XNL-SERIES TRAINING GROUP

RABU-KAMIS, 28-29 MARET 2018

FLAGGING & INTERPRETASI HASIL

XN-350

XN-450

XN-550
ANDRIYANSYAH
APPLICATION STAFF
PT. SABA INDOMEDIKA
 Mask & Mark
Masks Meaning
----- Analysis impossible due to analysis error and value cannot be display
++++ Data cannot be display because value out of display range
( ) Order not exist

Marks Meaning
* Low reliability
@ Result out of linearity limit
! Result higher or lower than the clinical panic value. Also indicate the
value is higher than background check.
+ Higher than reference interval
- Lower than reference interval
 Positive/Negative result
[Positive] Displayed if there were any abnormalities in the blood cell count or
blood cell morphology.

[Diff.] Indicates an abnormal blood cell differentiation value.

[Morph.] Indicates an abnormal cell morphology.
[Count] Indicates an abnormal blood cell count.

[Negative] Displayed if the sample had no errors and result normal.

 Error
• Displays the errors that occurred during the analysis.
– Result
– Func

• [Result] One of the following errors has occurred:

– Blood cannot be aspirated
– Insufficient blood volume
– Low count error

• [Func.]
– An error other than [Result] and Barcode Reader errors has
occurred.
 XN-L Action Message
[Check] There may be a mix-up of samples. Otherwise, there is a significant
difference in the analysis results. Check the sample.
[Review] Channel difference has occurred. Check the analysis results.
[Retest] Check the analysis mode, the order and the status of the sample, and then
re-analyze.

Action Action Message Condition

[Check] The sample might be wrong. Check the Delta check
sample.
[Check] Significant change in XXXXX. Check the Delta check
sample.
(XXXXX : WBC, HGB, MCV, PLT)
[Review] Difference between RBC and RET. RBC-O / RBC > 1.2 or
Check the results. RBC-O / RBC < 0.8
[Retest] Recommend other method to check PLT-I is low reliable.
number of platelets. (Same condition in PLT-I/O
switching rule)
 XN Action Message
[Check] There may be a mix-up of samples. Otherwise, there is a significant
difference in the analysis results.
– “The sample might be wrong. Check the sample.”
– “Significant change in XXXXX. Check the sample.”
(XXXXX : WBC, HGB, MCV, PLT)

[Review] Displayed when channel difference has occurs, for example, and the
analysis results need to be reviewed.
– “Difference between RBC and RET. Check the results.” (RBC-I and RBC-O)
– “Difference between WNR and WDF. Check the results.” (TNC-N & TNC-D)
– “Different between PLT and PLT-F. Check the results.” (PLT-I and PLT-F)

Do not have in XN-L

[Retest] Displays the mode and order. This is displayed to prompt an analysis.
– “Reflex PLT.” (when PLT-I is low reliable) (Same condition as PLT-I/O switching rule)
– “Sample mixing failure” (on version 16) “Suspect sample, check the sample” (on version 17)
– this action message is based on WNR

Do not have in XN-L

 IP Messages
Types of IP Messages
Abnormal
WBC
Suspect

Abnormal
IP Message RBC/RET
Suspect

Abnormal
PLT
Suspect
 IP Messages

1. Abnormal flagging
- Result out of limit
- Can be define by user (except abnormal scattergrams and
abnormal histograms)

2. Suspect flagging
- Abnormal morphological finding
- abnormal histogram or scattergram
- flagging with “?”
- sample is possibly abnormal
Information behind each flag Q-Flag:
 The Grade of the Q-Flag
• The grade of the Q-Flag is based on different rules (formulas)
in different combinations.

• Abnormal cells do not behave with constant patterns

• There is no quantifiable relation between the grade value and

the concentration of abnormal cells

• Therefore the Q-Flag value may differ from analysis to analysis

 Definitions
• Q-Flag setting Value
– The default Q-Flag setting is 100

• Result
– The result means the number or the percentage of cells counted in an
abnormal area of the scattergram

• Threshold
– Threshold means the default settings for the number or percentage of
abnormal cells in the formula.

