Case 291 Ana L Ruano Juraj Bodo Megan

Case 291 Ana L. Ruano, Juraj Bodo, Megan O. Nakashima, Eric D. Hsi Department of Clinical Pathology Cleveland Clinic Foundation

Clinical History • Previously healthy 53 year old man. • Three day history of a generalized petechial rash, hematuria and rectal bleeding following a flu-like illness. • WBC = 8. 85 K/UL; Hgb=12. 5 g/d. L; Plt= 40 K/UL. • Laboratory studies showed evidence of disseminated intravascular coagulation.

Peripheral blood, 1000 x Bone marrow aspirate, 1000 x

Cytochemical Stains α-naphthyl butyrate esterase Myeloperoxidase

1000 x Bone marrow biopsy, 100 x

• Interphase FISH for PML-RARA (dual fusion probes): Positive • Karyotype: 47, XY, +8, t(15; 17)(q 24; q 21)[20]

Proposed Diagnosis Acute promyelocytic leukemia with (t 15; 17)(q 22; q 12)/PML-RARA. CONSENSUS DX: Acute promyelocytic leukemia with t(15; 17)(q 22; q 12) PML-RARA

Clinical History (cont. ) • Initially treated with systemic corticosteroids, vitamin K, platelets, fresh frozen plasma and cryoprecipitate. • Upon diagnosis of acute promyelocytic leukemia, ATRA was initiated.

• Increasing shortness of breath, low Sa. O 2, development of altered mental status and left hemiplegia. Head CT showed intraparenchymal hemorrhage. • Bilateral multifocal opacities on CXR; systemic corticosteroids initiated for apparent “differentiation syndrome”. • Clinical condition rapidly deteriorated. Brain death declared; patient expired shortly after removal from ventilator.

Acute Promyelocytic Leukemia • Time to diagnosis prognosis • Expedient methods of diagnosis may significantly improve patient outcomes

Patient sample Negative control (HL 60) Proximity Ligation Assay: PML and RARA primary antibodies for detection of PML-RARA fusion protein Positive control (NB 4)

Proximity Ligation Assay • Method for co-localizing any two biologic features that can be targeted by antibodies • Formats – Homogenous mixtures – Solid phase – Localized (in situ)

Applications Detect and quantify single protein expression A B Detection of post-translational protein modifications (eg. phosphorylation, mucin glycoforms) Detect and quantify protein interactions Duolink Brightfield II User Manual Olink Bioscience Uppsala, Sweden www. olink. com

Procedure 1 2 3 Primary antibodies PLA probes Ligation solution Duolink Brightfield II User Manual Olink Bioscience Uppsala, Sweden www. olink. com

4 Rolling circle amplification (RCA) 5 Detection -HRP Duolink Brightfield II User Manual Olink Bioscience Uppsala, Sweden www. olink. com

Patient sample Negative control (HL 60) Proximity Ligation Assay: PML and RARA primary antibodies for detection of PML-RARA fusion protein Positive control (NB 4)

Advantages • • Amenable to bright field microscopy Fast - Results in approximately 6 hours Easy to quantify – use of image analysis Single cell analysis possible • Independent of PML gene break point

Conclusion • The case illustrates the application of a an alternate technology to test for fusion proteins via an easily interpretable bright field method potentially adaptable to the clinical laboratory.

References • • • Bodo J, Lin JJ, Maciejewski JP, Schade AE, Hsi ED. Detection of PML/RARA Fusion Protein in APL Using Proximity Ligation Assay as an Alterative to FISH Testing. 2013 Annual meeting of United States and Canadian Academy of Pathology, Baltimore, MD. Duolink Brightfield II User Manual Olink Bioscience Uppsala, Sweden www. olink. com Gustafsdottir SM et al. Proximity Ligation Assays for Sensitive and Specific Protein Analysis. 2005 Anal Biochem. 345(1): 2 -9. Zieba A et al. Bright-field microscopy visualization of proteins and protein complexes by in situ proximity ligation with peroxidase detection. 2010 Clin Chem 56(1): 99 -110 Gullberg M et al. A sense of closeness: protein detection by proximity ligation. 2003 Curr Opin Biotechnol 14(1): 82 -6. Koos B et al. Analysis of Protein Interactions in situ by Proximity Ligation Assays Current Topics in Microbiology and Immunology Springer-Verlag Berlin Heidelberg 2013. Figueiredo J et al. The importance of E-cadherin binding partners to evaluate the pathogenicity of E-cadherin missense mutations associated to HDGC. 2013 Eur J Hum Genet; 21(3): 301 -9. Pinto R et al. Identification of new cancer biomarkers based on aberrant mucin glycoforms by in situ proximity ligation. 2012 J Cell Mol Med Jul; 16(7): 1474 -84. Leuchowius KJ et al. High content screening for inhibitors of protein interactions and post-translational modifications in primary cells by proximity ligation. 2010 Mol Cell Proteomics Jan; 9(1): 178 -83. Chen TC et al. Protein phosphorylation profiling using an in situ proximity ligation assay: phosphorylation of AURKA-elicited EGFR-Thr 654 and EGFR-Ser 1046 in lung cancer cells. 2013 PLo. S One ; 8(3): e 55657. Aubele M et al. In situ quantification of HER 2 -protein tyrosine kinase 6 (PTK 6) protein-protein complexes in paraffin sections from breast cancer tissues. 2010 Br J Cancer 103(5): 663 -7.