Krishna Leons G, Sharma P, Gupta SK
… +4 more, Bakhshi S, Gupta R, Gajendra S, Pushpam D
Int J Lab Hematol
· 2026 Jun · PMID 41667079
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INTRODUCTION: The B-ALL risk-stratification needs improvement. The prevalence and impact of Retinoblastoma 1, that is, RB transcriptional corepressor 1 (RB1) deletion in pediatric B-ALL, alone and in concurrence with IKA...INTRODUCTION: The B-ALL risk-stratification needs improvement. The prevalence and impact of Retinoblastoma 1, that is, RB transcriptional corepressor 1 (RB1) deletion in pediatric B-ALL, alone and in concurrence with IKAROS family zinc finger 1 (IKZF1) deletion was estimated. METHODS: Multiplex ligation-dependent probe amplification (MLPA) was used to analyze the pediatric B-ALL cases for gene deletions. The cases were divided into subgroups based on RB1 deletions and IKZF1 deletions. IKZF1plus profile (IKZF1 and additional CDKN2A/B, PAX5, pseudoautosomal region deletion in absence of ERG deletion) was also noted. RESULTS: In 517 patients with median age 7 years (1-18), 41 (7.9%) had RB1 deletion and 99 (19.1%) IKZF1 deletion. Concurrent RB1 and IKZF1 deletions were 14 (2.7%), RB1 deletion without IKZF1 deletion 27 (5.2%), IKZF1 deletion without RB1 deletion 85 (16.4%), and none of RB1 or IKZF1 deletion 391 (75.6%). Of the treated patients (n = 465), cases with concurrent RB1 and IKZF1 deletions had the worst post-induction remission rate (54.6%; p = 0.019) compared to cases lacking RB1 or IKZF1 deletions (86%). The median event-free and overall survival were poor in cases with concurrent RB1 and IKZF1 deletions (8.9 months; p = 0.0002 and 11.5 months; p = 0.007 respectively) compared to cases lacking RB1 or IKZF1 deletions (41.4 months, and not reached respectively). The cases with RB1 deletion along with IKZF1plus profile had a trend of early deaths and relapses compared to IKZF1plus alone. CONCLUSIONS: The B-ALL patients with concurrent RB1 and IKZF1 deletions had worse outcomes compared to cases without any of these deletions. The RB1 deletion increased the risk of early events in patients with the IKZF1plus profile.
Ravi S, Kannan N, Manivannan P
… +2 more, Kar R, Kayal S
Int J Lab Hematol
· 2026 Jun · PMID 41650945
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INTRODUCTION: Early T-cell precursor acute lymphoblastic leukemia (ETP-ALL) is a distinct subtype of T-ALL defined by an immature immunophenotype and unique molecular features. It is often associated with chemoresistance...INTRODUCTION: Early T-cell precursor acute lymphoblastic leukemia (ETP-ALL) is a distinct subtype of T-ALL defined by an immature immunophenotype and unique molecular features. It is often associated with chemoresistance and poor outcomes. Accurate recognition is crucial for therapy optimization and consideration of hematopoietic stem cell transplantation. This study evaluated the Tokyo Children's Cancer Study Group (TCCSG) six-marker flow cytometric scoring system in identifying ETP-ALL and assessed its clinicopathological features and treatment outcomes. METHODS: All consecutive T-ALL cases diagnosed between 2019 and 2023 were retrospectively analyzed. Clinical, immunophenotypic, and treatment-related data were compared between ETP-ALL and non-ETP-ALL subgroups. The TCCSG six-marker scoring system (CD34, HLA-DR, CD8, CD5, CD13, CD33) was applied, and receiver operating characteristic curve analysis determined the optimal cutoff for diagnosis. RESULTS: Among 104 T-ALL cases, 25 (24.1%) were classified as ETP-ALL. ETP-ALL was more common in adults (> 18 years; 72.0% vs. 48.1%; p = 0.037). Compared with non-ETP-ALL, patients showed lower leukocyte counts (< 100 × 10/L), fewer peripheral blasts, and higher platelet counts (p < 0.05). At end-of-induction (EOI), complete remission rates were lower in ETP-ALL (73.3% vs. 96.6%; p = 0.014), though no significant differences were observed in EOI measurable residual disease, consolidation response, or survival between the groups. A cutoff score ≥ 3 using the TCCSG system yielded 88% sensitivity and 94.9% specificity (AUC = 0.986; p = 0.0001). CONCLUSION: ETP-ALL represents a biologically distinct T-ALL subtype with inferior early treatment responses. The TCCSG six-marker scoring system is reliable, accurate, and practical for routine diagnosis, particularly in resource-limited settings.
