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Test Code BLBLF B-Cell Lymphoblastic Leukemia/Lymphoma, FISH, Tissue


Ordering Guidance


This test does not include a pathology consultation. If a pathology consultation is requested, order PATHC / Pathology Consultation, and appropriate testing will be added at the discretion of the pathologist and performed at an additional charge.

 

For testing non-paraffin bone marrow or blood specimens from patients with B-cell acute lymphoblastic leukemia/lymphoma, order either BALPF / B-Cell Acute Lymphoblastic Leukemia/Lymphoma (ALL), Pediatric, FISH, Varies or BALAF / B-Cell Acute Lymphoblastic Leukemia/Lymphoma (ALL), FISH, Adult, Varies, depending on the patient's age. If a non-paraffin embedded bone marrow or blood specimen is received for this test, this test will be canceled, and either BALPF or BALAF, depending on patient's age, will be added and performed as the appropriate test.

 

For patients with B-cell lymphoma, order BLYM / B-Cell Lymphoma, FISH, Tissue.



Shipping Instructions


Advise Express Mail or equivalent if not on courier service.



Necessary Information


1. A pathology report is required for testing to be performed. If not provided, appropriate testing and/or interpretation may be compromised or delayed. Acceptable pathology reports include working drafts, preliminary pathology, or surgical pathology reports.  

2. The following information must be included in the report provided.?? 

1. Patient name? 

2. Block number - must be on all blocks, slides, and paperwork?? 

3. Date of collection? 

4. Tissue source? 

3. A reason for testing must be provided. If this information is not provided, an appropriate indication for testing may be entered by Mayo Clinic Laboratories.



Specimen Required


Submit only 1 of the following specimens:

 

Preferred

Specimen Type: Tissue block

Collection Instructions: Submit a formalin-fixed, paraffin-embedded tumor tissue block. Blocks prepared with alternative fixation methods may be acceptable; provide fixation method used.

Additional Information:

1. Paraffin-embedded specimens can be from any anatomic location (skin, soft tissue, lymph node, etc).

2. Bone specimens that have been decalcified will be attempted for testing, but the success rate is approximately 50%.

 

Acceptable

Specimen Type: Tissue slides

Slides: 1 Hematoxylin and eosin stained and 20 unstained

Collection Instructions: Submit 1 slide stained with hematoxylin and eosin and 20 consecutive unstained, positively charged, unbaked slides with 5-micron thick sections of the tumor tissue.


Forms

If not ordering electronically, complete, print, and send 1 of the following forms with the specimen:

-Hematopathology/Cytogenetics Test Request (T726)

-Children's Oncology Group Test Request (T829)

Useful For

Detecting, at diagnosis, recurrent common chromosome abnormalities associated with B-cell acute lymphoblastic leukemia/lymphoma (B-ALL/LBL) and Philadelphia chromosome-like acute lymphoblastic leukemia (Ph-like ALL) in paraffin-embedded specimens

Reflex Tests

Test ID Reporting Name Available Separately Always Performed
_IL25 Interphases, <25 No, (Bill Only) No
_I099 Interphases, 25-99 No, (Bill Only) No
_I300 Interphases, >=100 No, (Bill Only) No
_PADD Probe, +1 No, (Bill Only) No
_PB02 Probe, +2 No, (Bill Only) No
_PB03 Probe, +3 No, (Bill Only) No
_PBCT Probe, +2 No, (Bill Only) No

Testing Algorithm

This test includes a charge for the probe application, analysis, and professional interpretation of results for one probe set (2 individual fluorescence in situ hybridization [FISH] probes). Additional charges will be incurred for all reflex or additional probe sets performed. No analysis charges will be incurred if an insufficient number of representative cells are available for analysis.

 

This FISH test allows different combinations of probes to be utilized based on the patient's age and clinical question, including the standard (diagnostic) B-cell lymphoblastic lymphoma (B-LBL) FISH panel and the individual B-LBL FISH probes (per client request).

