CLB-09363; No.

of pages: 3; 4C:
Clinical Biochemistry xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Clinical Biochemistry

journal homepage: www.elsevier.com/locate/clinbiochem

Short Communication

Diagnostic efficiency of the Sysmex XN WPC channel for the reduction of

blood smears
Madelon Noordegraaf, Paul Meijer, Janneke Ruinemans-Koerts ⁎
Department of Clinical Chemistry and Haematology, Rijnstate Hospital, Arnhem, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Background: Several small studies showed that the WPC (white precursor cell) channel in the Sysmex
Received 15 June 2016 haematology analyser for leukocyte differentiation analysis leads to a significant reduction of microscopic
Received in revised form 25 August 2016 blood smears. We determined the added value of the WPC channel for blood smear reduction in a large teaching
Accepted 29 August 2016 hospital and whether this reduction was cost-effective and save.
Available online xxxx
Methods: Retrospectively, for 7850 leukocyte differentiation orders the percentage of samples resulting in a
WPC analysis and the outcomes of the WPC analysis were analysed and compared with the blood smear results.
Keywords:
Diagnostic efficiency
Results: WPC analysis resulted in a 12% reduction of blood smears, which is much lower than observed in
Sysmex XN haematology analyser other studies. This means 3–4 blood smears/day less of a total of 28 smears/day at the expense of missing 14
WPC channel patient samples with pathology (blasts or abnormal lymphocytes) in a 9 weeks period. The estimated total
Reduction blood smear costs of WPC analysis per year was more than the reduction in costs due to less blood smear reviews.
Conclusions: In a large teaching hospital, the small reduction in blood smears by the WPC channel does not
outweigh the costs and the slight reduction in sensitivity for pathology.
© 2016 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

1. Introduction flag 3) “atypical lymphocytes, suspect reactive” flag or 4) no flag. Several

Modern haematology analysers offer high throughput analysis of
complete blood cell counts (CBC), reticulocyte count, nucleated red
blood cell (NRBC) counts and leukocyte differentiation. Different
flagging algorithms can discriminate between suspected pathological
and non-pathological samples. Despite the high specificity for detection
of pathological cells, the number of false positives remains high and
microscopic evaluation of a peripheral blood smear remains necessary
for confirmation and classification [1]. As diagnostic test results need
to be produced faster and cheaper, there is an increasing demand for
more specific flagging algorithms to reduce the number of unnecessary
blood smears without a reduction in sensitivity.
In 2011, Sysmex introduced the XN haematology analyser with
among others modification of the white cell differentiation channel
and introduction of a new channel. The white cell differentiation chan-
nel (WDF) performs a leukocyte differentiation (except the basophil
count) and flags for among other things presence of “blast/abnormal
lymphocytes”. The new white precursor cell (WPC) channel separates
the “blast/abnormal lymphocytes” flag generated in the WDF channel
into suspect malignant and reactive processes, or removes the positive
flag, i.e. 1) “blast” flag, 2) “abnormal lymphocytes, suspect neoplastic”
⁎ Corresponding author at: Department of Clinical Chemistry and Haematology,
Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands.
E-mail address: JRuinemans-Koerts@rijnstate.nl (J. Ruinemans-Koerts).
small studies with selected patient samples (n = 300–1005) from a
cancer, paediatric and university centre showed that the XN WDF/
WPC channel, compared to the former Sysmex XE-2100/5000 analyser,
will lead to a significant reduction (10–58%) of unnecessary microscopic
blood smears [2–4]. This reduction was attributed to the introduction of
the WPC channel. However, so far no studies have been published
concerning the added value of the WPC to the WDF channel in a large
teaching hospital in the reduction of blood smears and whether this
reduction counterbalances the investment in the WPC channel and
reagents costs and the potential reduction in sensitivity for pathology.
2. Materials and methods
We retrospectively analysed all EDTA anti-coagulated blood samples
(n = 7850) received in the Rijnstate hospital for which a leukocyte dif-
ferentiation was ordered during a 9 weeks period. Our population
consisted of clinical patients (15%, of which 16% from the department
of haematology/oncology), patients visiting our outpatient clinic (45%)
and patients who were sent by their general practitioner to our labora-
tory (40%). Patients were between 6 months and 97 years old (mean
age 55 years old). Samples were analysed on a Sysmex XN-10/XN-20
analyser in the WDF mode, with automatic reflex testing for WPC
analysis (for test principles and flagging algorithms see Briggs et al.
[2]). The WDF channel can generate two types of flags, i.e. WBC abnor-
mal and WBC suspect flag. The customer can decide whether a flag is

http://dx.doi.org/10.1016/j.clinbiochem.2016.08.020
0009-9120/© 2016 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Please cite this article as: M. Noordegraaf, et al., Diagnostic efficiency of the Sysmex XN WPC channel for the reduction of blood smears, Clin
Biochem (2016), http://dx.doi.org/10.1016/j.clinbiochem.2016.08.020
2 M. Noordegraaf et al. / Clinical Biochemistry xxx (2016) xxx–xxx

