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HelpTest ID BALAF B-Cell Acute Lymphoblastic Leukemia/Lymphoma (ALL), FISH, Adult, Varies
Ordering Guidance
This test is only performed on specimens from patients with B-cell acute lymphoblastic leukemia/lymphoma (B-ALL/LBL) who are 31 years of age or older.
This test is intended to be ordered when the entire B-ALL/LBL fluorescence in situ hybridization (FISH) panel is needed for an adult patient.
-If this test is ordered on a patient 30 years of age or younger, this test will be canceled and automatically reordered by the laboratory as BALPF / B-Cell Acute Lymphoblastic Leukemia/Lymphoma (ALL), Pediatric, FISH, Varies.
-If this test is ordered and the laboratory is informed that the patient is on a Children's Oncology Group (COG) protocol, this test will be canceled and automatically reordered by the laboratory as COGBF / B-Cell Acute Lymphoblastic Leukemia/Lymphoma (ALL), Children's Oncology Group Enrollment Testing, FISH, Varies
-If TALAF / T-Cell Acute Lymphoblastic Leukemia/Lymphoma (ALL), Adult, FISH, Varies, is ordered concurrently with this test, the laboratory may cancel BALAF and automatically reorder as BALMF / B-Cell Acute Lymphoblastic Leukemia/Lymphoma (ALL), Specified FISH, Varies with the following FISH probes: ETV6/RUNX1, PBX1/TCF3, 4/10/17, break-apart IGH, break-apart CRLF2, break-apart P2RY8, break-apart ABL2, and IKZF1/cep7. If an abnormality is identified that would result in reflex testing in BALAF, the same reflex testing will be performed in the BALMF. This cancellation is necessary to avoid duplicate testing. Probes for break-apart PDGFRB, break-apart JAK2, CDKN2A/D9Z1, ABL1/BCR, break-apart ABL1, break-apart MLL, TP53/D17Z1 will still be performed as part of the adult T-ALL FISH panel.
If PHLDF / Philadelphia Chromosome-like Acute Lymphoblastic Leukemia (Ph-like ALL), Diagnostic FISH, Varies, is ordered concurrently with this test, PHLDF testing will be canceled. The probes offered in PHLDF are included within this test, when appropriate.
If limited B-cell ALL FISH probes are preferred, order BALMF / B-Cell Acute Lymphoblastic Leukemia/Lymphoma (ALL), Specified FISH, Varies.
At follow-up, conventional cytogenetic studies (CHRBM / Chromosome Analysis, Hematologic Disorders, Bone Marrow) and targeted B-ALL FISH probes can be evaluated based on the abnormalities identified in the diagnostic study. Order BALMF / B-Cell Acute Lymphoblastic Leukemia/Lymphoma (ALL), Specified FISH, Varies and request specific probes or abnormalities.
If the patient clinically relapses, a conventional chromosome study may be useful to identify cytogenetic changes in the neoplastic clone or the possible emergence of a new therapy-related myeloid clone.
For patients with B-cell lymphoma, order BLPMF / B-Cell Lymphoma, Specified FISH, Varies.
For testing paraffin-embedded tissue samples from patients with B-ALL/LBL, order BLBLF / B-Cell Acute Lymphoblastic Leukemia/Lymphoma, FISH, Tissue. If a paraffin-embedded tissue sample is submitted for this test, it will be canceled and BLBLF will be added and performed as the appropriate test.
Additional Testing Requirements
At diagnosis, conventional cytogenetic studies (CHRBM / Chromosome Analysis, Hematologic Disorders, Bone Marrow) and this panel should be performed per National Comprehensive Cancer Network guidelines. If there is limited specimen available, only this test will be performed.
Shipping Instructions
Advise Express Mail or equivalent if not on courier service.
Necessary Information
A reason for testing and a flow cytometry and/or bone marrow pathology report should be submitted with each specimen. The laboratory will not reject testing if this information is not provided; however, appropriate testing and interpretation may be compromised or delayed in some instances. If not provided, an appropriate indication for testing may be entered by Mayo Clinic Laboratories.
Specimen Required
Submit only 1 of the following specimens:
Preferred
Specimen Type: Bone marrow
Container/Tube:
Preferred: Yellow top (ACD)
Acceptable: Green top (heparin) or lavender top (EDTA)
Specimen Volume: 2-3 mL
Collection Instructions:
1. It is preferable to send the first aspirate from the bone marrow collection.
2. Invert several times to mix bone marrow.
3. Send bone marrow specimen in original tube. Do not aliquot.
Acceptable
Specimen Type: Whole blood
Container/Tube:
Preferred: Yellow top (ACD)
Acceptable: Green top (heparin) or lavender top (EDTA)
Specimen Volume: 6 mL
Collection Instructions:
1. Invert several times to mix blood.
2. Send whole blood specimen in original tube. Do not aliquot.
Forms
If not ordering electronically, complete, print, and send a Hematopathology/Cytogenetics Test Request (T726) with the specimen.
