Flow cytometry: An Indian Scenario
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Flow cytometry: An Indian Scenario Multicolor Immunophenotyping: Applications and Standardization TMH, Mumbai March 9-11, 2012 Sumeet Gujral, MD Professor, Department of Pathology, Tata Memorial Hospital, Mumbai s_gujral@hotmail.com. Flow cytometry: An Indian Scenario. History

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Flow cytometry: An Indian Scenario

Multicolor Immunophenotyping: Applications and Standardization

TMH, Mumbai

March 9-11, 2012

Sumeet Gujral, MD


Department of Pathology,

Tata Memorial Hospital, Mumbai


Flow cytometry: An Indian Scenario


The Cytometry Society (TCS)

- Research Arm

- Clinical Cytometry

a. Health care in India

b. Management of HLN (Trained staff, Equipped labs, Cancer Hospitals, Costing)

c. Immunophenotyping

- Indian Data

- First Meeting, 2008 (Indian Guidelines)

- PT program and Standardization

- Training programs

Present meeting


Uniformity in Diagnostics

1. History

Mid 80s - Dr. VK Jain’s (NIMHANS), followed by Drs. Ganguly, Pande, Rath, Muthukaruppan, Moudgal, Indranath, Sehgal & Chakraborty.In 90s - Pande & Rath: trg pgms.In 2000 - A Krishan of Univ. of Miami started Indo-US cytometry workshops (12 workshops+).

First fluorescent based FCM developed in

1968 by W Guhde. Pulse cytophotometry


Research labs, early 80s

Diagnostic labs,1990s

  • TMC Mumbai

  • AIIMS, New Delhi

  • Hinduja Hospital

  • Pvt Reference Labs

  • Others

  • CD4 counts

2. The Cytometry Society (TCS) of India, 2005

The Cytometry Society (TCS) - 2005

  • 2005 at CCMB

  • 2006 – ICCS meeting in USA, Phil McCoy

  • 2007 – Together, Clinical & Research

  • Self nominations and proposed election…

  • Executive council, President, 2 VPs, 2 Secretaries, various committees.

  • Pande, Amar, Krishnamurthy,..

  • Annual meetings & IndoUS cytometry workshops.

  • Membership and Website: tcs.res.in

7th Indo-US Cytometry Workshop, JNU, New Delhi, 2006

Basic/research cytometry

  • Institute based (government agencies)

  • Last decade – Industry

  • > 1000 cytometers

Total pubmed publications – 126505, first in 1974

Total Indian publications - 1092, first in 1989

Clinical Cytometry

  • Management of HLN in India

  • Cancer Hospitals, Labs, Trained staff, Costing

  • Immunophenotyping

  • - Indian Data

  • - First Meeting, 2008 (Indian Guidelines)

  • - PT program and Standardization

  • - Training programs

Management of leukemia/lymphoma – IndiaCancer HospitalsLabs with Ancillary TechniquesTrained StaffCosting

Dream: Comprehensive diagnostic workup followed by a “protocol based treatment”.

“WHO 2008”

Reality: Protocol based treatment vis-a-vis modified one based on resources available (on individual basis)

No Indian guidelines for most disciplines, opinion/experience based.

Health care in India

  • Hospitals (Government versus Private)

  • Labs with Ancillary techniques

  • Training program

  • Costing

Cancer Hospitals (<25) n=60/70

Tertiary Care Cancer Centers: 6-8

Regional Cancer Centers: 15-20

Private/Corporate Hospitals: 35-40

Medical College

Nursing Homes

Management of HLN

Hematolymphoid neoplasm treated at <50 centers

SCT being done at 10-20 centers

Labs with Ancillary Techniques <15 FCM, Cytogenetics, Molecular Diagnostics

Tertiary care cancer centers including pvt. hospitals (8-10)

Stand alone private laboratories (3/4)

Regional cancer centers (3/4)

Management of HLN

Trained staffStructured training programs

Hematopathologists (DM+fellows+residents): 5+10/year

Management of HLN

  • Medical Oncologists (Ped & Adult): 20-25/year

  • Hematologists: 5/year

  • There are no structured training programs for any of the ancillary techniques (both for pathologists as well as for technologists).

Hematopathology training in India

Post MD pathologists: 3 year DM, 2 year fellowship and one year residency program.

An occasional center in India train hematopathologists both in lymph nodes and bone marrow.

Management of HLN

Management of HLN

Amongst various ancillary techniques, flow is better off in..

  • Training programs, conferences/ CMEs

  • Larger pool of young cytometrists

  • Students (DM, Fellows and Residents) get rotation in flow lab (2-5 months, 7-8 centers in India).