 

The FISH initial (diagnostic) panel for patients aged 30 years or younger includes testing for the following abnormalities using the FISH probes listed:

+9/9p-, CDKN2A/D9Z1

t(9;22)(q34;q11.2), BCR/ABL1

11q23 rearrangement, MLL (KMT2A) break-apart

-17/17p-, TP53/D17Z1

t(1;19)(q23;p13), PBX1/TCF3

Hyperdiploidy, +4,+10,+17, D4Z1/D10Z1/D17Z1

t(12;21)(p13;q22), ETV6/RUNX1 fusion and iAMP21

14q32 rearrangement, IGH break-apart

8q24.2 rearrangement, MYC break-apart

 

If results for the initial panel are negative or demonstrate nonclassical abnormalities, the Philadelphia chromosome-like acute lymphoblastic leukemia (Ph-like ALL) panel will be performed as a secondary panel. The Ph-like ALL panel includes testing for the following kinase activating chromosome abnormalities, using the FISH probes listed below, as well as IKZF1 deletion, which often accompanies Ph-like ALL.

1q25 rearrangement, ABL2 break-apart

5q32 rearrangement, PDGFRB break-apart

9p24.1 rearrangement, JAK2 break-apart

9q34 rearrangement, ABL1 break-apart

 

The FISH initial (diagnostic) panel for patients aged 31 years or older includes testing with the following FISH probe: t(9;22)(q34;q11.2), BCR/ABL1

 

If BCR::ABL1 fusion is not observed, the Ph-like ALL panel will be performed as a secondary panel. The Ph-like ALL panel includes testing for the following kinase activating chromosome abnormalities, using the FISH probes listed below.

1q25 rearrangement, ABL2 break-apart

5q32 rearrangement, PDGFRB break-apart

9p24.1 rearrangement, JAK2 break-apart

9q34 rearrangement, ABL1 break-apart

 

Finally, if results for the Ph-like panel are negative or demonstrate nonclassical abnormalities, the following probe sets will be performed as a tertiary panel:

t(1;19)(q23;p13), PBX1/TCF3 fusion

Hyperdiploidy, +4,+10,+17, D4Z1/D10Z1/D17Z1

t(12;21)(p13;q22) or iAMP21, ETV6/RUNX1

14q32 rearrangement, IGH break-apart

11q23 rearrangement, MLL (KMT2A) break-apart

 

Appropriate ancillary probes may be performed at consultant discretion to render comprehensive assessment. Any additional probes will have the results included within the final report and will be performed at an additional charge.

 

When an MLL(KMT2A) rearrangement is identified, appropriate reflex testing will be performed to identify the translocation partner. Probes include identification of t(4;11)(q21;q23) AFF1::MLL(KMT2A), t(6;11)(q27;q23) MLLT4(AFDN)::MLL(KMT2A), t(9;11)(p22;q23) MLLT3::MLL(KM2TA), t(10;11)(p12;q23) MLLT10::MLL(KMT2A), t(11;19)(q23;p13.3) MLL(KMT2A)::MLLT1, or t(11;19)(q23;p13.1) MLL(KMT2A)::ELL. In the event an 11q23 translocation is (or has been) identified by chromosome or FISH analysis, only the targeted MLL(KMT2A) reflex probe will be performed if applicable.

 

In the absence of BCR::ABL1 fusion, when an extra ABL1 signal is identified, reflex testing may be performed at the laboratory's discretion using the ABL1 break-apart probe set to evaluate for the presence of a potential variant translocation involving ABL1, t(9;var)(q34;?). Laboratory discretion may be influenced by available karyotype or other FISH results.

 

In the absence of ETV6::RUNX1 fusion, when an extra ETV6 signal is identified, reflex testing may be performed at the laboratory's discretion using the ETV6 break-apart probe set to evaluate for the presence or absence of a potential variant translocation involving ETV6, t(12;var)(p13;?). Laboratory discretion may be influenced by available karyotype or other FISH results.

 

If a MYC rearrangement is identified, both the BCL2 and BCL6 break-apart probe sets will be performed.

 

For more information see B-Lymphoblastic Leukemia/Lymphoma Algorithm.

Method Name

Fluorescence In Situ Hybridization (FISH)

Reporting Name

B-Lymphoblastic Leuk/Lymph, FISH,Ts

Specimen Type

Tissue

Specimen Minimum Volume

Slides: 1 Hematoxylin and eosin stained and 15 unstained

Specimen Stability Information

Specimen Type Temperature Time Special Container
Tissue Ambient (preferred)
  Refrigerated 

Reject Due To

All specimens will be evaluated at Mayo Clinic Laboratories for test suitability.

