Test Id : LLTOF

Note: This test is only available to clients who have MayoAccess or MayoLink.

The client is responsible for the interpretation and billing of the professional component; Mayo Clinic will bill the technical component only.

The testing process begins with a screening panel. The panel will be charged based on the number of markers tested (FIRST for first marker, ADD1 for each additional marker). Additional testing may be performed at an additional charge for each marker tested (ADD1, as applicable) if needed to fully characterize a disease state or clarify any abnormalities from the screening panel.

The triage panel is initially performed to evaluate for monotypic B cells by kappa and lambda immunoglobulin light chain expression, increased numbers of blasts by CD34 and CD45 expression along with side scatter gating, and increased plasma cells by CD45 expression with side scatter gating. The triage panel also includes antibodies to assess the number of CD3-positive T cells and CD16-positive/CD3-negative natural killer (NK) cells present. This triage panel also determines if there is an increase in the number of T cells that aberrantly coexpress CD16, an immunophenotypic feature of T-cell granular lymphocytic leukemia.

This initial testing, together with the provided clinical history and morphologic review is used to determine what, if any, additional testing is needed for disease diagnosis or classification. If additional testing is required, it will be added per algorithm to fully characterize a disease state with a charge per unique antibody tested.

Cases requiring the testing for granular lymphocytic leukemia (killer-cell immunoglobulin-like receptor panel) will have an interpretation added and performed by a Mayo Clinic pathologist at an additional charge.

If no abnormalities are detected by the initial triage panel, no further flow cytometric assessment will be performed unless otherwise indicated by specific features of the clinical presentation or prior laboratory results.

For more information, the following algorithms are available:

-Bone Marrow Staging for Known or Suspected Malignant Lymphoma Algorithm

-Acute Promyelocytic Leukemia: Guideline to Diagnosis and Follow-up

This test is available to clients through MayoAccess or MayoLink.

For B-cell acute lymphoblastic leukemia minimal residual disease testing in either blood or bone marrow, order BALLM / B-Cell Lymphoblastic Leukemia Monitoring, Minimal Residual Disease Detection, Flow Cytometry, Varies.

This test is appropriate for hematopoietic specimens only. For solid tissue specimens, order LLTOT / Leukemia and Lymphoma Immunophenotyping, Technical Only, Tissue.

For bone marrow specimens being evaluated for possible involvement by a myelodysplastic syndrome (MDS) or a myelodysplastic/myeloproliferative neoplasm (MDS/MPN) including chronic myelomonocytic leukemia (CMML), order MYEFL / Myelodysplastic Syndrome by Flow Cytometry, Bone Marrow.

Bronchoalveolar lavage specimens submitted for evaluation for leukemia or lymphoma are appropriate to send for this test.

This test is not appropriate for and cannot support diagnosis of sarcoidosis, hypersensitivity pneumonitis, interstitial lung diseases, or differentiating between pulmonary tuberculosis and sarcoidosis (requests for CD4/CD8 ratios); specimens sent for these purposes will be rejected.

This test is not intended for product of conception (POC) specimens. For POC specimens see CMAPC / Chromosomal Microarray, Autopsy, Products of Conception, or Stillbirth.

For bone marrow testing, if cytogenetic tests are desired along with this test request, an additional specimen should be submitted. It is important that the specimen be obtained, processed, and transported according to instructions for the other test.

Specimen must arrive within 4 days of collection.

The following information is required:

1. Reason for testing

2. Specimen source

3. For spinal fluid specimens, spinal fluid cell and differential counts are required.

Submit only 1 of the following specimens:

Specimen Type: Whole blood

Container/Tube:

Preferred: Yellow top (ACD solution A or B)

Acceptable: Lavender top (EDTA) or green top (sodium heparin)

Specimen Volume: 10 mL

Collection Instructions:

1. Send whole blood specimen in original tube. Do not aliquot.

2. Label specimen as blood.

3. If possible, include 5 to 10 unstained blood smears, which must be labeled with two unique identifiers

Specimen Stability Information: Ambient 4 days/Refrigerated 4 days

Specimen Type: Bone marrow

Container/Tube:

Preferred: Yellow top (ACD solution A or B)

Acceptable: Lavender top (EDTA) or green top (sodium heparin)

Specimen Volume: 1 to 5 mL

Collection Instructions:

1. Submission of bilateral specimens is not required.

2. Send bone marrow specimen in original tube. Do not aliquot.

3. Label specimen as bone marrow.

4. If possible, include 5 to 10 unstained bone marrow aspirate smears, which must be labeled with two unique identifiers

Specimen Stability Information: Ambient 4 days/Refrigerated 4 days

Note: A fresh (less than 4 days post-collection), unfixed, nonembedded bone marrow core biopsy, bone or bone lesion is acceptable as an equivalent source for bone marrow aspirate for this test only in the event of a dry tap during the bone marrow harvesting procedure. Indicate "dry tap" in performing lab notes or paperwork when submitting this specimen type.