Secondary ID
609537Useful For
Detecting a neoplastic clone associated with the common chromosome abnormalities and classic rearrangements seen in adult patients with B-cell acute lymphoblastic leukemia/lymphoma (B-ALL/LBL)
An adjunct to conventional chromosome studies for patients with B-ALL/LBL
Evaluating specimens in which standard cytogenetic analysis is unsuccessful
Testing Algorithm
This test includes a charge for the probe application, analysis, and professional interpretation of results for 2 probe sets (4 individual fluorescence in situ hybridization [FISH] probes). Additional charges will be incurred for all reflex or additional probe sets performed.
The initial panel includes testing for the following abnormalities using the probes listed:
t(9;22), BCR/ABL1
t(X;14)(p22.33;q32)/ t(Y;14)(p11.32;q32), CRLF2/IGH
If results for the initial panel are negative, the following reflex probe sets will be performed as a secondary panel:
1q25 rearrangement, ABL2 break-apart
5q32 rearrangement, PDGFRB break-apart
9p24.1 rearrangement, JAK2 break-apart
9q34 rearrangement, ABL1 break-apart
t(Xp22.33;var) or t(Yp11.32;var), CRLF2 rearrangement
t(Xp22.33;var) or t(Yp11.32;var), P2RY8 rearrangement
Finally, if results for the secondary panel are negative, the following probe sets will be performed as a tertiary panel:
t(1;19)(q23;p13), PBX1/TCF3 fusion
Hyperdiploidy, +4,+10,+17: D4Z1/D10Z1/D17Z1
t(12;21)(p13;q22), ETV6/RUNX1 & iAMP21
14q32 rearrangement, IGH break-apart
11q23 rearrangement, MLL(KMT2A) break-apart
7p-, IKZF1/CEP7
When a KMT2A (MLL) rearrangement is identified, reflex testing will be performed to identify the translocation partner. Probes include identification of:
t(4;11)(q21;q23) AFF1/MLL
MLLT4(AFDN)/MLL
t(6;11)(q27;q23)
t(9;11)(p22;q23) MLLT3/MLL
t(10;11)(p12;q23) MLLT10/MLL
t(11;19)(q23;p13.1) MLL/ELL
t(11;19)(q23;p13.3) MLL/MLLT1
For more information, see B-Lymphoblastic Leukemia/Lymphoma Algorithm.
Special Instructions
Method Name
Fluorescence In Situ Hybridization (FISH)
Reporting Name
Adult ALL (B-cell), FISHSpecimen Type
VariesSpecimen Minimum Volume
Blood: 2 mL
Bone Marrow: 1 mL
Specimen Stability Information
| Specimen Type | Temperature | Time | |
|---|---|---|---|
| Varies | Ambient (preferred) | ||
| Refrigerated | |||
Clinical Information
In the United States, the incidence of acute lymphoblastic leukemia (ALL) is roughly 6000 new cases per year (as of 2019). ALL accounts for approximately 70% of all childhood leukemia cases (ages 0-19 years), making it the most common type of childhood cancer. Approximately 85% of pediatric cases of ALL are of B-cell lineage (B-ALL) and 15% are of T-cell lineage. It has a peak incidence at 2 to 5 years of age. The incidence decreases with increasing age, before increasing again at around 50 years of age. ALL is slightly more common in male patients than female patients. There is an increased incidence of ALL in individuals with Down syndrome, Fanconi anemia, Bloom syndrome, ataxia telangiectasia, X-linked agammaglobulinemia, and severe combined immunodeficiency. The overall cure rate for ALL in children is about 90%, and about 45% to 60% of adults have long-term disease-free survival. CRLF2/IGH rearrangements are more commonly observed in patients with Down syndrome or of Hispanic descent.
Specific genetic abnormalities are identified in the majority of cases of B-ALL, either by conventional chromosome studies or fluorescence in situ hybridization (FISH) studies. Each of the B-ALL genetic subgroups is important to detect and can be critical prognostic markers. The decision for early transplantation may be made if t(9;22)(q34;q11.2), MLL (KMT2A) translocations, RUNX1 duplication/amplification (iAMP21) or a hypodiploid clone is identified. In contrast, if the ETV6/RUNX1 fusion is detected by FISH or hyperdiploidy is identified by chromosome studies, the patient has a favorable prognosis and transplantation is rarely considered.
A newly recognized World Health Organization entity BCR-ABL1-like ALL, also known as Philadelphia chromosome-like acute lymphoblastic leukemia, is increasing in importance due to the poor prognosis seen in pediatric, adolescent, and young adult ALL. Common features of this entity involve rearrangements with tyrosine kinase genes involving the following genes: ABL2, PDGFRB, JAK2, ABL1, CRLF2, and P2RY8. Deletion of IKZF1 often accompanies this entity. Some patients who have failed conventional therapies have demonstrated favorable responses to targeted therapies in clinical trials when rearrangements involving these specific gene regions have been identified.
