0 (0-10 scale) in 72 (76.5%) while 21 (22.3%) reported pain up to 5 just before the procedure (avg=2). The post-procedure pain score in the same patients was 0 in 78 (83%) and up to 4 in six (6%) (avg=1). No patients had post-procedure bleeding or complications requiring medical care. Seventy patients were reached 24 hrs post-procedure: 33 (47%) reported no pain and 37 (53%) reported pain up to 8 (avg=2.5). Nurse BMBX Team Satisfaction: Team members reported 100% satisfaction with the process of inserting the OnControl biopsy needle through soft tissues and acquiring a core biopsy. The nurses reported having satisfactory control of the depth of needle through the cortex and into the medullary space using the needle guide 95% of the time. Team members were satisfied with the ease of obtaining an aspirate 93% of the time. Nearly all (95%) nurses felt improved ergonomics using the battery-powered driver compared to the manual method. The nurses reported that OnControl was easy to use, with 83% of them obtaining a core biopsy on their first attempt. All nurses indicated they would use OnControl over the manual method if given the choice. Specimen Quality: H&E-stained bone core biopsy slides and W-G-stained aspirate smears from 83/94 specimens collected using OnControl were reviewed and graded. All but two (2.4%) of the bone core specimens were adequate for diagnosis. Of adequate samples, 45.8% were excellent, 12% good, and 39.8% fair. Aspiration artifact was seen in 18/83 (21.6%) of cores, and that artifact was the reason for a downgrade to fair quality in 17/18 (94%). Extra aspirate material for research was collected in 7/18 with fair quality bone core biopsies. Similar grading applied to 25 core biopsy samples collected using the manual method revealed 44% of cores to be excellent, 20% good, 32% fair, and 4% poor. The average core length using OnControl and the traditional method was 1.6 cm and 1.7 cm, respectively. Five of 83 (6%) aspirates obtained using OnControl were poor quality due to lack of bone marrow cells. Of the remaining aspirates, 54.2% were excellent, 20.5% good, and 19.2% fair. Factors related to bedside technique caused a downgrade in 10/16 samples graded as fair and 5/17 samples graded as good. Aspirates obtained by the standard method were graded as 52% excellent, 28% good, 12% fair, and 8% poor. Conclusions: Trained nurses can safely and effectively perform BMBX procedures using traditional methods as well as novel techniques such as the OnControl battery-powered driver system. In the hands of experienced individuals, OnControl can consistently yield high-quality BMBX specimens. Aspiration artifact was the most common flaw found in bone cores obtained with OnControl, but it was usually focal and did not hinder interpretation. When artifact associated with technical aspects out of the control of the BMBX operator was excluded, the OnControl needle produced good-excellent aspirate in 87% of patients. Disclosures: No relevant conflicts of interest to declare.

Abstract Introduction Primary mediastinal large B-cell lymphoma (PMLBCL) is recognized as a distinct lymphoid neoplasm. However, differentiation from diffuse large B-cell lymphoma (DLBCL) can be difficult due to the need for close clinicopathologic correlation and variability in morphology and immunophenotype. In addition, a recent study identified lymphomas that share molecular and morphological features with PMBCL, yet do not involve the mediastinum. Correct classification of PMBCL may impact therapeutic decision making, increasing the demand for more accurate diagnostic methods. Recent research identified a new gene expression signature that robustly differentiated PMLBCL from DLBCL in both training and independent validation cohorts using RNA isolated from routinely available formalin-fixed, paraffin-embedded (FFPE) tissues. Methods This assay, known as the “Lymph3Cx,” utilizes the nCounter platform (NanoString Technologies, Seattle, WA) and consists of probes for 58 target genes (including both discriminatory and housekeeping genes) that can distinguish PMLBCL cases from DLBCL as well as the “cell-of-origin” subtypes of DLBCL. In the current study reported here, the Molecular Diagnostics–Arizona Laboratory (MDAZL) performed a full validation of the Lymph3Cx assay for use in our clinical diagnostic laboratory. Results Assay performance included accuracy (92.9%), precision (100%), analytical sensitivity (100 ng RNA limit of detection), analytical specificity (measures are in place to prevent interfering substances), reproducibility between technologists and technical replicates (100%), specimen stability (18 months for unstained tissue sections), and RNA Isolation Kit Utility (two kits with equal performance) in order to become the first CLIA-certified, CAP-accredited clinical diagnostics laboratory to offer a molecular assay for distinction of PMLBCL from DLBCL. Conclusion The Lymph3Cx assay will be prospectively used for evaluation of Mayo Clinic patients and for use as an integrated biomarker in clinical trials.

Abstract Introduction Lymph2Cx lymphoma cell-of-origin assay (LM2CX) was developed by the Lymphoma/Leukemia Molecular Profiling Project (LLMPP) to better categorize diffuse large B-cell lymphoma (DLBCL). NanoString has licensed the assay and is currently pursuing FDA approval. In the meantime, the test is offered exclusively as a lab-developed test (LDT) by the Mayo Clinic Molecular Diagnostics–Arizona Lab (MDAZL) to Mayo Clinic Enterprise patients. In order to comply with these restrictions, the normal workflow for Mayo Clinic Rochester has been modified as cases are sent to Arizona. Rochester consultants order LM2CX using their local laboratory information system (LIS). Slides are prepared by Rochester histology and then shipped to Arizona, where they are entered into the Arizona LIS and processed. In July 2018, we discovered numerous cases that were ordered but not shipped. Because this step took place at the LIS transition between Arizona and Rochester, it was not detected immediately. Methods Allied Health Staff (AHS) colleagues in Rochester and Arizona had the unique opportunity to collaborate. After Arizona AHS identified the problem, they reached out to the Rochester pathology reporting specialists (PRSs) and began a joint improvement project. Together, we were able to measure the impact of the problem, with Arizona auditing digitally, while Rochester audited physical cases. We found 29% of the cases were handled improperly over a 6-month time period. In order to eliminate the gap, Rochester implemented several improvements, including training, tagging all LM2CX cases, and huddle discussions, while Arizona AHS monitored the process digitally. Results Since implementation of improvements, we have had zero defects. Modifications to AHS/consultant training in Rochester will ensure continued success. Conclusions This intervention illustrates the importance of strong collaborations in order to quickly respond to testing issues and provide the greatest value to patients.