Specimen Type: Body fluid

Sources: Serous effusions, pleural, pericardial, or abdominal (peritoneal fluid)

Container/Tube: Body fluid container

Specimen Volume: 20 mL

Collection Instructions:

1. If possible, body fluids other than spinal fluid should be anticoagulated with heparin (1 U/mL of fluid).

2. Label specimen with body fluid type.

Additional Information: The volume of serous effusion necessary to phenotype lymphocytes or blasts depends upon the cell count in the specimen. Usually, 20 mL of pleural or peritoneal fluid is sufficient. Smaller volumes can be used if there is a high cell count.

Specimen Stability Information: Refrigerated 4 days/Ambient 4 days

Specimen Type: Spinal fluid

Container/Tube: Sterile vial

Specimen Volume: 1 to 1.5 mL

Collection Instructions:

1. An original cytospin preparation (preferably unstained) should be included with the spinal fluid specimen so correlative morphologic evaluation can occur.

2. Label specimen as spinal fluid.

Specimen Stability Information: Refrigerated /Ambient 4 days

Additional Information: The volume of spinal fluid necessary to phenotype the lymphocytes or blasts depends upon the cell count in the specimen. A cell count should be determined and submitted with the specimen. Usually, 1 to 1.5 mL of spinal fluid is sufficient. Smaller volumes can be used if there is a high cell count. If the cell count is less than 10 cells/mcL, a larger volume of spinal fluid may be required. When cell counts drop below 5 cells/mcL, the immunophenotypic analysis may not be successful.

• Hematopathology Patient Information
• Bone Marrow Staging for Known or Suspected Malignant Lymphoma Algorithm
• Acute Promyelocytic Leukemia: Guideline to Diagnosis and Follow-up

1. Hematopathology Patient Information (T676)

2. If not ordering electronically, complete, print, and send a Hematopathology/Cytogenetics Test Request (T726) with the specimen.

Whole blood: 3 mL; Bone marrow: 0.5 mL; Spinal fluid: 1 mL; Fluid from serous effusions: 5 mL

Evaluating lymphocytoses of undetermined etiology

Identifying B- and T-cell lymphoproliferative disorders involving blood and bone marrow

Distinguishing acute lymphoblastic leukemia from acute myeloid leukemia (AML)

Immunologic subtyping of acute leukemias

Distinguishing reactive lymphocytes and lymphoid hyperplasia from malignant lymphoma

Distinguishing between malignant lymphoma and acute leukemia

Phenotypic subclassification of B- and T-cell chronic lymphoproliferative disorders, including chronic lymphocytic leukemia, mantle cell lymphoma, and hairy cell leukemia

Recognizing AML with minimal morphologic or cytochemical evidence of differentiation

Recognizing monoclonal plasma cells

This test is not intended for detection of minimal residual disease below 5% blasts.

This test is not appropriate for and cannot support diagnosis of sarcoidosis, hypersensitivity pneumonitis, interstitial lung diseases, or differentiating between pulmonary tuberculosis and sarcoidosis.

Note: This test is only available to clients who have MayoAccess or MayoLink.

The client is responsible for the interpretation and billing of the professional component; Mayo Clinic will bill the technical component only.

The testing process begins with a screening panel. The panel will be charged based on the number of markers tested (FIRST for first marker, ADD1 for each additional marker). Additional testing may be performed at an additional charge for each marker tested (ADD1, as applicable) if needed to fully characterize a disease state or clarify any abnormalities from the screening panel.

The triage panel is initially performed to evaluate for monotypic B cells by kappa and lambda immunoglobulin light chain expression, increased numbers of blasts by CD34 and CD45 expression along with side scatter gating, and increased plasma cells by CD45 expression with side scatter gating. The triage panel also includes antibodies to assess the number of CD3-positive T cells and CD16-positive/CD3-negative natural killer (NK) cells present. This triage panel also determines if there is an increase in the number of T cells that aberrantly coexpress CD16, an immunophenotypic feature of T-cell granular lymphocytic leukemia.

This initial testing, together with the provided clinical history and morphologic review is used to determine what, if any, additional testing is needed for disease diagnosis or classification. If additional testing is required, it will be added per algorithm to fully characterize a disease state with a charge per unique antibody tested.

Cases requiring the testing for granular lymphocytic leukemia (killer-cell immunoglobulin-like receptor panel) will have an interpretation added and performed by a Mayo Clinic pathologist at an additional charge.

If no abnormalities are detected by the initial triage panel, no further flow cytometric assessment will be performed unless otherwise indicated by specific features of the clinical presentation or prior laboratory results.

For more information, the following algorithms are available:

-Bone Marrow Staging for Known or Suspected Malignant Lymphoma Algorithm

-Acute Promyelocytic Leukemia: Guideline to Diagnosis and Follow-up

Diagnostic hematopathology has become an increasingly complex subspecialty, particularly with neoplastic disorders of blood and bone marrow. While morphologic assessment of blood smears, bone marrow smears, and tissue sections remains the cornerstone of lymphoma and leukemia diagnosis and classification, immunophenotyping is a very valuable and important complementary tool.

Immunophenotyping hematopoietic specimens can help resolve many differential diagnostic problems posed by the clinical or morphologic features. This test is appropriate for hematopoietic specimens only.

