Case Report: Early diagnosis of Hodgkin’s disease based On Flow Cytometry parameters

Case Report: Early diagnosis of Hodgkin’s disease based On Flow Cytometry parameters

Mohammad S Al-Haggar (1), Ahmad A Settin (1), Seham A AlMansy (2), Tarek A Atia (3), Rizk A ElBaz (1), Zakaria I AlMorsy (1)

(1) Genetics Unit, Mansoura University Children Hospital
(2) Faculty of Science (Damietta), Mansoura University,
(3) Histology Department, Al-Azhar University, Cairo

Correspondence: Mohammad Al-Haggar, MD, Paediatrics Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt, e-mail: mhajjar2000@yahoo.co.uk


Presentation:

On October 2004, a male patient aged 5.6 years presented to the outpatient clinic of Mansoura University Children’s Hospital, Mansoura, Egypt with cervical lymphadenopathy. Generally, the patient was clinically fit with no local signs other than the above, with no generalized manifestations of any systemic disease or other gland enlargements. Local examination revealed significant lymphadenopathy of 2X3 cm size which is rubbery in consistency and not tender. Laboratory workup included CBC, ESR and serum ferritin; all were found within the normal range. Chest radiograph and abdominal ultrasound were non revealing. Because of the significant size and suspicious consistency we tried to convince the family for the need to do an excision lymph node biopsy but in vain. They only accepted close fine needle aspiration for histological examination and Flow Cytometry (FCM) evaluation of DNA ploidy and apoptosis using FACS caliber flow cytometer (Becton Dickinson, Sunnyvale, CA, USA). The average number of evaluated nuclei per specimen was 20.000; with the rate of nuclei scanning of 120 per second. For the patient, FCM revealed highly suspicious plot diagrams for Lymphoma (figure: 1) although the histological examination was non-informative. The attending oncologist recommended either observational follow up or open biopsy for confirmation followed by chemotherapy. As the case was cold, patient was asked to attend monthly for serial evaluation of the gland size and routine laboratory workup. In March 2005, there was a slight elevation in the sedimentation rate associated with more enlargement of the lymph gland coupled with some tenderness over the gland to the degree the surgeon suspected abscess formation. Excision biopsy was done and a pathological diagnosis of large cell Hodgkin’s was made thus confirming the finding of the Flow Cytometry (figure: 2).

Discussion:
In lymphoma Fine needle aspiration samples sometimes contain few normal cells, a single peak deviation more than 5% from the expected position for diploid cells which is considered as aneuploidy (1). The degree of aneuploidy could be determined by the DNA index (DI), which represents the ratio of fluorescence intensity of aneuploid cells to the diploid cells; DI of a diploid tumor is 1.0, whereas those of aneuploid tumors are progressively higher (2). In Hodgkin’s disease, FCM might miss the diagnosis because of either the intra-tumor DNA heterogeneity or the limited sample size for DNA analysis, thus minimizing the clinical significance of DNA content as a diagnostic parameter in Hodgkin’s disease (3).
Fortunately in our case, DNA content was so informative that it gave a high DI (more than 1.0), low S-phase portion with highly suspicious aneuploidy pattern and apoptotic percentage on FCM evaluation. However, other DNA cycle parameters were not conclusive so that the final conclusion of borderline malignancy was considered. In such cases pathological diagnosis is highly recommended to confirm the possibility of malignancy for early therapeutic intervention.

Reference:
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2. Gِrdon KM, Duckett L, Dual B, Petrie HT: A simple method for detecting up to five immunofluorescent parameters together with DNA staining for cell cycle or viability on a bench top flow cytometry. J Immunol Methods (2003); 275:113-121.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12667675&query_hl=5

3. Kushibe K, Lioka S, Nezu K, Tojo T, Sawabata N, Kitamura S: Flow cytometric analysis of the DNA content of thymoma. Surg Today (1995); 25:334-337. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7633125&query_hl=7