Costing of Immunophenotyping: Year 2008

Activity Based Costing method is used to calculate per cost test

Indirect costs: Hidden costsalaries, depreciable value,furniture,funds for personnel training and CMEs, ancillary equipments, stationary, electricity and rental chargesMedical insurance, deputation etc

Direct cost: Visible cost1. One time cost of instrumentOutright purchase versus Reagent rental2. Recurring costReagents, antibodies, tubes, fluids, dyes and kits.3. Annual maintenance contract

Direct cost of IPT

Indirect cost of IPT

  • Number of SM studies in a year = 1300

  • Per sample indirect cost is Rs 124

  • Indirect cost for SM is 1300 x 124 = Rs 1,61,000

Management of HLN

Per sample cost of IPT at TMH, 20083-color, 15-18 markers

  • Total cost= Direct cost + Indirect Cost

    = 51,96,025 + 1,61,000

    = 53,57,025

  • Per sample cost of SM: 53,57,025 / 1300 = 4120

Costing of one IPT test - Rs. 4120 (USD 100)

Costing of CD34 counts - Rs. 1700 (USD 40)

Gujral, IJPM, 2010

Management of HLN

Other factorsCost per test decreases as number of samples increase.Cost increases as the number of color/panels increase. Maximum expense is on reagents and consumables, followed by manpower.Cost per test is higher for specialized tests done by a pathologist.

Gujral, IJPM, 2010


Population of 1000 million, 6000 children may develop ALL each year

Three tier society (based on socio-economic backgrounds):

Profile I (70%) being extremely poor who cannot afford any treatment

Profile II (25%) from the middle class, and

Profile III (<5%) who can afford to have the best possible treatment

Treatment costs approximately 10% of western costs

Management of HLN

Pediatric Acute Leukemia - India

Government / social organizations fund pediatric cases get treated

Chandy M et al

All patients have a complete work up for diagnosis.

Pediatric patients: 70% are treated with a curative intent

(protocol based).

Adult patients: protocol based treatment given to ALL

(70%), AML (70%), CML (100%), CLL (70%), NHL (90%).

Management of HLN

Leukemia/lymphoma - TMH

Gujral, Leukemia 2009

Management of HLN at TMH

Lab tests constitute 2-6% of total cost of management (BMT excluded)

Most labs in India still follow FAB classification systems in diagnosing and sub-typing of hematolymphoid neoplasm.Few centers use WHO 2008 classification system of HLN.

Management of HLN

Immunophenotyping - India

  • 1. Introduction to IPT

  • 2. Indian Data

  • 3. First Meeting, 2008 (Indian Guidelines)

  • 4. PT program and Standardization

Flow Cytometry

It is the measurement of cellular properties as cells move in a fluid stream (flow), past a stationary set of detectors

Technique of quantitative single cell analysis

It analyses

- physical, and

- chemical properties (immunofluorescence) of cell

IHC and FCM – complementaryMandatory for any center doing HLN

FCMmulticolor immunophenotypingfluids

Immunohistochemistry mostly single colorbiopsy

>400 labs do CD4 counts (started in mid 80s).

>60 labs do leukemia IPT (started in mid 90s).

  • most do 3 colors,

  • few do 4 colors,

  • very few do 6 colors.

    Few do autoimmune workup, PNH studies, CD34

    stem cell counts etc.

2008 WHO classification of

Hematolymphoid Neoplasms

WHO classification: still a distant reality

  • Myeloid neoplasms

  • Precursor lymphoid neoplasms

  • Mature B cell neoplasms

  • Mature T- and NK- cell neoplasms

  • Hodgkin lymphoma

  • Immunodeficiency associated LPD

  • Histiocytic and dendritic cell neoplasms

TMH Data

Hematopathology Lab, TMH, Mumbai

  • Approx. 50,000 new patients come to TMH/year and 8% of these are hematolymphoid neoplasm.

  • 4000 new cases every year.

Leuk & Lymphoma, 2009 Clinical Cytometry, 2008

IJC, 2010,

Acute Leukemia, n=2511

Common subtypes of AML

AMLM2 (27%),

AMLM5 (15%),

AMLM0 (12%),

AMLM1 (12%),

APML (11%), and

AML t(8;21) (9%)

CMLBC was commonly of myeloid blast crisis

subtype (40 cases)

ALL (58%)

AML (38%)

Common subtypes of ALL vs WestB-cell ALL - 76% (85%)T-cell ALL - 24% (10-15%)

Lymphomas in BM/PBS - CLPDs

B cell Lymphomas

CLL - 68.5%,

FL - 8.5%

MCL - 5.5%

SMZL - 5%)

HCL - 5%

T/NK cell lymphomas

4% (nine cases) of all mature

lymphoid neoplasms.

