Comparison of Diagnostic Yield Among M-FISH, FISH Probe Panel and Conventional Cytogenetic Analysis in AML

Study Overview
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Brief Summary
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Conventional cytogenetic studies have been the gold standard for more than five decades for detecting genetic alterations that are greater than 10 Mb (mega base pairs) in size. Conventional cytogenetic studies have paved the way in identifying specific chromosomal aberrations associated with clinically and morphologically definitive subsets of hematological neoplasms. Fluorescence in situ hybridization (FISH) has become a reliable and rapid complementary test in targeting critical genetic events associated with diagnostics and prognosis in hematological neoplasms. In the current health care environment, which increasingly focuses on value and efficiency, it is critical for pathologists and clinicians to effectively navigate this environment and judiciously incorporate these high-complexity and expensive techniques into routine patient care. While conventional karyotyping provides a comprehensive view of the genome, FISH can detect cryptic or submicroscopic genetic abnormalities and identify recurrent genetic abnormalities in nondividing cells. As a consequence, it is commonly extrapolated that FISH will improve the sensitivity of detecting all genetic abnormalities compared with conventional karyotyping analysis. This assumption has then been translated in clinical practice to having clinicians and pathologists routinely ordering both conventional karyotyping and FISH studies in patients with hematological neoplasms. Depending on how comprehensive the FISH panel is, the cost for this testing may be quite expensive, and its additive value remains questionable. It is common practice for laboratories to use FISH panels in conjunction with karyotyping both in diagnostic specimens and during follow-up to monitor response to therapy. Multiplex FISH (M-FISH) represents one of the most significant developments in molecular cytogenetics of the past decade. In tumor and leukemia cytogenetics, two groups have been targeted by M-FISH to identify cryptic chromosome rearrangements not detectable by conventional cytogenetic studies: those with an apparently normal karyotype (suspected of harboring small rearrangements not detectable by conventional cytogenetics) and those with a complex aberrant karyotype (which are difficult to karyotype accurately due to the sheer number of aberrations).

Detailed Description
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Neoplastic hematology is at the forefront of personal¬ized medicine. The World Health Organization (WHO) classification incorporates genetic data with microscopic, immunophenotypic, and clini¬cal findings and categorizes hematologic neoplasms into clinically and biologically distinct categories. This system guides diagnosis, prognosis and therapeutic choices, which has become increasingly important with emerging targeted therapies for lymphoma and leukemia. However, laboratory tests for hematologic neoplasms are of high complexity and are generally quite costly. The initial assessment of many hematologic neoplasms includes morphological, histological, immunophenotypic (flow cytometric and/or immunohistochemical), and conventional cytogenetic studies. Data obtained from cytogenetic analysis can be pathognomonic for specific leukemias in the WHO classification (for example, acute myeloid leukemia (AML) with recurrent cytogenetic abnormalities and chronic myelogenous leukemia (CML)) and are likely to assume a greater role in defining specific categories in further classifications. Conventional cytogenetic studies have been the gold standard for more than five decades for detecting genetic alterations that are greater than 10 Mb (mega base pairs) in size. They have paved the way in identifying specific chromosomal aberrations associated with clinically and morphologically definitive subsets of hematological neoplasms. Fluorescent in situ hybridization (FISH) has become a reliable and rapid complementary test in targeting critical genetic events associated with diagnostics and prognosis in hematological neoplasms. FISH has addressed the issues with conventional cytogenetic studies by targeting interphase cells in addition to metaphases. It has become clear that FISH studies may also be an integral component of the diagnostic evaluation, particularly where the abnormality is cryptic i.e. not evident by conventional cytogenetic studies. Although complementary FISH testing increases the overall detection of aberrations, its benefit is not uniform across all types of hematological neoplasms. This is because FISH probes are restricted to the detection of only specific abnormalities and genetic alterations beyond the scope of the FISH probes would therefore be completely missed. It is common practice for laboratories to use FISH probe panels in conjunction with karyotyping both in diagnostic specimens and during follow-up to monitor response to therapy. FISH is targeted toward specific abnormalities, and results can be evaluated in an automated fashion on interphase nuclei, allowing for examination of more cells than conventional cytogenetic studies. FISH has higher analytic and, in certain circumstances, higher clinical sensitivity compared with conventional cytogenetic studies. The usage of FISH probe panels in aiding diagnosis or in monitoring follow-up samples of hematologic neoplasms is critical. The Eastern Collaborative Oncology Group (ECOG) compared conventional cytogenetic studies and FISH in AML patients and found that a probe panel to detect monosomy 5/deletion 5q, monosomy 7/deletion 7q, trisomy 8, t(8;21), t(9;22), MLL rearrangements with various partners, t(15;17), and inv(16)/t(16;16), had a concordance between 98% and 100%. On the other hand, He et al study demonstrates the limited value of FISH testing in adult AML in the setting of an adequate karyotyping study. Despite of many significant technological advances made in recent years in the area of clinical genetic testing, conventional cytogenetic studies and routine FISH studies remain important laboratory testing tools available for evaluating hematologic neoplasms. Usually these two testing methods complement each other and often FISH serves to clarify and better define cytogenetic results. Therefore, there is a very strong expectation that cytogenetic and FISH results should confirm each other in spite of cases that appear to be exceptions. When conflicting results occur by these two testing methods on the same specimen, clinical laboratories are challenged to offer explanations based on empirical data beyond simply stating that it was or was not due to laboratory error. Multiplex FISH (M-FISH) represents one of the most significant developments in molecular cytogenetics of the past decade. In tumor and leukemia cytogenetics, two groups have been targeted by M-FISH to identify cryptic chromosome rearrangements not detectable by conventional cytogenetic studies: those with an apparently normal karyotype (suspected of harboring small rearrangements not detectable by conventional cytogenetics) and those with a complex aberrant karyotype (which are difficult to karyotype accurately due to the sheer number of aberrations). Zhang et al. used spectral karyotype (SKY) to re-evaluate the karyotypes of AML cases reported as normal by G-banding. This resulted in the identification of one case of t(11;19)(q23;p13), a subtle but recognized cytogenetic abnormality, and a minor clone containing monosomy for chromosome 7 in another case. In a similar study, Mohr et al. compared SKY to conventional karyotyping in patients with AML or MDS with normal karyotypes. No abnormalities were identified. With the lack of an evidence-based standardized algorithmic approach, misuse and overutilization of laboratory tests are common and result in increased health care costs and patient care complexity. In the current health care environment, which increasingly focuses on value and efficiency, it is critical for pathologists and clinicians to incorporate high-complexity and expensive techniques into routine patient care. While conventional cytogenetic studies provide a comprehensive view of the genome, FISH probe panel can detect cryptic or submicroscopic genetic abnormalities and identify recurrent genetic abnormalities in nondividing cells. M-FISH can identify cryptic chromosome rearrangements that are not detected by conventional cytogenetic studies. As a consequence, it is commonly extrapolated that FISH will improve the sensitivity of detecting all genetic abnormalities compared with conventional cytogenetic studies. This assumption has then been translated in clinical practice to having clinicians and pathologists routinely ordering both conventional cytogenetic studies and FISH studies in patients with hematological neoplasms. Depending on how comprehensive the FISH probe panel is, the cost for this testing may be quite expensive, and its additive value remains questionable.

