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FISH Panel for CLL Diagnosis Everyday Health MenuNewslettersSearch Leukemia
FISH Panel for CLL Diagnosis
By Dr. Vijayakrishna K GadiReviewed: September 23, 2010Fact-CheckedQ1. I recently had my first FISH panel done after being diagnosed with CLL.
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I know it shows abnormalities in cancerous cells, but how exactly does it work, and how does it know which cells to isolate? — Janine, Maryland Bear with me — this is complicated. First, note that normal cells can accumulate mutations over time.
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Some mutations in the genes lead to more destruction of the genome (the term for all the genes in a cell). After a while, it's apparent that the genome is highly unstable, and entire large chunks of chromosomes may be moved from one location to another. FISH (fluorescent in situ hybridization) helps test what chunks have been moved where.
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During this process, certain genetic elements are "stained" with chemicals that make the DNA glow in different colors when special wavelengths of light are shone on it. In a genome in which the colors show up in the wrong locations, relative to other color markers, too many times (more than twice) or not at all (a chromosome segment is deleted entirely), FISH can help identify specific genetic defects.
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After the hematopathologist (blood pathologist) obtains a specimen of your blood or bone marrow, it's used to make a microscope slide with a thin, single layer of cells. The hematopathologist then uses the colored markers to examine your cells.
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The specific aberrant location of the FISH color markers can help your oncologist/hematologist determine a prognosis and possibly treatment for your CLL. There are too many known genetic defects in CLL to describe here.
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But I can give you a couple of examples: The 13q deletion (loss of an entire "arm" of the 13th chromosome) is associated with a very good prognosis because the median time for survival (that is, 50 percent survival) is almost 12 years from diagnosis. Contrast this with the 17p deletion, where median survival is historically only 3 years from the time of diagnosis. Based on your cytogenetics, as well as other factors, your doctors may recommend when it's best to consider treatment and how aggressive that treatment should be.
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Q2. I was just diagnosed with CLL in May.
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The diagnosis was made by flow cytometry. What does it mean if I tested atypically weak staining for CD20?
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Also, I had CD38 co-expressed on 1 percent of CD5, CD19 and B cells. Is that a good prognostic factor, and if so, in what way? Does having a low percentage of CD38 coincide with an unmutated status?
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My IGM serum measured a 41, which they indicated as low. Their reference range was between 48 and 271. What exactly does that mean, and will it ever be normal?
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The rest of my blood work was in the normal range. Can you help me out in understanding my lab results? Thanks!
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You are asking questions about proteins expressed on the CLL cells that are visualized by a machine called a flow cytometer. CD stands for “cluster of differentiation,” referring to those molecules on the cell surface. Based on what is positive or negative, doctors can make estimates about prognostic outcomes and tailor their recommendations for potential treatments.
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Most CLL cells will express the protein CD20 on the surface, and absence is considered “atypical.” This is important because one of the major therapies, Rituxan (rituximab), is less likely to work well when CD20 is low or absent. Low CD38 on the CLL cells is considered a good prognostic factor. It is often low when the cells are mutated for a specific antibody gene in the CLL cells.
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Being mutated for the antibody gene is a good characteristic for CLL. The IgM of 41 is not really a marker of how aggressive your disease is.
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It is just a reflection of how immune-suppressed you are, in terms of one specific aspect of your immune system. If the immunoglobulins (such as IgM) are low, a patient is more susceptible to certain infections. Thankfully, these low immunoglobulins can be routinely replaced intravenously (this is called IVIG) if necessary to help reduce the number of infections.
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Once CLL therapy is successful, immunoglobulin levels may gradually rise back to the normal levels. I would urge you to take your lab report to your oncologist and ask for a thorough explanation of the findings as well as an overall assessment of prognosis. Q3.
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I know that an 11q deletion (per FISH) indicates a poor prognosis for CLL, but do any of the standard treatments work for people with this deletion? I have read that a 17p deletion does not respond at all to Fludara therapies — only Campath to some degree.