followed by a blood smear for microscopic review. In our laboratory the channel. From these 720 samples 22% had only a “blast/abnormal lym-
WBC abnormal flags “lymphocytosis”, “monocytosis”, “eosinophilia” phocytes” (WBC suspect) flag, the others also had at least 1 WBC abnor-
and “IG” (immature granulocytes) and the WBC suspect flags “blasts/ mal flag from the WDF channel. From the samples (n = 161) with only a
abnormal lymphocytes” and “atypical lymphocytes” are always follow- “blast/abnormal lymphocytes” flag 86 samples didn't receive a flag in
ed by a blood smear review. All included samples in this study followed the WPC channel. From the samples (n = 559) with both a “blast/ab-
this procedure (independent of the WPC results). Morphological normal lymphocytes” flag and minimal 1 WBC abnormal flag 135 sam-
findings are compared with data from the pathologist and our own ples were negative in the WPC channel. From the 221 samples with a
flow cytometric data (all standard procedures). Blood smears were pre- negative WPC flag 14 samples showed the presence of pathological
pared by the slide-maker stainer SP-10. Slides were subsequently cells in the blood smear, i.e. 5 samples with myeloid blasts and 2 sam-
analysed by digital microscopy using the digital morphology device ples with lymphatic blasts (N 1%), 3 samples with a CLL (41–75%
DI-60 (Cellavision AB, Lund, Sweden). The flagging results from the abnormal lymphocytes), 1 sample with localisation of a T-NHL (26%
WDF channel and the final flagging results from the WDF channel abnormal lymphocytes), 2 samples with large lymphatic cells of a Dif-
followed by WPC reflex testing were compared to the results of the fuse Large B-cell Lymphoma (1%), 1 sample with non-haematologic ma-
microscopic analysis and checked with the definite diagnosis in the lignant cells (1%).
medical record (based on flow cytometry and/or histopathology). Thus, from the 1778 samples resulting in blood smear in a 9 weeks
period 221 samples with a “blast/abnormal lymphocytes” flag in the
3. Results WDF channel didn't receive a flag in the WPC channel, which could
lead to a 12% reduction of blood smears. In daily practise this means
From the 7850 samples for which a leukocyte differentiation was or- 3–4 blood smears/day less of a total of 28 smears/day at the expense
dered 1778 samples (23%) had a positive WDF (WBC abnormal and/or of missing 14 patient samples with pathology in this 9 weeks period.
WBC suspect) message, resulting in a manual smear review (Fig. 1).
847 of these 1778 (48%) samples had at least a “blast/abnormal lympho- 4. Discussion
cytes” flag and should be analysed in the WPC channel. Unfortunately,
only 720 of these 847 samples were actually measured in the WPC In our large teaching hospital we observed a 12% reduction in blood
smears in a non-selected large patient population (n = 7850) due to the
addition of the WPC analysis to the WDF channel. The much higher
reduction rates published by others might be due to non-randomly
7850 selected patient samples, differences in patient populations (age and
Leukocyte
differential orders disease state) and differences in WDF flagging criteria for blood smear
analysis [2–4].
The WPC channel costs €25,000 and the reagent cost per WPC anal-
ysis is around €1.80 (list prices, excluding taxes). Taken into account a
1778 5950 10 years write off period for the WPC channel the total costs for WPC
with WBC abn/
suspect flag from
without WBC
abn/suspect flag
analysis is around €11,500 per year. The estimated labour costs for a
WDF channel from WDF channel blood smear review of samples without pathology with the DI-60 is
low due to a very short analysis time, and estimated to be around
€2.50 (investment DI-60 is omitted as this device proved to be valuable
for increasing the workflow efficiency and reduction of technical staff
240 787
with WBC suspect with WBC
751 time for blood smears with a WBC abnormal/suspect flag). The 12% re-
with WBC abn flag
flag abn/suspect flag duction in blood smears can save €3200 per year. Thus, introduction of
the WPC in our laboratory will not outweigh the costs. Furthermore, in
our patient population there was a slight reduction in sensitivity for de-
tection of pathology as was also published by Lee at al. recently [5]. As
847
847 the purpose of our study was to determine the added value of the
Blast/abn lympho
Blast/abn
flag fromlympho
WDF WPC channel for the reduction of blood smears and consequently
flag
channel
the cost-benefit for the laboratory, we don't know the effect of
application of the WPC channel on patient care due to the missed
pathology; e.g. a delay in diagnosis and an increase in health care cost.
720 This is subject for further research.
WPC analysis Conclusion, the degree of reduction of blood smears by the WPC
channel is dependent on the tested patient population. As in large
clinical laboratories automation of blood smear review is common, the
small reduction in blood smears by the WPC channel does not outweigh
the costs and certainly not as this results in missing pathology.
221 499
no WPC flag with WPC flag

Funding

14
This research did not receive any specific grant from funding
Samples with a agencies in the public, commercial, or not-for-profit sectors.
haematologic
malignancy

Fig. 1. Flowchart of 7850 patient samples for which a leukocyte differentiation was
ordered. Samples are categorized based on the WBC abnormal or suspect flags from the
WDF channel. Samples with a “blast/abnormal lymphocytes” flag from the WDF channel
are analysed in the WPC channel.
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Please cite this article as: M. Noordegraaf, et al., Diagnostic efficiency of the Sysmex XN WPC channel for the reduction of blood smears, Clin
Biochem (2016), http://dx.doi.org/10.1016/j.clinbiochem.2016.08.020
 M. Noordegraaf et al. / Clinical Biochemistry xxx (2016) xxx–xxx 3

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Please cite this article as: M. Noordegraaf, et al., Diagnostic efficiency of the Sysmex XN WPC channel for the reduction of blood smears, Clin
Biochem (2016), http://dx.doi.org/10.1016/j.clinbiochem.2016.08.020