Cost-Effectiveness of Limited Screening Panel for Acute Lymphoblastic Leukemia Diagnosis in a Resource-Limited Setting

Authors

DOI:

https://doi.org/10.21141/PJP.2021.04

Keywords:

limited screening panel, acute lymphoblastic leukemia, pediatric population, Filipino

Abstract

Background: Flow cytometry is an invaluable tool in the diagnostic evaluation of acute leukemia and post therapy monitoring; however, majority of Filipino population cannot afford the cost. The use of a minimal screening panel which is both cost-effective and provides an accurate diagnosis of acute lymphoblastic leukemia is seen as an alternative.

Objectives: We aim to determine the cost-effectiveness and accuracy of using a minimal screening panel for the diagnosis of acute lymphoblastic leukemia (ALL).

Methodology: We selected a limited panel of 9 antibodies comprising of CD45/CD19/CD20/CD10/HLA-DR/CD34/cCD3/cCD79a/cTdt and retrospectively reviewed newly diagnosed cases of B-cell and T-cell ALL from September 2016 to December 2019 using this panel.

Results: Out of 719 bone marrow aspirates submitted for basic leukemia flow cytometric analysis we identified 268 ALL cases (239 B-ALL and 29 T-ALL).

In all cases, a diagnosis was established using the limited panel. Compared to the current cost of our comprehensive panel (₱ 9,903.60). This limited panel cost ₱ 3,062.29, that offers a 69.08% savings per test, which translated to a ₱1.2 million savings a year (for an average of 180 annual cases).

Conclusion: We underscore the utility of a limited panel for the diagnosis of ALL. Although this panel remains to be assessed with a larger validation cohort, its application in resource-limited developing countries is diagnostically useful and cost-effective.

Recommendation: The use of a limited panel of 9 antibodies is recommended as a screening panel for patients who are highly suspected of having ALL both clinically and initial bone marrow smear assessment.

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Author Biographies

Ivy Mae Medalla, Philippine Children’s Medical Center

Medical Officer II, Division of Pathology

Maria Beatriz Gepte, Philippine Children’s Medical Center

Clinical Oncology Unit Head, Cancer and Hematology Center

Qareem Pido, Philippine Children’s Medical Center

Visiting Consultant, Division of Pathology

Daphne Ang, Philippine Children’s Medical Center

Medical Specialist III, Division of Pathology

References

1. Swerdlow SH, Campo E, Harris NL, et al, ed. WHO classification of tumours of haematopoietic and lymphoid tissues, 4th ed. Lyon : IARC; 2017.

2. Weir EG, Borowitz MJ. Flow cytometry in the diagnosis of acute leukemia. Sem Hematol. 2001;38(2):124-38. https://pubmed.ncbi.nlm.nih.gov/11309694. https://doi.org/10.1016/s0037-1963(01)90046-0.

3. Cagle PT, Allen TC, Popper HH. Basic concepts of molecular pathology. Arch Pathol Lab Med. 2008;132(10):1551-6. https://pubmed.ncbi.nlm.nih.gov/18834208. https://doi.org/10.5858/2008-132-1551-BCOMP.

4. Singh N, Pati HP, Tyagi S, Deka R, Sharma R, Saxena R. Proposed minimal panel of antibodies for cost-effectiveness and accuracy in acute leukemias immunophenotyping: prospective study at a tertiary care center. Hematology. 2016;21(6):338-42. https://pubmed.ncbi.nlm.nih.gov/ 26907095. https://doi.org/10.1080/10245332.2016.1139792.

5. Terwilliger T, Abdul-Hay M. Acute Lymphoblastic Leukemia: A Comprehesive Review and 2017 Update. Blood Cancer J. 2017;7(6):e577. https://pubmed.ncbi.nlm.nih.gov/28665419.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5520400. https://doi.org/10.1038/bcj.2017.53.

6. Adan A, Alizada G, Kiraz Y, Baran Y, Nalbant A. Flow cytometry: basic principles and applications. Crit Rev Biotechnol. 2017;37(2):163-76. https://pubmed.ncbi.nlm.nih.gov/26767547. https://doi.org/10.3109/07388551.2015.1128876.

7. Laudico AV, Mirasol-Lumague MR, Medina V, Mapua CA, Valenzuela FG, Pukkala E. 2015 Philippine Cancer Facts and Estimates. Manila: Philippine Cancer Society. 2015.

8. Chiaretti S, Zini G, Bassan R. Diagnosis and subclassification of acute lymphoblastic leukemia. Mediterr J Hematol Infect Dis. 2014;6(1):e2014073. https://pubmed.ncbi.nlm.nih.gov/25408859.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235437. https://doi.org/10.4084/MJHID.2014.073.

9. Orfao A, Ortuño F, de Santiago M, Lopez A, San Miguel J. Immunophenotyping of acute leukemias and myelodysplastic syndromes. Cytometry A. 2004;58(1): 62-71. https://pubmed.ncbi.nlm.nih.gov/14994223. https://doi.org/10.1002/cyto.a.10104.