Police P, Noikongdee P, Phojanasenee T
… +1 more, Apipongrat D
Int J Lab Hematol
· 2026 Jun · PMID 41622716
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BACKGROUND: The activated partial thromboplastin time (aPTT) mixing test is widely used to investigate prolonged aPTT from factor deficiencies, inhibitors, or lupus anticoagulant (LA), but its interpretation remains chal...BACKGROUND: The activated partial thromboplastin time (aPTT) mixing test is widely used to investigate prolonged aPTT from factor deficiencies, inhibitors, or lupus anticoagulant (LA), but its interpretation remains challenging. Refining protocols and indices may improve accuracy. OBJECTIVES: To compare classical and modified aPTT mixing tests using conventional and novel indices for distinguishing FVIII deficiency, FVIII inhibitors, LA, and heparin, and to develop a structured interpretation algorithm. METHODS: A total of 215 plasma samples (50 factor deficiencies, 51 FVIII inhibitors, 64 LA-positive, 50 heparinized) underwent classical and modified 1:1 mixing tests. ICA and %Correction were calculated for immediate and 2-h incubated mixes, while ΔICA and Δ%Correction were derived from their differences. Diagnostic performance was assessed by ROC analysis, and a proposed algorithm was designed. RESULTS: Both protocols demonstrated excellent reliability (ICC > 0.90) and substantial agreement in interpretation (κ = 0.65-0.75). The modified protocol consistently outperformed the classical approach, with index of circulating anticoagulant (ICA)-based indices showing the greatest improvement. Novel indices ΔICA and Δ%Correction further enhanced diagnostic specificity compared with single indices. ΔICA achieved the highest performance, with near-perfect accuracy in distinguishing factor deficiency from FVIII inhibitors and FVIII inhibitors from LA (AUC = 0.99 for both). The algorithm applying ΔICA after ICA of the immediate mix effectively separated factor deficiencies, FVIII inhibitors, and LA with high sensitivity and specificity, minimizing diagnostic overlap. CONCLUSIONS: The modified aPTT mixing test provides a reliable and practical approach for interpreting prolonged aPTT. The structured algorithm, combining the modified protocol with ΔICA, offers a systematic and clinically applicable framework for laboratory evaluation.