• Grade Value
– The Grade Value is the result of a calculation from the flagging rule
Principle of Q-flag algorithm
 Q-flag calculation
• Each Q-flag has a few rules

• The rules can be:

I) result ≥ threshold, result>threshold,
II) result ≤ threshold or result<threshold.

• Example: Hgb defect?

Rule 1: RDW-CV ≤15 and
Rule 2: MCV<75fl
 Q-flag calculation
• Grade value calculated from
a: result/threshold x 10 if rules set as ≥/>
b: threshold/result x 10 if rule set as ≤/<

Example: RDW:13.5 MCV:90fl

• Grade value 1= 15/13.5 x 10 = 11.11
• Grade value 2= 75/90 x 10 =8.33
 Grade Value selection
• The minimum grade value is generated when the flagging
rules are connected with AND

• The maximum grade value is generated when the flagging

rules are connected with OR

Example: In this case, ‘and’ is using, choose minimum grade

value which is Grade value 2.
 Compare grade value with Q flag setting

• If Grade value x 10 is < Q-flag setting value. Judge as negative.

• If Grade value x 10 is > Q flag setting value. Judge as positive.

Example:
Q flag setting value is 100.
Grade 2 x 10 = 8.33 x 10 = 83.3
This Q-flag judge is negative.
 XN-L WBC Abnormal Flags (Whole Blood Mode)
Message Meaning Channel Judgment Method

WBC Abn Scattergram Abnormal WBC WDF Based on clustering in WNR and WDF scattergrams.For
Scattergram body fluid analysis, based on clustering in the WDF
scattergram and the HF-BF value.
Low neutrophil
Neutropenia WDF NEUT# < 1.00 x 109/L or NEUT% < 0.0 %
count
High neutrophil
Neutrophilia WDF NEUT# > 11.00 x 109/L or NEUT% > 100.0 %
count
Low lymphocyte
Lymphopenia WDF LYMPH# < 0.80 x 109/L or LYMPH%< 0.0 %
count
High lymphocyte
Lymphocytosis WDF LYMPH# > 4.00 x 109/L or LYMPH% > 100.0 %
count
High monocyte
Monocytosis WDF MONO# > 1.00 x 109/L or MONO% > 100.0 %
count
High eosinophil
Eosinophilia WDF EO# > 0.70 x 109/L or EO% > 100.0 %
count
Basophilia High basophil count WDF BASO# > 0.20 x 109/L or BASO% > 100.0 %

Leukocytopenia Low leukocyte count WDF WBC < 2.50 x 109/L

High leukocyte
Leukocytosis WDF WBC > 18.00 x 109/L
count
High nucleated RBC
NRBC Present WNR NRBC% > 2.0 %
count
Increased immature
IG Present WDF IG# > 0.10 x 109/L or IG% > 100.0 %
granulocyte
 XN-L WBC Suspect Flags (Whole Blood Mode)
Message Meaning Channel Judgment Method

Possibility that nucleic RBC Judged from the presence of NRBC on the WDF
NRBC? WDF
are present scattergram.

Possibility that blasts are

Judged from the presence of Blasts/AbnLympho on
Blasts/Abn Lympho? present/Possibility of WDF
the WDF scattergram.
abnormal lymphocytes

Possibility that blasts are WDF+ Judged from the presence of Blasts on the WDF and
Blasts?*1
present WPC WPC scattergrams.

Possibility of abnormal WDF+ Judged from the presence of AbnLympho on the WDF
Abn Lympho?*1
lymphocytes WPC and WPC scattergrams.

Based on the distribution state of the upper right

Left Shift? Possibility of left shift WDF
area of the NEUT in the WDF scattergram.
WDF,
Possibility of atypical Based on the distribution state of the upper area of
Atypical Lympho? WDF+
lymphocytes the lymphocytes in the WDF scattergram.
WPC
 XN-L RBC Abnormal Flags (Whole Blood Mode)

Message Meaning Channel Judgment Method

RBC Abn
Abnormal RBC distribution RBC Arithmetic calculation and numerical comparison
Distribution

Dimorphic Gap between the high and low points and shape of
Multi-peak RBC distribution RBC
Population distribution peak.