This is a technical only test and does not include interpretation unless reflex testing is performed. At any point, clients may request to have a Mayo Clinic hematopathologist provide an interpretation at an additional charge.

Not applicable

Report will include a summary of the procedure.

Specimens will be initially screened to determine which, if any, of the immunophenotyping panels should be performed.

1. Jevremovic D, Dronca RS, Morice WG, et al. CD5+ B-cell lymphoproliferative disorders: Beyond chronic lymphocytic leukemia and mantle cell lymphoma. Leuk Res. 2010;34(9):1235-1238

2. Hanson CA. Acute leukemias and myelodysplastic syndromes. In: McClatchey KD, ed. Clinical Laboratory Medicine. Williams and Wilkins; 1994:939-969

3. Jevremovic D, Olteanu H. Flow cytometry applications in the diagnosis of T/NK-cell lymphoproliferative disorders. Cytometry B Clin Cytom. 2019;96(2):99-115

4. Rosado FG, Morice WG, He R, Howard MT, Timm M, McPhail ED. Immunophenotypic features by multiparameter flow cytometry can help distinguish low grade B-cell lymphomas with plasmacytic differentiation from plasma cell proliferative disorders with an unrelated clonal B-cell process. Br J Haematol. 2015;169(3):368-376

5. Shi M, Ternus JA, Ketterling RP, Jevremovic D, McPhail ED. Immunophenotypic and laboratory features of t(11;14)(q13;q32)-positive plasma cell neoplasms. Leuk Lymphoma. 2018;59(8):1913-1919

6. Morice WG, Kimlinger T, Katzmann JA, et al. Flow cytometric assessment of TCR-V-beta expression in the evaluation of peripheral blood involvement by T-cell lymphoproliferative disorders: a comparison with conventional T-cell immunophenotyping and molecular genetic techniques. Am J Clin Pathol. 2004;121(3):373-383

7. Shi M, Jevremovic D, Otteson GE, Timm MM, Olteanu H, Horna P. Single antibody detection of T-cell receptor alpha-beta clonality by flow cytometry rapidly identifies mature T-cell neoplasms and monotypic small CD8-positive subsets of uncertain significance. Cytometry B Clin Cytom. 2020;98(1):99-107

8. Jevremovic D, Olteanu H. Flow cytometry applications in the diagnosis of T/NK-cell lymphoproliferative disorders. Cytometry B Clin Cytom. 2019;96(2):99-115

Flow cytometric immunophenotyping of peripheral blood, bone marrow, and body fluids is performed using the following antibodies:

Triage Panel: CD3, CD10, CD16, CD19, CD34, CD45, and kappa and lambda immunoglobulin light chains.

Possible Additional Panels: Performed per algorithmic approach

-B-cell Panel: CD5, CD11c, CD19, CD20, CD22, CD23, CD38, CD45, CD103, CD200 and kappa and lambda immunoglobulin light chains

-T-cell Panel: CD2, CD3, CD4, CD5, CD7, CD8, CD45, TRBC1, and gamma/delta

-Sezary Panel: CD2, CD3, CD4, CD5, CD7, CD8, CD26, CD45, and TRBC1.

-Killer-cell immunoglobulin-like receptor (KIR) Panel: CD3, CD8, CD16, CD56, CD57, CD94, CD158a, CD158b, CD158e (p70), and NKG2a

-Acute Panel: CD2, CD7, CD13, CD15, CD16, CD33, CD34, CD36, CD38, CD45, CD56, CD64, CD117, and HLA-DR

-B-cell acute lymphocytic leukemia (ALL) Panel: CD10, CD19, CD20, CD22, CD24, CD34, CD38, CD45, CD58, and CD66c

-Myeloperoxidase/terminal deoxynucleotidyl transferase (MPO/TdT) Panel: cytoplasmic CD3, CD13, cytoplasmic CD22, CD34, CD45, cytoplasmic CD79a, nuclear TdT, and cytoplasmic MPO

-Plasma Cell Panel: CD19, CD38, CD45, CD138, and cytoplasmic kappa and lambda immunoglobulin light chains

-Mast Cell Panel (bone marrow only): CD2, CD25, CD69, CD117.(Keren P, McCoy JP, Carey J, eds. Flow Cytometry in Clinical Diagnosis. 4th ed. ASCP Press; 2007; Betters DM. Use of flow cytometry in clinical practice. J Adv Pract Oncol. 2015;6[5]:435–440)

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• Clients without access to Test Prices can contact Customer Service 24 hours a day, seven days a week.
• Prospective clients should contact their account representative. For assistance, contact Customer Service.

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.

88184-Flow cytometry; first cell surface, cytoplasmic or nuclear marker

88185-Flow cytometry; additional cell surface, cytoplasmic or nuclear marker (each)

Additional CPTs may be added if consultative help is needed with the case, or algorithm dictates Mayo consultant involvement.

88187-Flow cytometry interpretation, 2 to 8 markers (if appropriate)

88188-Flow cytometry interpretation, 9 to 15 markers (if appropriate)

88189-Flow cytometry interpretation, 16 or more markers (if appropriate)