Official Title
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Comparison of Diagnostic Yield Among Multiplex Fluorescent in Situ Hybridization, Fluorescent in Situ Hybridization Probe Panel and Conventional Cytogenetic Studies in Acute Myeloid Leukemia

Conditions
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Acute Myeloid Leukemia

Intervention / Treatment
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* Diagnostic Test: Conventional Cytogenetics Studies
* Diagnostic Test: Fluorescent in Situ Hybridization (FISH) Panels
* Diagnostic Test: Multiplex FISH (M-FISH)


Participation Criteria
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Eligibility Criteria
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Inclusion criteria: Patients with newly diagnosed acute myeloid leukemia. Age group: patients more than 18 years old. Exclusion criteria: Patients less than 18 years old. Patients with other types of hematologic neoplasms. Relapsed patients.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Acute Myeloid Leukemia (AML) group<br>Patients who are diagnosed as Acute Myeloid Leukemia based on peripheral blood, bone marrow aspiration and immunophenotyping and fulfill WHO criteria for diagnosis. Fluorescent in Situ Hybridization (FISH) Panels for AML, Multiplex FISH (M-FISH) and Conventional Cytogenetics Studies will be performed for AML patients. | Diagnostic Test: Conventional Cytogenetics Studies<br>* Metaphase cytogenetic studies will be performed in all cases according to standard methods. Chromosome preparations will be G-banded using trypsin and Giemsa, and karyotypes will be described according to the International System for Human Cytogenetic Nomenclature (ISCN) 2016.<br>* Other names: Karyotyping;Diagnostic Test: Fluorescent in Situ Hybridization (FISH) Panels<br>* AML Panel includes: t(8;21) (RUNX1-RUNX1T1). inv(16), t(16;16) (CBFB-MYH11). t(9;22) (BCR-ABL). 11q23 KMT2A rearrangements. inv(3) MECOM rearrangements. DEK-NUP214 rearrangements. Del(5q) Deletion Del(7q) Deletion Acute Promyelocytic Leukemia panel includes: t(15;17) (PML-RARA). 17q RARA rearrangements<br>Diagnostic Test: Multiplex FISH (M-FISH)<br>* 24-color karyotyping<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluation of cytogenetic profile of AML patients in South Egypt | Study the hematological and cytogenetic profile of AML patients in a tertiary center in Egypt | 2 years | 
| Comparing Diagnostic Yield among Multiplex Fluorescent in situ hybridization, fluorescent in situ hybridization probe panel and conventional cytogenetic analysis in newly diagnosed patients with AML. | Compare M-FISH, karyotyping and FISH probe panel in AML patients in a limited resource institute | 2 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Correlation between cytogenetic results and demographic, clinical and hematological data of AML patients | Correlating cytogenetic results and demographic and clinicopathological data in AML patients | 2 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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M-FISH, FISH, AML