RET Abn
Abnormal RET scattergram RET Clustering in the RET scattergram
Scattergram*2

Reticulocytosis*2 Reticulocytosis RET RET% > 5.00% or RET# > 200 x 109/L

Anisocytosis Anisocytosis RBC RDW-SD > 65.0 fL or RDW-CV > 20.0%

Microcytosis Microcytosis RBC MCV < 70.0fL

 XN-L RBC Abnormal Flags (Whole Blood Mode)

Message Meaning Channel Judgment Method

Macrocytosis Macrocytosis RBC MCV > 110 fL

Hypochromia Hypochromia RBC+HGB MCHC < 290g/L

Anemia Anemia HGB HGB < 100g/L

Erythrocytosis Erythrocytosis RBC RBC > 6.50 x 1012/L

 XN-L RBC Suspect Flags (Whole Blood Mode)

Message Meaning Channel Judgment Method

Possibility of RBC
RBC Agglutination? RBC+HGB Arithmetic calculation and numerical comparison
agglutination

Turbidity/HGB Possibility of effect on HGB by

RBC+HGB Arithmetic calculation and numerical comparison
Interf? chylemia

Iron Deficiency? Possibility of iron deficiency RBC+HGB Arithmetic calculation and numerical comparison

HGB Defect? Possibility of HGB abnormality RBC Arithmetic calculation and numerical comparison

Possibility of fragmented red RBC, PLT,

Fragments? Arithmetic calculation and numerical comparison
blood cells RET

Possibility that parasitized Judged from the presence of pRBC on the WDF
pRBC? WDF + RET
RBC are present scattergram.
 XN-L PLT Abnormal Flags (Whole Blood Mode)

Message Meaning Channel Judgment Method

PLT Abn Distribution Abnormal PLT distribution PLT Arithmetic calculation and numerical comparison

PLT-O
PLT Abn Scattergram*2 Abnormal PLT scattergram PLT clustering in the PLT scattergram
PLT-F

PLT, RET,
Thrombocytopenia Thrombocytopenia PLT# < 60 x 109/L
PLT-F

PLT, RET,
Thrombocytosis Thrombocytosis PLT# > 600 x 109/L
PLT-F
 XN-L PLT Suspect Flags (Whole Blood Mode)

Message Meaning Channel Judgment Method

WNR, WDF, Judged from the presence of PLT Clumps on the

PLT Clumps? Possibility of PLT clumps
PLT-F WNR, WDF and PLT-F scattergrams.
 XN-L Flags Summary (Whole Blood Mode)
WBC RBC PLT
Abnormal WBC Abnormal Scattergram RBC Abnormal Distribution PLT Abnormal Distribution
Neutropenia Dimorphic Population Thrombocytopenia
Neutrophilia Anisocytosis Thrombocytosis
Lymphopenia Microcytosis PLT Abnormal Scattergram
Lymphocytosis Macrocytosis
Monocytosis Hypochromia
Eosinophilia Anemia
Basophilia Erythrocytosis
Leukocytopenia RET Abnormal Scattergram
Leukocytosis Reticulocytosis
IG Present
Suspect Blasts/Abn Lympho? RBC Agglutination? PLT Clumps?
Left Shift? Turbidity/HGB Interf?
Atypical Lympho? Iron Deficiency?
NRBC? HGB Defect?
Fragments?
pRBC?
XN-L Flags Summary
Comparing Flags between
XN-L vs XN and XN-L vs XS
 XN-L vs XN Flagging

XN-L series XN series

Principle Channel Channel

WDF WDF

- WNR

FCM with semiconductor laser - WPC

RET/PLT-O RET/PLT-O

- PLT-F

Hydrodynamic Focusing DC
RBC/PLT RBC/PLT
Method

SLS-Hemoglobin method HGB HGB

 XN-L vs XN Flagging

XN-L series XN series

WBC Abnormal - NRBC present

NRBC? -

WBC Suspect - Blasts?