Clinical Information

In the United States, the incidence of B-lymphoblastic leukemia/lymphoma (B-ALL/LBL) is roughly 6000 new cases per year, or approximately 1 in 50,000. B-ALL/LBL accounts for approximately 70% of all childhood leukemia cases (ages 0 to 19 years), making it the most common type of childhood cancer. It has a peak incidence at 2 to 5 years of age. This incidence decreases with age before increasing again at around 50 years of age.

 

Per National Comprehensive Cancer Network guidelines, a combination of cytogenetic and FISH testing is currently recommended in all pediatric and adult patients with B-ALL/lymphoblastic lymphoma (LBL). Additional cytogenetic techniques, such as chromosomal microarray (CMAH / Chromosomal Microarray, Hematologic Disorders, Varies), may be helpful in resolving either questions related to ploidy (hyperdiploid clone vs doubled hypodiploid clone) or certain clonal structural rearrangements, such as the presence or absence of intra-chromosomal amplification of chromosome 21 (iAMP21). A summary of the characteristic chromosome abnormalities identified in B-ALL is listed in the following table.

 

Table. Common Chromosome Abnormalities in B-cell Acute Lymphoblastic Leukemia

Leukemia type

Cytogenetic change

Typical demographic

Risk category

B-acute lymphoblastic leukemia

 

t(12;21)(p13;q22), ETV6::RUNX1

Pediatric

Favorable

Hyperdiploidy

Pediatric

Favorable

t(1;19)(q23;p13.3), PBX1::TCF3

Pediatric

Intermediate to favorable

t(9;22)(q34;q11.2), BCR::ABL1

All ages

Unfavorable

iAMP21, RUNX1

Pediatric

Unfavorable

del(9p), CDKN2A

All ages

Unknown

t(11q23;var), MLL rearrangement

All ages

Unfavorable

t(4;11)(q21;q23), AFF1::MLL

All ages

Unfavorable

t(6;11)(q27;q23), MLLT4(AFDN)::MLL

All ages

Unfavorable

t(9;11)(p22;q23), MLLT3::MLL

All ages

Unfavorable

t(10;11)(p12;q23), MLLT10::MLL

All ages

Unfavorable

t(11;19)(q23;p13.1), MLL::ELL

All ages

Unfavorable

t(11;19)(q23;p13.3), MLL::MLLT1

All ages

Unfavorable

t(14q32;var), IGH rearrangement

All ages

Variable

t(X;14)(p22;q32)/t(Y;14)(p11;q32), CRLF2::IGH

Adolescent/ young adult

Unfavorable

t(Xp22.33;var) or t(Yp11.32;var), CRLF2 rearrangement

All ages

Unfavorable

t(Xp22.33;var) or t(Yp11.32;var), P2RY8 rearrangement

All ages

Unfavorable

-17/17p-, TP53

All ages

Unfavorable

t(8q24.2;var), MYC rearrangement
*representing Burkitt or other mature B-cell lymphoma

Pediatric/ adolescent/ young adult

Complex karyotype (≥4 abnormalities)

Adult

Unfavorable

Low hypodiploidy/near triploidy

Adult

Unfavorable

Near-haploid/hypodiploid

All ages

Unfavorable

del(7p) IKZF1

All ages

Unfavorable in absence of ERG deletion

Philadelphia chromosome-like acute lymphoblastic leukemia (Ph-like ALL)

t(1q25;var), ABL2

Pediatric/ adolescent/ young adult

Unfavorable

t(5q32;var), PDGFRB

t(9p24.1;var), JAK2

t(9q34;var), ABL1

t(Xp22.33;var) or t(Yp11.32;var), CRLF2

t(Xp22.33;var) or t(Yp11.32;var), P2RY8

Reference Values

An interpretive report will be provided.

Interpretation

A neoplastic clone is detected when the percent of cells with an abnormality exceeds the normal reference range for any given probe set.

 

A positive result is not diagnostic for B-cell lymphoblastic lymphoma but may provide relevant prognostic information.

 

The absence of an abnormal clone does not rule out the presence of an acute B-cell lymphoblastic leukemia/lymphoma or another neoplastic disorder.