Singh MK, Sanjeev Y, Pandey A
… +9 more, Rahman K, Vijayran M, Kapoor P, Roy SS, Gupta R, Chandra D, Kumar K, Sharma V, Kashyap R
Int J Lab Hematol
· 2026 Jun · PMID 41552907
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INTRODUCTION: The myeloma patients with baseline normal/near-normal serum free light chain (SFLC) ratio have been reported to respond favorably to the treatment, unlike patients with extreme/abnormal SFLC ratio. We hypot...INTRODUCTION: The myeloma patients with baseline normal/near-normal serum free light chain (SFLC) ratio have been reported to respond favorably to the treatment, unlike patients with extreme/abnormal SFLC ratio. We hypothesized that this normal SFLC ratio could serve as a biomarker for favorable cytogenetic and outcome profiles. MATERIALS AND METHODS: The flow cytometric immunophenotyping (FCM-IPT) and interphase FISH analysis of marrow aspirate were performed as per recommended guidelines, in all the newly diagnosed patients of plasma cell proliferative disorders, enrolled during this prospective study. Patients were risk-stratified as per ISS, R-ISS, and R2-ISS criteria. The outcome evaluation, in patients treated with standard 3-/4-drugs induction, was done at least 3 months after initiation of therapy. RESULTS: A total of 306 patients with plasma cell proliferative disorders were enrolled; myeloma patients were 240 (n_SFLC = 23/240, 9.6%) and (ab_SFLC = 217/240, 90.4%). IgG lambda M-protein was more significantly seen in (n_SFLC) patients. None of the patients in the (n_SFLC) group showed circulating blood plasma cells. The (n_SFLC) patients did not show the presence of TP53 gene deletion and relatively lacked other high-risk genetics. The outcome analysis showed that more patients in the (n_SFLC) group attained ≥ VGPR (88.9% vs. 65.4% of ab_SFLC). CONCLUSION: Based on this, we infer that the patients with a normal SFLC ratio are enriched with non-high-risk features and behave less aggressively.
INTRODUCTION: Improvements in treatment of patients with haemophilia A have meant that their quality of life has majorly improved. However, a disadvantage to these developments has come at a cost to the laboratory when m...INTRODUCTION: Improvements in treatment of patients with haemophilia A have meant that their quality of life has majorly improved. However, a disadvantage to these developments has come at a cost to the laboratory when monitoring patient Factor VIII (FVIII) levels and there is the potential for under- or overtreatment leading to clinical risk towards the patient. METHODS: A global study performed in 2023 to investigate the differences in FVIII assay results in a large cohort of laboratories has enabled users to understand the challenges that new products can cause. Five FVIII modified/extended half-life (EHL) products were studied by distributing spiked samples via 3 external quality assessment (EQA) schemes (ECAT, NEQAS and RCPAQAP). RESULTS: Participating laboratories used either one-stage assays (OSA), chromogenic assays (CA), or both methods when performing the assays. Most centres running the OSA used IL Hemosil Synthasil, Siemens Actin FS, Siemens Pathromtin SL, or Stago Cephalin/Kaolin/C.K. Prest reagents, and for the CA, the Chromogenix Coamatic FVIII kit and the Siemens chromogenic FVIII kit were utilised. CONCLUSION: The FVIII results submitted by participants showed that currently available OSA and CA do not provide consistent results in some products with both an under- and over-estimation of the expected recovery based on potency at either concentration level. Results for Afstyla Lonoctocog alfa suggest that centres were not clear on whether OSA results were before or after application of the correction factor (multiplication of initial result by 2).
Int J Lab Hematol
· 2026 Jun · PMID 41498143
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INTRODUCTION: Elevated vitamin B12 concentration can be caused by supplementation, liver disease, kidney disease, or myeloid malignancies. Persistent, unexplained elevations of vitamin B12 can raise concern among patient...INTRODUCTION: Elevated vitamin B12 concentration can be caused by supplementation, liver disease, kidney disease, or myeloid malignancies. Persistent, unexplained elevations of vitamin B12 can raise concern among patients and may lead to invasive diagnostic procedures, including bone marrow biopsy. A potential benign cause of this elevation is macro-B12, a complex of vitamin B12, transcobalamin, and immunoglobulins. Although not bioactive, this complex can cause elevated plasma vitamin B12 concentrations due to reduced clearance. METHODS: Polyethylene glycol (PEG) precipitation is a laboratory technique that can be used to support the suspicion of macro-B12. Here, a case is described in which a PEG precipitation could potentially have prevented an unnecessary bone marrow biopsy. In addition, the presence of macro-B12 was studied in a group of patients with and without myeloid malignancies. RESULTS: Macro-B12 was identified in 24% of 72 individuals with vitamin B12 > 1476 pmol/L. In one of these patients, a functional vitamin B12 deficiency was confirmed by an elevated methylmalonic acid (MMA) concentration. Macro-B12 was not detected in 8 patients with a myeloid malignancy. CONCLUSION: These findings suggest that, in patients with persistently elevated vitamin B12 concentrations and a low suspicion of a myeloid malignancy, PEG precipitation may help to explain the elevated vitamin B12 and prevent unnecessary diagnostic procedures including bone marrow punctures.