- Abn Lympho?
 XN-L vs XS Flagging

XN-L series XS series

Principle Channel Channel

WDF DIFF

- -

FCM with semiconductor laser - -

RET/PLT-O -

- -

Hydrodynamic Focusing DC
RBC/PLT RBC/PLT
Method

SLS-Hemoglobin method HGB HGB

 XN-L vs XS Flagging
XN-L series XS series
WBC Abnormal IG present -

Blasts/
-
Abnormal lymph?
WBC Suspect - Blasts?
- Abn Lympho?
- Immature Gran?
RBC Suspect pRBC? PRBC?
PLT Suspect PLT Abnormal -
Scattergram
PLT Clumps? PLT Clumps?
- PLT Clumps(s)?
WBC Flagging
 WBC Abnormal IP message
IP message Channel
WBC ABNORMAL WBC Abn Scattergram WDF
Neutropenia WDF
Neutrophilia WDF
Lymphopenia WDF
Lymphocytosis WDF
Monocytosis WDF
Eosinophilia WDF
Basophilia WDF
Leukocytopenia WDF
Leukocytosis WDF
IG Present WDF
 WBC suspect IP message
IP message Channel
WBC SUSPECT Left Shift? WDF
Atypical Lympho? WDF
Blasts/ Abn Lymph? WDF
NRBC? WDF
WDF Scattergram Suspect Flags
 WDF: SAFLAS method
SAFLAS
(Sysmex Adaptive FLagging Algorithm based on Shape-recognition)

Hasmpir sama dengan algoritma penandaan sebagai XN yang didasarkan pada

pengenalan geometri. SAFLAS menilai kelainan (mis. Kehadiran sel tumor)
dengan menganalisa secara holistik fitur bentuk klaster yang terkait dengan
dispersi, centroid, ukuran, sudut, dll. (Metode seperti pemeriksaan visual).
Algoritma ini memberikan kontribusi untuk mendeteksi sel-sel abnormal
dengan sensitivitas tinggi.

Metode gating konvensional terbatas dalam mendeteksi kelainan bentuk

klaster, dan beberapa jenis sel tumor dapat muncul terutama di daerah
normal (misalnya sel limfoma dewasa). SAFLAS memungkinkan untuk
mendeteksi kelainan seperti itu. XN-series memiliki sensitifitas tinggi untuk
mendeteksi sel-sel tumor darah menggunakan SAFALAS dan metode gating.
WBC Abn Scattergram
Ketika cluster tidak dapat
dibedakan pada scattergram
WDF karena tingginya jumlah
sel abnormal
Left Shift?

Dari scattergram WDF dipicu oleh

kehadiran Neutrofil Band (Batang)
IG present

Dari scattergram WDF. Dipicu ketika

ada granulosit matang (metamyelocye,
Myelocyte atau Promyelocyte). Flag ini
dapat diubah oleh pengguna
RBC Flagging
 RBC histogram
RL RU

RBC

PLT

25-75 fl 200-250 fl
• Ukuran RBC : 80-100 fL
• Mendeteksi RBC antara 25 and 250 fL
• Kurva distribusi dipisahkan oleh diskriminator flexibel dan harus
selalu dimulai pada garis dasar
Normal RBC histogram
RBC histogram abnormal cell detection area

Small RBC
Cell counts
 RBC abnormal IP message
IP message Channel
RBC ABNORMAL RBC Abn Distribution RBC
Dimorphic Population RBC
RET Abn Scattergram RET
Reticulocytosis RET
Anisocytosis RBC
Microcytosis RBC
Macrocytosis RBC
Hypochromia RBC + HGB
Anemia HGB
Erythrocytosis RBC
 RBC suspect IP message

IP message Channel
RBC SUSPECT RBC Agglutination? RBC + HGB
Turbidity/HGB Interf? RBC + HGB
Iron Deficiency? RBC + HGB
HGB Defect? RBC
Fragments? RBC, PLT, RET
pRBC? WDF + RET
 RBC Abn Distribution
1. Histogram yang dihasilkan dari RBC channel yang abnormal
2. RL, RU, DW, MP (multi peak) atau
3. RBC < 0.5 x 1012/L atau
4. RDW-SD tidak dapat dianalisa