BackgroundB‐lymphoblastic leukemias (B‐LBL) with combined IGH/BCL2 and MYC rearrangement are rare and their clinical, cytogenetic and immunophenotypic features are not well characterized. Here, we describe a case of a 61‐year‐old woman with B‐LBL associated with these cytogenetic alterations and present a review of the literature of this disease.MethodsFour‐color flow cytometry (FC) was performed on a BD FACSCanto II flow cytometer. Data were analyzed with BD FACSDiva software. Cytogenetic, fluorescence in situ hybridization (FISH), and molecular studies were performed by conventional methods. A review of the literature was performed by a PubMed‐assisted search.ResultsIncluding our case, eight B‐LBLs associated with a documented “double‐hit” karyotype (IGH/BCL2 and 8q24/MYC rearrangement) were identified in the literature (male/female 2/6, age 15‐65). Three occurred de‐novo, and five had a history of a CD10+ B‐cell lymphoma. The typical immunophenotype was CD10, CD19, TdT positive, and negative for CD34 and surface immunoglobulin (Ig), established either by FC or immunohistochemistry. Seven cases were CD20‐, and one case was CD20+. Translocation partners of MYC varied, and included IGH, lambda light chain, and an unknown gene on chromosome 9. Prognosis was poor with median survival of five months.ConclusionsPatients with B‐LBL associated with a combined IGH/BCL2 and MYC rearrangement often have a history of a mature B‐cell lymphoma. The immunophenotype of these cases is different from that of mature “double‐hit” lymphomas; FC is essential to differentiate the B‐LBL cases from the leukemic phase of mature B‐cell lymphomas. © 2015 International Clinical Cytometry Society

Primary Epstein-Barr virus (EBV) infection occurs mainly in adolescents and young adults, with more than 90% of adults having serological evidence of past infection. Primary infection in those over the age of 40 is associated with an atypical and often more severe presentation that can lead to more extensive and invasive, and often unnecessary, diagnostic testing. The incidence of severe EBV-related illness in older adults has been observed to be increasing in industrialized nations. The characteristic presentation of infectious mononucleosis (IM) syndrome in elderly patients (age > 65) is not clearly defined in the literature. Here, we describe a case of primary EBV infection in an 80-year-old female and review the literature regarding primary seroconversion in elderly patients.

Abstract Introduction: Only few genetic studies have been performed in PCNSL, partly due to the rarity of the tumors and the limited amount of available tissue. Unlike nodal DLBCL, PCNSL is poorly understood in terms of its precise histogenetic origin and molecular pathogenesis. It is still a matter of debate whether PCNSL differs from nodal DLBCL with respect to their molecular features and pathogenesis and also if there is a genomic signature PCNSL-specific. Materials and Methods: To determine the pattern of genetic alterations, 17 immunocompetent (EBV-, HIV-) PCNSL were analyzed by aCGH. Seven cases were analyzed using fresh tumor samples and 10 using formalin-fixed paraffin embedded (FFPE) tissues. B-cell differentiation status was characterized by immunostains for CD10, MUM-1, and BCL-6. The aCGH profile from PCNSL cases was compared with aCGH data obtained from 59 nodal DLBCL. Results: We found a complex karyotype with a median of 21 copy-number abnormalities (CNA) per case (range 10-49). Overall, 18 regions (10 losses and 8 gains) were affected in >20% of cases. Loss of 9p21 (CDKN2A) was the commonest CNA (82% of cases). Other common CNAs were loss of 6q23.3 (TNFAIP3; 59%), 6p21 (HLA genes; 53%), 6q21 (PRDM1; 47%) and gain of 12q21-q24 (53%), 7q21-q31 (35%) and 19q13 (35%). Five novel recurrent focal CNAs were found in PCNSL; loss of 3p21.31, 3q26.32, 10p15.3-p14, 12q24.31 and 16q12.1-q21 (29% of cases each). All of them, excluding –16q12.1-q21, were found either in less than 5% or absent in nodal DLBCL, thus suggesting to be unique to PCNSL. Recurrent homozygous deletions were found in CDKN2A, TMEM30A, TOX and CD58, the latter two involved in T-cell development and activation. CD58 was also recurrently affected by small focal deletions in the Ig-like C2-type domain. Furthermore, DNA sequencing analysis showed missense mutations in the Toll/IL-1 receptor domain of MYD88 in 35% of PCNSLs. Another 34 genes, including B2M, ETV6, MHC class II genes, PRDM1, and TNFRSF10A were homozygously deleted. Bioinformatics analysis including the most commonly affected genes showed an enrichment of networks associated with immune response, NF-kB pathway, proliferation, regulation of the apoptosis and lymphocyte differentiation and activation. Conclusions: We showed evidence of a highly complex genome and identified a subset of genes with potential relevance in PCNSL pathogenesis. The genomic profile described here reinforces the existence of a specific molecular signature in PCNSL, thus helping to genetically differentiate this entity from the nodal DLBCL and related lymphomas. Additionally, the results obtained from FFPE samples are encouraging and larger archival tissue collections can now be analyzed in order to complement the still fragmented knowledge we have of the genetic basis of the disease. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5081. doi:1538-7445.AM2012-5081