Cautions

This test is not approved by the US Food and Drug Administration and is best used as an adjunct to existing clinical and pathologic information.

 

Fixatives other than formalin (eg, Prefer, Bouin's) may not be successful for fluorescence in situ hybridization (FISH) assays. Non-formalin fixed specimens will not be rejected. 

 

Paraffin-embedded tissues that have been decalcified may not be successful for FISH analysis. The success rate of FISH studies on decalcified tissue is approximately 50%.

 

FISH studies will be attempted if sufficient tumor is present for analysis. If insufficient tissue/tumor is available for testing, the pathologist reviewing the hematoxylin and eosin-stained slide may find it necessary to cancel testing.

 

If no FISH signals are observed post-hybridization, the case will be released indicating a lack of FISH results.

Supportive Data

For each probe set, blinded fluorescence in situ hybridization analysis was performed on 20 to 25 normal paraffin-embedded, formalin-fixed tissue controls and between 2 and 20 paraffin-embedded, formalin-fixed tissue samples from patients diagnosed with B-cell lymphoblastic leukemia or lymphoma. Results from the 25 controls were used to generate the normal cutoff values.

Method Description

This test is performed using commercially available and laboratory-developed probes. Deletion of the CDKN2A locus on chromosome 9, the TP53 locus on chromosome 17, and gain of chromosomes 4, 10, and 17 are detected using enumeration strategy probes. Rearrangements involving ABL2, PDGFRB, MYC, JAK2, ABL1, MLL, ETV6, and IGH are detected using a dual-color break-apart (BAP) strategy probe. Dual-color, dual-fusion fluorescence in situ hybridization strategy probe sets are used to detect t(9;22), t(12;21), t(1;19), and in reflex testing when rearrangements of the MLL gene are detected. If separation of the MYC gene is identified, break-apart BCL2 and BCL6 will be evaluated using a dual-color BAP strategy probe.

 

Paraffin-embedded tissue samples are cut at 5 microns and mounted on positively charged glass slides. The selection of tissue and the identification of target areas on the hematoxylin and eosin (H and E)-stained slide are performed by a pathologist. Using the H and E-stained slide as a reference, target areas are etched with a diamond-tipped engraving tool on the back of the unstained slide to be assayed. The probe set is hybridized to the appropriate target areas, and 2 technologists each independently analyze 50 interphase nuclei (100 total) with the results expressed as the percent of abnormal nuclei.(Unpublished Mayo method)

Day(s) Performed

Monday through Friday

Report Available

7 to 10 days

Specimen Retention Time

Slides and H and E used for analysis are retained by the laboratory in accordance with regulatory requirements. Client provided paraffin blocks and extra unstained slides will be returned after testing is complete.

Performing Laboratory

Mayo Clinic Laboratories in Rochester

Test Classification

This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. It has not been cleared or approved by the US Food and Drug Administration.

CPT Code Information

88271 x 2, 88291-DNA probe, each (first probe set), interpretation and report

88271 x 2-DNA probe, each; each additional probe set (if appropriate)

88271-DNA probe, each; coverage for sets containing 3 probes (if appropriate)

88271 x 2-DNA probe, each; coverage for sets containing 4 probes (if appropriate)

88271 x 3-DNA probe, each; coverage for sets containing 5 probes (if appropriate)

88274 w/modifier 52-Interphase in situ hybridization, <25 cells, each probe set (if appropriate)

88274-Interphase in situ hybridization, 25 to 99 cells, each probe set (if appropriate)

88275-Interphase in situ hybridization, 100 to 300 cells, each probe set (if appropriate)

LOINC Code Information

Test ID Test Order Name Order LOINC Value
BLBLF B-Lymphoblastic Leuk/Lymph, FISH,Ts 102100-5

 

Result ID Test Result Name Result LOINC Value
609452 Result Summary 50397-9
609453 Interpretation 69965-2
609454 Result Table 93356-4
609455 Result 62356-1
GC057 Reason for Referral 42349-1
609456 Specimen 31208-2
609457 Source 31208-2
609458 Tissue ID 80398-1
609459 Method 85069-3
609460 Additional Information 48767-8
609461 Disclaimer 62364-5
609462 Released By 18771-6