T-LGL - 4 cases,

T-PLL - 2 (small cell variant),

ATLL – 2


IJC, 2010

Leuk Lymphoma, 2009

Hematolymphoid Neoplasm - One year DMG/clinic data

Pediatric data, 2011

  • Total number of cases – 1704

  • Solid tumors - 921

  • Hematolymphoid neoplasms - 783

Total number HLN

treated - 665

ALL - 396

AML - 73

NHL - 85

HL - 74

Total number HLN

treated - 665

Newly diagnosed - 587

Previously treated – 65

Second opinion – 7

Investigation only - 5

Newly diagnosed HLN - 665

On protocol – 439 (66%)

Untreated – 85

On other treatment -42

Referred on protocol - 21

March 2005

March 2005, MumbaiTMH started a ILCP for IPTFive local laboratories joined (sample sent, results, feedback)Quarterly meetings

After 6 cycles of the PT program

Results: Wide variation starting from sample collection, clone and fluorochrome conjugates selection, processing, gating strategies, analysis and reporting format

Planned First Meeting

Focus on “Indian Guidelines for Panel selection”Antibody panel selection plays a vital role in obtaining an accurate diagnosis. Lot of diversity in panel selection.Numerous guidelines have addressed antibody panels. Most Guidelines - North America and EuropeOther issues: Sample collection, transport, viability, adequacy of cell yield, storing of samples - recommendations as described elsewhere1,2

Propose guidelines for a minimal antibody panel without compromising on accuracyTo enable uniformity in reporting Educational exercise (evolving technology)PT program


Avoid ultrashort panels

These documents were circulated, taking opinion from cytometrists, hematopathologists, medical and pediatric oncologists and others

Over next three years (2005-08), consensus Guidelines were formulated based on: - Published Data (Indian and western) - Results of the PT program- Practice Based Questionnaire and- Experience/opinion

“Guidelines for Immunophenotyping of Hematolymphoid Neoplasms by Flow Cytometry”March 13-15, 2008TMH, Mumbai

First Meeting, 2008

Revised 3 document (consensus) presented

Presentations: Cytometrists from India, Rest of the Asia, Europe, Australia and America presented their perspective on panel selectionDelegates: 180 delegates including 30 from outside India

Report of proceedings of the national meeting on "Guidelines for Immunophenotyping of Hematolymphoid Neoplasms by Flow Cytometry". Gujral S, Subramanian PG, Patkar N, Badrinath Y, Kumar A, Tembhare P, Vazifdar A, Khodaiji S, Madkaikar M, Ghosh K, Yargop M, Dasgupta A. Indian J Pathol Microbiol. 2008 Apr-Jun;51(2):161-6

2008 Guideline meeting, TMH, Mumbai

B cell:CD10, CD19T cell: CD7, CD5Myeloid: CD13, CD33, CD117Other: CD34, HLA-DR, CD45

Recommended minimal screening panel of Acute Leukemia, (n=10)

Recommended minimal screening panel of CLPD / Mature lymphomas, (n=9)

CD3, CD5,CD19, CD23, CD10, CD20, FMC7, Kappa, Lambda

Review of Literature

AL - Recommendation by various panels(n = 10-18)

CLPD - Recommendation by various panels (n = 7-11)

All lymphoid cellsCD45+ (LCA)

B-cellsCD19, CD10, cCD22

T-cells CD3, CD5,cCD3

Myeloid cellsCD13, CD33, CD117, anti MPO

MegakaryocyticCD41, CD61

Blasts CD34, Tdt, CD99

Other: HLA-DR, CD23, FMC-7, CD43, CD11c, CD25, CD103, CD38, CD138, CD20, CD79a, Kappa and Lambda light chains, TCR alpha beta, TCR gamma delta, CD4, CD64, CD55, CD59

Recommended markers in a leukemia lab

IJPM. 2008

At same time were published

2006 Bethesda International Consensus Guidelines.

Bethesda uses a panel of antibodies which are sensitive to pick up cells of a particular lineage.3Most guidelines use a panel of antibodies for diagnosis of AL or CLPDA combination of markers is used for a particular medical indication or symptom (for example lymphadenopathy or blasts in the blood). Wood et al, Clinical Cytometry, 2007

Similarities and Differences Bethesda versus Indian approach

US – indication based, Indian - morphology (& clinical) based

Both rely on a screening panel - 33 versus 10 antibodies

US - comprehensive panels, more T-cell reagents in screening

Secondary reagents differ

Indian – don’t address maturation pattern, CD45 gating optional

Indian panel includes CD23, FMC7 in primary screen

Leukemia, 2009

Cytometry A, 2009

Acceptability of Bethesda Consensus Guidelines?