Yasin NM, Somasundram S, Hassan S
… +12 more, Aziz NA, Hamid FSA, Zulkefli ES, Mohamad NN, Lee CM, Darawi MN, Papasavva T, Stephanou C, Kountouris P, Arkesteijn SJG, Koopman T, Harteveld CL
Int J Lab Hematol
· 2026 Apr · PMID 41493435
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BACKGROUND: Accurate classification of novel globin gene variants is critical for the diagnosis and management of thalassaemia. The adaptation of ACMG/AMP guidelines for globin genes represents an important step toward s...BACKGROUND: Accurate classification of novel globin gene variants is critical for the diagnosis and management of thalassaemia. The adaptation of ACMG/AMP guidelines for globin genes represents an important step toward standardising variant interpretation and enhancing clinical utility in the field. This study reports the haematological and molecular characteristics of a novel α2-globin variant identified in a Malay family. METHODS: A Malay family from Taiping, Perak, Malaysia, with a history of α-thalassaemia, was recruited for this study. The proband's phenotype was assessed through comprehensive haematological analysis and clinical evaluation. Known α-thalassaemia deletions and non-deletional mutations were screened using gap-PCR and ARMS-PCR. Sanger sequencing of the HBA genes was conducted to characterise the proband's genotype in detail. RESULTS: A novel pathogenic HBA2 variant was identified, expanding the known mutational spectrum of α-thalassaemia. This variant introduces a premature stop codon, occurs in trans with a known pathogenic allele associated with a significant clinical phenotype, segregates with the disease in the family, and is absent from major population databases. Based on haematological data, molecular findings, in silico predictions, and protein modeling, the variant meets the ACMG/AMP criteria for pathogenicity adapted for α-globin genes. We have designated this variant Hb Taiping, named after the location of its discovery. Its accurate classification is vital for carrier screening, genetic counselling, and prenatal diagnosis, thereby supporting improved clinical management. CONCLUSION: This study identifies and characterises a novel α-globin gene variant, Hb Taiping, in a Malay family with α-thalassaemia. The discovery contributes to the growing body of pathogenic mutations linked to α-thalassaemia and underscores the importance of precise variant classification for effective diagnosis, risk assessment, and genetic counselling.
Int J Lab Hematol
· 2026 Jun · PMID 41493425
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Vacuoles in hematopoietic cell precursors have garnered significant attention in recent years due to their association with a newly characterized clonal hematopoiesis with acquired mutations of ubiquitin like modifier ac...Vacuoles in hematopoietic cell precursors have garnered significant attention in recent years due to their association with a newly characterized clonal hematopoiesis with acquired mutations of ubiquitin like modifier activating enzyme 1 (ubiquitin-activating enzyme E1, UBA1) gene associated with clinical systemic autoinflammatory manifestations, known as VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. The cytomorphologic hallmark of this rare disorder is vacuolization involving the granulocytic and erythroid precursors. While affected vacuolated cells are seen in most patients, the mere presence of such is not entirely specific for VEXAS syndrome; therefore, an aggregate of clinicopathologic correlates is needed to help distinguish VEXAS syndrome from morphologic mimics and prompt appropriate confirmatory genetic testing. Vacuolated hematopoietic cells could be seen in varied reactive conditions and neoplastic and nonneoplastic hematologic disorders and affect different lineages and cell types. This article aims to review the spectrum of vacuolated hematopoietic cells and their disease-association including VEXAS syndrome, among others.