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Is that true with the 11q deletion, as well? Should someone with an 11q deletion use a particular treatment (i.e., Campath) when the time arrives for treatment?
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My husband is negative for the 17p deletion, trisomy-12 and monosomy-13 deletions. But he unfortunately did test positive for the 11q and 13q deletions. The 11q deletion is at 30 percent.
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What does that mean? Also, what does negative for a CCND1/IGH rearrangement mean? Is that the same thing as IGH unmutated status?
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Thanks, as always, for all your insight and knowledge. These are very complex and sophisticated questions.
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So at the risk of losing some of the audience, here are my thoughts. Doctors use FISH (fluorescence in situ hybridization) to detect chromosomal abnormalities.
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There are a number of these abnormalities that are recurring themes with patients who have CLL. Some of these are associated with a worse prognosis than for the average CLL patient who doesn’t have them. For example, the 11q deletion (part of the 11th chromosome is missing) that your husband harbors in some of his CLL cells is likely to be less responsive to standard therapies and to behave more aggressively over time.
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That being said, many patients with the 11q deletion will still respond quite well to combination therapies such as Fludara (fludarabine), Cytoxan (cyclophosphamide) and Rituxan (rituximab), known by the acronym FCR. The 13q deletion is generally a favorable factor, but when in combination with other alterations such as 11q, the good is outweighed by the bad.
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Most cancers are not comprised of exactly identical cells but rather are a mixed bag of cells. In your husband’s case, for example, only 30 percent of the cells harbor the 11q deletion.
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Because of this heterogeneity (mixed bag), therapy may not uniformly kill all the cancer cells, allowing some clones of cancer cells to survive and reproduce again. This is the basis of therapy resistance. Finally, CCND/IGH is not the same as IGH unmutated.
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The former (CCND/IGH) is a specific chromosome abnormality in which part of one chromosome gets “glued” to another. The CCND/IGH rearrangement is characteristic of another very similar appearing but much more aggressive lymphoma known as mantle cell lymphoma.
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Trust me — it’s a good thing that he is negative for this abnormality. The latter — immunoglobulin heavy chain, or IGH, mutation status — is another genetic characteristic that is often examined in CLL to help determine prognosis.
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Q4. I had the FISH test done in September 2007, and it showed normal. The rest of the tests showed CLL.
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Why did this test not show CLL, and should I get it done again? Fluorescence in situ hybridization (FISH) looks for very specific large genetic abnormalities in the DNA inside the cancer cells.
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It is important to know about some of these large gene changes because they have both impact on how your disease is treated, and how fast it might progress. However, a person with chronic lymphocytic leukemia can have normal results on the FISH test, meaning that the changes in the genes simply cannot be detected with this method.
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Your doctor or oncologist might have FISH test performed again on your CLL cells if there is change in the status of your disease (recurrence or increased aggressiveness, for example). Q5.
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After recently being diagnosed with CLL, I've undergone further testing. I had a test done for CD38, which came out at 1 percent, and Zap70, which came out at 3 percent. Both results indicate that these are positive prognostic markers.
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What exactly do these numbers mean? Is it good that they are both low numbers? As we've discussed often in this forum, all cases of CLL aren't created equal.
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Trying to figure out which patients will ultimately do fine with the disease and which will do poorly is a major challenge. The search by doctors for biologic indicators (also known as prognostic markers) for CLL is intense. While no single one of these markers paints a perfect picture of how CLL will proceed, looking at several can be helpful.
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CD38 is a protein on the surface of some aggressive CLL cell subtypes. It is considered favorable if less than 30 percent of the CLL cells express this protein on the cell surface.
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The story of Zap70 is less clear. Zap70 is also a protein on the surface of some patients' CLL cells.
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There is no good cutoff (like the one for CD38), but low expression is generally associated with a better outcome. This number does tend to rise over time as the disease gets worse. In your case, it is certainly good that these numbers are low; it suggests that you may have a slowly developing form of the disease.
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Simply put, prognosis good. Learn more in the Everyday Health Leukemia Center.
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