10. Redaniel MT, Laudico A, Mirasol-Lumague MR, Alcasabas AP, Pulte D, Brenner H.Geographic and ethnic differences in childhood leukaemia and lymphoma survival: comparisons of Philippine residents, Asian Americans and Caucasians in the United States. Br J Cancer. 2010103(1):149-54. https://pubmed.ncbi.nlm.nih.gov/20485290.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2905294. https://doi.org/10.1038/sj.bjc.6605703.

11. van Dongen JJM, Lhermitte L, Bottcher S, et al. EuroFlow antibody panels for standardization n-dimenional flow cytometric immunophenotyping for normal, reactive and malignant leukocytes. Leukemia. 2012;26(9):1908-75. https://pubmed.ncbi.nlm.nih.gov/22552007.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437410. https://doi.org/10.1038/leu.2012.120.

12. Gupta S, Chatterjee T, Sharma S, et al. Flowcytometric comparative analysis in acute leukemias between indian and proposed minimal screening panel. Med J Armed Forces India. 2016;72(3):220-30. https://pubmed.ncbi.nlm.nih.gov/27546960.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4982965. https://doi.org/10.1016/j.mjafi.2016.01.002.

13. Ratei R, Karawajew L, Lacombe F, et al. Discriminant function analysis as decision support system for the diagnosis of acute leukemia with a minimal four color screening panel and multiparameter flow cytometry immunophenotyping. Leukemia. 2007;21(6):1204-11. https://pubmed.ncbi.nlm.nih.gov/17410192. https://doi.org/10.1038/sj.leu.2404675.

14. Pido QG, Ang DC, Lo RW. Immunophenotypic and hematologic profile of pediatric acute lymphoblastic leukemia in the Philippines. Archives of Pathology. 2018; 142(9). http://www.pcmc.gov.ph/images/RF2020/PIDOALLPATHO.pdf.

15. Artaiz JP, Pido QG, Sandoval SA, Verana E, Lo RW, Ang DC. Spectrum of hematologic malignancies in a tertiary pediatric center in the Philippines. Archives of Pathology. 2018;142(9). http://www.pcmc.gov.ph/images/RF2020/ARTAIZ_CPPATHO.pdf.

16. Ikoma MRV, Sandes AF, Thiago LS, et al. First proposed panels on acute leukemia for four-color immunophenotyping by flow cytometry from the brazilian group of flow cytometry-GBCFLUX. Cytometry B Clin Cytom. 2015;88(3):194-203. https://pubmed.ncbi.nlm.nih.gov/24753208. https://doi.org/10.1002/cyto.b.21175.

17. Stewart CC, Behm FG, Carey JL, et al. U.S.-Canadian consensus recommendations on the immunophenotypic analysis of hematologic neoplasia by flow cytometry: selection of antibody combinations Cytometry. 1997;30(5):231-5. https://pubmed.ncbi.nlm.nih.gov/9383096. https://doi.org/10.1002/(sici)1097-0320(19971015)30:5<231::aid-cyto3>3.0.co;2-k.

18. Borowitz MJ. Immunologic markers in childhood acute lymphoblastic leukemia. Hematol Oncol Clin North Am. 1990;4(4):743-65. https://pubmed.ncbi.nlm.nih.gov/2228895.

19. Illingworth A, Liu L, Rolf N. Current status of TdT testing by flow cytometry-survey results. International Clinical Cytometry Society. 2019.

20. Wood BL, Arroz M, Barnett D, et al. 2006 Bethesda International Consensus recommendations on the immunophenotypic analysis of hematolymphoid neoplasia by flow cytometry: optimal reagents and reporting for the flow cytometric diagnosis of hematopoietic neoplasia. Cytometry B Clin Cytom. 2007;72 Suppl 1:S14-22. https://pubmed.ncbi.nlm.nih.gov/17803189. https://doi.org/10.1002/cyto.b.20363.

21. Haycocks NG, Lawrence L, Cain JW, Zhao XF. Optimizing abtibody panels for efficient and cost-effective flow cytometric diagnosis of acute leukemia.Cytometry B Clin Cytom. 2011:80(4):221-9. https://pubmed.ncbi.nlm.nih.gov/21298777. https://doi.org/10.1002/cyto.b.20586.

22. World Bank. Making growth work for the poor: a poverty assessment for the Philippines. World Bank, Manila. 2018. https://openknowledge.worldbank.org/handle/10986/29960

Published

2021-06-29

How to Cite

Medalla, I. M., Gepte, M. B., Pido, Q., & Ang, D. (2021). Cost-Effectiveness of Limited Screening Panel for Acute Lymphoblastic Leukemia Diagnosis in a Resource-Limited Setting. PJP, 6(1), 27–30. https://doi.org/10.21141/PJP.2021.04

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Original Articles