Salvadores-Álvarez V, Molinos-Quintana Á, Morales-Camacho RM
… +6 more, Martín-Chacón E, Reinoso Segura M, Vargas MT, Carrillo-Cruz E, Soria-Saldise E, Prats-Martín C
CBL syndrome is caused by a heterozygous germline mutation in the CBL gene. It is a rare RASopathy that shares many clinical features with mild forms of Noonan syndrome. These patients have a higher risk of developing ju...CBL syndrome is caused by a heterozygous germline mutation in the CBL gene. It is a rare RASopathy that shares many clinical features with mild forms of Noonan syndrome. These patients have a higher risk of developing juvenile myelomonocytic leukaemia (JMML) during early childhood. Here we report a case of an 11-month-old infant with JMML and CBL syndrome. It was caused by a heterozygous de novo germline mutation in the CBL gene and acquired biallelic inactivation of the gene through copy-neutral loss of heterozygosity (CN-LOH) in haematological cells. CBL mutation was not found in parents and siblings. CN-LOH was confirmed by single nucleotide polymorphism array. This patient presented with an aggressive clinical course and required an allogeneic stem cell transplant.
Srinivasan T, Mallik N, Bose P
… +10 more, Kumar A, Lal B, Jawallia K, Sharma P, Sreedharanunni S, Sachdeva MUS, Das R, Khadwal A, Malhotra P, Tehran A
Int J Lab Hematol
· 2026 Jun · PMID 41466451
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INTRODUCTION: Minimal/measurable residual disease (MRD) is a key prognostic factor in B-lymphoblastic leukemia/lymphoma (B-ALL/LBL), commonly assessed via multiparametric flow cytometry (MFC). This study evaluated 12 leu...INTRODUCTION: Minimal/measurable residual disease (MRD) is a key prognostic factor in B-lymphoblastic leukemia/lymphoma (B-ALL/LBL), commonly assessed via multiparametric flow cytometry (MFC). This study evaluated 12 leukemia-associated immunophenotype (LAIP) markers-CD81, CD86, CD123, CD58, CD9, CD73, CD13/CD33, CD44, CD97, CD66c, CD49f, and CD304-to determine their suitability for MRD detection. METHODS: Marker expression was analyzed in 103 B-ALL cases at diagnosis, and 54 post-therapy follow-up samples, including 16 MRD-positive cases. Additionally, 25 non-B-ALL bone marrow samples were examined for marker expression in hematogones. Clinical and genetic correlation was also performed. RESULTS: Median age of patients was 9 years (range: 0.3-89), with male: female ratio of 1:1. We found that CD97, CD73, CD86, and CD58 are excellent markers for MRD analysis in B-ALL, as they are expressed in more than 85% of cases at baseline, and their expression is preserved in more than 75% of cases post-therapy. Two other extremely promising markers are CD81 and CD49f, both of which are expressed as LAIP in more than 50% of B-ALL cases, with retention of expression in more than 85% of cases post-therapy, and importantly, expression as LAIP in some post-therapy samples despite their absence at baseline. Hyperdiploidy was significantly associated with expression of CD86, CD97, CD123, CD66c, and CD9; BCR::ABL1 fusion was associated with CD49f, CD81, and CD66c. CONCLUSION: CD97, CD73, CD86, and CD58 are the best amongst newer markers in B-ALL MRD assessment. Our findings support integrating these into MRD panels to enhance post-therapy MRD detection, thus improving prognostication and guiding treatment decisions.
