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EVALUATION OF THE MORPHOLOGICAL FLAGGING EFFICIENCY (Q-FLAGS) OF THE SYSMEX XE-2100

Article  in  Acta clinica Belgica · March 2011

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 EVALUATION OF THE MORPHOLOGICAL FLAGGING
EFFICIENCY (Q-FLAGS) OF THE SYSMEX XE-2100
Drieghe S, Baatout S, Louagie H and Ghys T
Clinical Laboratory AZ Sint-Lucas/Volkskliniek, Ghent, Groenebriel 1, 9000 B-Ghent, Belgium

INTRODUCTION B. Comparison of the XE-2100 with the manual differential

The Sysmex XE-2100 (Sysmex Corporation, Kobe, Japan) is a fully, automated haematology Results for the comparison of the XE-2100 with the manual reference leucocyte differential are
analyser designed for high-volume testing in clinical laboratories. The analyser provides a presented in Table 3 and Figure A-F. Overall comparison with the manual differential was good. R-
complete blood count, as well as a five-part leucocyte differential, a reticulocyte analysis and a values were ≥ 0.95, except for the comparison of eosinophils (r = 0.82), monocytes (r = 0.76) and
nucleated red blood cell count (NRBC). It incorporates a system of flags to alert for basophils (r = 0.11).
morphological abnormalities (e.g. abnormal or immature cells, …). Our purpose was to evaluate this
morphological flagging efficiency (Q-Flags). Secondly, we also evaluated the correlation between Table 3. Comparison of the XE-2100 with the manual differential method
the Sysmex XE-2100 and a 100-cell manual leucocyte differential.
Parameter n Correlation coefficient (r) Intercept Slope
Neutrophils 497 0,95 1,08 0,92
MATERIALS AND METHODS Lymfocytes 496 0,95 4,25 0,90
Eosinophils 497 0,82 0,76 0,71

For comparison of the XE-2100 with the manual leucocyte differential, 497 random patient Monocytes 492 0,76 4,07 0,78
samples were used. Wright-Giemsa stained peripheral blood smear slides were evaluated by two Basophils 497 0,11 0,50 0,09
morphologists who performed a manual leucocyte differential with the CellavisionTM DM96
(CellaVision AB, Lund, Sweden). Following criteria were used to designate a slide as being For the comparison of the monocytes between the XE-2100 and the manual leucocyte differential
abnormal: 5/497 samples were excluded. These were all samples from a patient with a chronic
myelomonocytic leukaemia, where differentiation between monocytes and immature granulocytes
 > 0% blasts; was very difficult (XE-2100 > 40% and manual differential < 10%).
 > 1% immature granulocytes (promyelocytes, myelocytes or metamyelocytes);
 > 5% band neutrophils;
Figure A Figure B
 > 3% atypical lymfocytes (EBV-like lymfocytes and lymphomas); and 100 100
 > 1% nucleated red blood cells (NRBC).

Neutrophils XE-2100 (%)

Neutrophils XE-2100 (%)

80 y = 0,921x + 1,083 80 y = 0,883x + 4,243
Overall and individual flagging efficiency (QFlag Blasts, Left Shift, Atypical Lymfocytes, NRBC R 2 = 0,896 R 2 = 0,880
and Immature Granulocytes) was evaluated using the manual differential as the reference. The 60 60
cut-off value for positivity for the different QFlags was set at 100. Finally, all results were
compared by lineair regression and correlation coefficients (r) were calculated.
40 40

RESULTS 20 20

A. Overall and individual flagging efficiency

0 0
0 20 40 60 80 100 0 20 40 60 80 100
The manual reference differential designated in Table 1. Overall flagging efficiency
46 samples the presence of abnormal or immature Sum neutrophils DM96 (%) Neutrophils DM96 (%)
cells (Table 1). The XE-2100 did not generate Positive Negative
flaggings in 24 of the 46 samples. Overall flagging Manual differential 46 451
sensitivity and specificity were 48% and 94%, QFlags XE-2100 51 446 Figure C Figure D
respectively. TN 422 100 20
TP 22
Individual analysis of the blast, immature FN 24 y = 0,901x + 4,251 y = 0,709x + 0,762
Lymfocytes XE-2100 (%)

Eosinophils XE-2100 (%)

granulocytes, left shift, nucleated red blood cell 80
R 2 = 0,899 15 R 2 = 0,671
FP 29
and atypical lymfocyte flags is presented in Table
2. The sensitivities of the individual QFlags was Sensitivity, % (CI) 48 (36-59) 60
rather low for all parameters. Specificity, % (CI) 94 (93-95) 10
NPV, % (CI) 95 (94-96) 40
PPV, % (CI) 43 (32-53)
5
Table 2. Individual flagging efficiency 20

Flagging n TP TN FP FN Sensitivity (%) Specificity (%) PPV NPV 0

0
Blasts 18 8 471 8 10 44 98 50 98 0 20 40 60 80 100 0 5 10 15 20

Lymfocytes DM96 (%) Eosinophils DM96 (%)

Immature granulocytes 35 11 455 7 24 31 98 61 95

Left shift 11 9 479 7 2 82 99 56 100

Figure E Figure F
Atypical lymfocytes 4 2 462 31 2 50 94 6 100
60 15
NRBC 7 3 483 7 4 43 99 30 99
50
Monocytes XE-2100 (%)

Basophils XE-2100 (%)

The sensitivity for the blast flag was only 44%. The ten false-negative results comprised all 40 10
regenerative blasts (1-4%). When we combined the QFlag Blasts and the QFlag Abnormal y = 0,092x + 0,504
Lymfocytes/L-blasts, sensitivity was slightly better (50%). However, all the ten false-negative 30 R 2 = 0,012
results were positive for other flaggings that would prompt manual review.
20 5

y = 0,776x + 4,072
The flag atypical lymfocytes showed a rather low sensitivity and specificity. 10
R 2 = 0,578
0 0
We don’t have a proper explanation for the rather low sensitivity for the NRBC flag. These all 0 10 20 30 40 50 60 0 5 10 15 20
included samples with 1-5% NRBC, but they were all positive for other flaggings. Monocytes DM96 (%) Basophils DM96 (%)

The flag for immature granulocytes showed the lowest sensitivity. A possible reason could be the
subjective manual differentiation. When we combined the QFlag Immature Granulocytes with the
QFlag Left Shift sensitivity was elevated to 43%. However, as there is a lot of controverse about
reporting band neutrophils in peripheral blood counts, a combination of these two flags isn’t
preferable.
When all/other flagging criteria were included (QFlags, SIS-rules, …) overall sensitivity was
elevated to 80%. Then, the XE-2100 didn’t generate any flagging for 9 samples, these all included
immature granulocytes (1.5 - 3.7%, cfr. low sensitivity of Qflag Immature Granulocytes).
CONCLUSION
The overall and individual flagging efficiency seems disappointing. A possible reason is a rather low
prevalence of samples with abnormal of immature cells in our study. However, when all flagging
criteria of the XE-2100 were included, no clinical important abnormalities were missed. Overall
correlation with the manual differential was good. However, the smaller cell populations (basophils,
and to a lesser extent monocytes) did not well correlate with the XE-2100 data, as already
described in literature.

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