Evaluation of the MYC gene region is included in all diagnostic B-ALL panels to evaluate for Burkitt lymphoma. If a positive result is obtained, additional testing for the BCL2 and BCL6 gene regions will be performed.
Per National Comprehensive Cancer Network guidelines, a combination of cytogenetic and FISH testing is currently recommended in all pediatric and adult patients with B-ALL/lymphoblastic lymphoma (LBL). Additional cytogenetic techniques such as chromosomal microarray (CMAH / Chromosomal Microarray, Hematologic Disorders, Varies) may be helpful to resolve questions related to ploidy (hyperdiploid clone vs doubled hypodiploid clone) or to resolve certain clonal structural rearrangements such as the presence or absence of intra-chromosomal amplification of chromosome 21 (iAMP21). A summary of the characteristic chromosome abnormalities identified in B-ALL is listed in the following table. A summary of the characteristic chromosome abnormalities identified in B-ALL is listed in the following table.
Table. Common Chromosome Abnormalities in B-cell Acute Lymphoblastic Leukemia
|
Leukemia type |
Cytogenetic change |
Typical demographic |
Risk category |
|
B-acute lymphoblastic leukemia
|
t(12;21)(p13;q22), ETV6/RUNX1 |
Pediatric |
Favorable |
|
Hyperdiploidy |
Pediatric |
Favorable |
|
|
t(1;19)(q23;p13.3), PBX1/TCF3 |
Pediatric |
Intermediate to favorable |
|
|
t(9;22)(q34;q11.2), BCR/ABL1 |
All ages |
Unfavorable |
|
|
iAMP21, RUNX1 |
Pediatric |
Unfavorable |
|
|
del(9p), CDKN2A |
All ages |
Unknown |
|
|
t(11q23;var), MLL |
All ages |
Unfavorable |
|
|
t(4;11)(q21;q23), AFF1/MLL |
All ages |
Unfavorable |
|
|
t(6;11)(q27;q23), MLLT4(AFDN)/MLL |
All ages |
Unfavorable |
|
|
t(9;11)(p22;q23), MLLT3/MLL |
All ages |
Unfavorable |
|
|
t(10;11)(p12;q23), MLLT10/MLL |
All ages |
Unfavorable |
|
|
t(11;19)(q23;p13.1), MLL/ELL |
All ages |
Unfavorable |
|
|
t(11;19)(q23;p13.3), MLL/MLLT1 |
All ages |
Unfavorable |
|
|
t(14q32;var), IGH |
All ages |
Variable |
|
|
t(X;14)(p22;q32)/t(Y;14)(p11;q32), CRLF2/IGH |
Adolescent/ young adult |
Unfavorable |
|
|
t(Xp22.33;var) or t(Yp11.32;var), CRLF2 |
All ages |
Unfavorable |
|
|
t(Xp22.33;var) or t(Yp11.32;var), P2RY8 |
All ages |
Unfavorable |
|
|
-17/17p-, TP53 |
All ages |
Unfavorable |
|
|
t(8q24.1;var), MYC |
Pediatric/ adolescent/ young adult |
||
|
Complex karyotype (≥4 abnormalities) |
Adult |
Unfavorable |
|
|
Low hypodiploidy/near triploidy |
Adult |
Unfavorable |
|
|
Near-haploid/hypodiploid |
All ages |
Unfavorable |
|
|
del(7p) IKZF1 |
All ages |
Unfavorable in absence of ERG deletion |
|
|
Philadelphia chromosome-like acute lymphoblastic leukemia (Ph-like ALL) |
t(1q25;var), ABL2 |
Pediatric/ adolescent/ young adult |
Unfavorable |
|
t(5q32;var), PDGFRB |
|||
|
t(9p24.1;var), JAK2 |
|||
|
t(9q34;var), ABL1 |
|||
|
t(Xp22.33;var) or t(Yp11.32;var), CRLF2 |
|||
|
t(Xp22.33;var) or t(Yp11.32;var), P2RY8 |
Reference Values
An interpretive report will be provided.
Cautions
This test is not approved by the US Food and Drug Administration, and it is best used as an adjunct to clinical and pathologic information.
Fluorescence in situ hybridization (FISH) is not a substitute for conventional chromosome studies because the latter detects chromosome abnormalities associated with other hematological disorders that would be missed by this FISH panel test.
Bone marrow is the preferred specimen type for this FISH test. If bone marrow is not available, a blood specimen may be used if there are malignant cells in the blood specimen (as verified by a hematopathologist).
Day(s) Performed
Monday through Friday
Report Available
7 to 10 daysPerforming Laboratory
Mayo Clinic Laboratories in Rochester
Test Classification
This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. It has not been cleared or approved by the US Food and Drug Administration.CPT Code Information
88271 x4,88275 x2, 88291 - FISH Probe, Analysis, Interpretation; 2 probe sets
88271 x2, 88275 - FISH Probe, Analysis; each additional probe set (if appropriate)
88271 - FISH Probe (if appropriate)