BACKGROUND: Direct oral anticoagulants (DOACs) have simplified anticoagulant therapy, but plasma level testing (i.e., anti-Xa and anti-IIa activities) remains important in specific clinical situations (e.g., emergency su...BACKGROUND: Direct oral anticoagulants (DOACs) have simplified anticoagulant therapy, but plasma level testing (i.e., anti-Xa and anti-IIa activities) remains important in specific clinical situations (e.g., emergency surgery, bleeding, renal impairment, or suspected non-adherence). However, the impact of sample storage on assay reliability is not well defined. This study evaluated the stability and potential systematic errors in DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) plasma levels after 24 h storage under different conditions. METHODS: We enrolled 182 patients on one of the four DOACs. Blood samples were collected in duplicate citrated tubes. The first tube was processed within 4 h to obtain baseline values, with plasma successively stored at room temperature, 4°C, and -20°C for 24 h. The second tube was stored as whole blood at room temperature before measuring DOACs concentrations. DOACs were measured using dedicated clotting or chromogenic assays. Stability was assessed using non-parametric statistics, Passing-Bablok regression, and Bland-Altman analysis, with Acceptable Change Limits based on assay variability. RESULTS: All DOACs showed good stability across conditions, with median recoveries ranging from 93% to 102%. No significant proportional errors were observed. Minor constant biases were observed for apixaban (at 4°C and -20°C), and more consistently for rivaroxaban and edoxaban. Dabigatran showed no significant bias. Variability was generally low (< 7%), and most measurements near clinical thresholds remained accurate. CONCLUSION: DOACs plasma levels remain stable after 24 h storage under various conditions. While minor biases exist, particularly for rivaroxaban and edoxaban, they are unlikely to affect clinical interpretation in most cases. Whenever needed, DOACs measurement can be deferred after blood drawing without jeopardizing results interpretation.
Nikler A, Bakarić I, Zilić D
… +2 more, Saračević A, Radišić Biljak V
Int J Lab Hematol
· 2026 Jun · PMID 41424070
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INTRODUCTION: Erythrocyte sedimentation rate (ESR) is a widely used inflammation marker. VISION Pro (Shenzhen YHLO Biotech Co. LTD, Shenzhen, China) is a fully automated ESR analyzer. This study verified its analytical p...INTRODUCTION: Erythrocyte sedimentation rate (ESR) is a widely used inflammation marker. VISION Pro (Shenzhen YHLO Biotech Co. LTD, Shenzhen, China) is a fully automated ESR analyzer. This study verified its analytical performance and comparability to the manual Westergren method. METHODS: Inter- and intra-run precision study was assessed using control and patient samples at low, medium, and high ESR levels. Accuracy was evaluated by comparing 240 KEDTA (ethylenediaminetetraacetic acid) whole blood samples with the Westergren method in citrate divided by ESR subgroups (< 40, 40-80, > 80 mm). Sample stability was tested in 8 samples at room temperature and 2°C-8°C over 24 h. Reference range verification included 40 healthy individuals (20 male, 20 female). The effects of testing order for ESR and complete blood count (CBC) (ESR/CBC/ESR vs. CBC/ESR/CBC) and analysis modes (Cycle, Random, Mixer+Random) were also explored. RESULTS: Inter- and intra-run precision were acceptable at medium and high ESR levels without temperature correction, while low levels exceeded acceptable criteria (e.g., CV = 24.4% vs. criterion 11.3%). Agreement with Westergren was excellent, with no significant differences (intercept = 1.1 [95% CI: 0.0-1.4]; slope = 1.0 [95% CI: 0.9-1.0]), while temperature-corrected results showed unsatisfactory agreement (intercept = -0.1 [95% CI: -0.7 to 0.4]; slope = 0.8 [95% CI: 0.7-0.8]). Sample stability was maintained for up to 3 h at room temperature and up to 10 h at 2°C-8°C. Reference range verification demonstrated all 20 samples within limits for men and 19/20 for women, while only 17/20 for temperature-corrected results for women. ESR/CBC/ESR order minimally affected the results (14/15 acceptable), while CBC/ESR/CBC order influenced CBC parameters (predominantly MPV). No significant differences occurred between measurement modes (p = 0.093). CONCLUSION: VISION Pro analyzer demonstrated acceptable ESR measurement performance without temperature correction and is suitable for routine laboratory use. Temperature-corrected results showed inconsistent performance and require cautious interpretation.