AnemiaPrimary lymphadenopathySplenomegalyStaging of bone marrow in lymphomas

Pancytopenia in India25-60% is megaloblastic anemia

Indian Guidelines - Lacunae

Gujral et al, Cytometry B Clin Cytom. 2008 Aug 25

Gujral et al, Indian J Pathol Microbiol. 2008 Apr-Jun;51(2):161-6.

a beginning..


Lineage associated markers

Gating strategies

Scanty sample size

MRD Studies

Rare tumors are not diagnosed

Increased turn around time

Repeated procedures

Multicolor Immunophenotyping: Applications and Standardization

More colors more issues..

How much is enough?..

Selection of fluorochromes and cocktailsLineage specific markers in one tube

3 color to 10 colors

Third party software

More colors, more issues

15 color

8-10 color

3 to 6 color

or more


PMT Voltage setup using signal/noise ratio






Intracytoplasmic stains

Normal Peripheral Blood Sample – FSC/SSC

Tube 1- AntiMPO FITC / -PE

Tube 2- -FITC /Cyto CD79aPE

Tube 3- AntiMPO FITC / Cyto CD79aPE

2.5% Formaldehyde Fix for 20 min-wash-0.05% saponin for 10 min

Titration of antibodies

5 µl

1 µl

2 µl

15 µl

10 µl

20 µl

Contribution of debris to background

Spread of CD19 from Negative to Positive

Effect of titration of PE-cy7 antibody on Per-CpCy5.5 background




Line placing and making quadrants

19/4/8 cells based quadrants

19/4/8 cells based quadrants

Isotype control based quadrants

Isotype control based quadrants

PerCP-Cy5.5Tandem dye split may give false readings

Tandem fluorochrome split

Major plus of our First Meeting

FCM got popular


ILCP / PT program:

Started with 5 local labs in 2005

Presently 16 labs participate

Sponsor – TMH

Delhi ILCP


Review of the First meeting

3. Second Meeting on Standardization of Reagents for Multicolor ImmunophenotypingMarch 9-11, 2012TMH, Mumbai

Recent spurt in clinical cytometry laboratories, both Institute based as well as stand alone labs.

Many labs have started doing 5-6 color IPT.

To be discussed

  • Standardization issues plus a CME on Hematopoietic cells in normal, malignancy and residual disease.

  • Collaborations, multicentric studies.

4. Collaborations

ISAC and ICCS in form of holding meetings. Indian cytometrists attend and present in their annual meetings.

IndoUS workshops, an annual event, combined with Annual TCS Meetings.

Panel discussion on day 3

8th Indo-US Cytometry Workshop, Lucknow, 2007

9th Indo-US Cytometry Workshop, Bangalore, 2008

10th Indo-US Cytometry Workshop, Bhubaneshwar, 09

11th Indo-US Cytometry Workshop, Bangalore, 2010,

Annual TCS meetings with IndoUS workshops

12th Indo-US Cytometry Workshop, PU, Chandigarh - 2011

12th Indo-US Cytometry Workshop, DYP Univ., Pune

Making friendsASEAN Cytometry Workshops, Kaula Lumpur, MalayasiaSingapore, Turkey, Thailand

5. Aiming for Uniformity

First meeting - Indian Guidelines on Panel selection Second Meeting – Multicolor IPT, Application and StandardizationPT program –16 labsHematopathology FellowshipVarious Training Programs for technologists and pathologists..

FCM Training Programs - TMH

TMH Mumbai offers various clinical cytometry courses (technologists and pathologists). AIIMS/Vedanta Hospital.BD-NCBS Centre of Excellence, Bangalore offers basic cytometry courses four times a year. TCS offers cytometry programs at various institutions.Centre for Cellular and Molecular Platforms, Bangalore offers basic cytometry courses four times year. Indo-US cytometry workshops at various centers annually.

FCM training programs - India

Conclude..We have progressed but still not there

Population: 1.21 Billion (year 2011)

289 Medical colleges, 31,548 doctors and 990 pathologists per year.

Only 30 oncologists and 15 hematopathologists per year

Labs with Ancillary Techniques <15

Hematolymphoid neoplasm treated at <50 centers

Treatment costs are 10% of western costs.

Lab tests constitute 2-6% of total cost of management

Hematopathology specialty (flow is a part).

Training programs in ancillary techniques for


Quality assurance program.

Collaboration amongst Indian cytometrists.

Multidisciplinary approach.

Thanks ICCS, faculty and the delegates

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