Recommendation: Cek slide untuk keberadaan morfologi RBC

abnormal (ansositosis, RBC fragmen, poikilositosis, ouleaux,
RBC aglutinasi)

Normal Abnormal
 Dimorphic Population
Dihasilkan ketika ada beberapa puncak pada histogram RBC

Recommendation : Cek slide untuk keberadaan morfologi

abnormal RBC (anisocytosis, fragmented RBC, poikilocytosis,
rouleaux, RBC agglutination)

Normal Abnormal RBC histogram

 RBC agglutination?
Dipicu oleh: Perbandingan RBC (MCHC [>40g/dL], MCH, RBC, RU%)

Recommendation : Cek slide untuk menunjukan ada tidaknya RBC

agglutination. Jika ada, hangatkan sample at 37⁰C dan periksa ulang.
Jika tidak bisa dipecahkan, lakukan replacment plasma
 Turbidity/HGB Interference ?
Dipicu oleh: MCHC > 36.5g/dL
Tanda flag: HGB, MCH & MCHC
Kemungkinan penyebab: Hemolysis, Lipemia, RBC cold
agglutination
Recommendation:
1. Periksa plasma, jika lipemik atau ikterus, lakukan replacement
plasma. Jika hemolisis in vitro, sampling ulang dan periksa
kembali

2. Jika disebabkan oleh WBC >100, encerkan sample dan rerun.

Jika HGB berubah, laporkan HGB dari pengenceran dan kalkulasi
ulang indeks RBC nya.
 Iron Deficiency?
Dipicu oleh MCHC (<31g/dl), MCV (<75fl), RDW-CV (>15%)

Recommendation : Cek apusan untuk keberadaan mikrositik dan

hipokromik RBC. Jika RBC mikrositik ekstrim terlihat, perkirakan PLT atau
konfirmasi dengan PLT-O
RDW-CV < 15,0% and MCV < 75fl
 HGB Defect?
Triggered by RDW-CV (<15%), MCV (<75fl)

Recommendation:
Cek apusan untuk keberadaan morfologi RBC abnormal seperti mikrositosis,
hipokromia, sel gtarget, sel sabit, kristal HGB C. Jika sel RBC mikrositik
ekstrim ditemukan, perkirakan PLT atau konfirmasi dengan PLT-O
Fragments?
 Fragments?
Dipicu oleh kombinasi dari :
• RDW-SD
• PLT Upper Discriminator
• MCV
• RBC Lower Discriminator
• MCHC

and,

Deteksi partikel sel di area 1 dan

2 di scattergram Ret

1
2
 Ret Abn Scattergram
• Ketika ada peningkatan aktivitas di
daerah RET-THR (threshold) UPP
(Upper Particle Platelet) region THR

• Pemisahan yang tidak memadai

RBC
anatara partikel fluoresensi tinggi
(WBC) dan Retikulosit fuoresensi tinggi
(HFR)

• Recommendation : Cek apusan untuk

keberadaan polychromasia, Howell-
Jolly Bodies, MP terinfeksi RBC atau
basophilic stippling. Lakukan
pemeriksaan retikulosit dengan metode
manual
 RET Abn scattergram
“RET abn scattergram” juga dipicu karena
(1)
abnormalitas PLT-O scattergram

Dua cluster PLT-O, satu di daerah berpendar

tinggi di area (1)

Terlalu banyak partikel tidak ber flag di bagian

(2)
kanan bawah area (2)

Terlalu banyak partikel di pernbatasan antara

RBC / RET dan PLT (3)
Note: Analyzer tidak beralih dalam kasus seperti itu
meskipun PLT-I mungkin juga tidak reliable.
(3)
PLT Flagging
 PLT histogram
PL PU
100%

Area of large PLT, PLT

clumps and small RBC

20%
PLT
RBC
fixed at
2-6 fl 12 fl 12-30 fl

• Ukuran PLT : 8-12 fL

• Mendeteksi PLT : antara 2 - 30 fL
• Fixed discriminator pada 12 fL
• Histogram harus berada dalam dua diskriminator dan memulai
dan mengakhiri pada garis dasar.
Normal PLT histogram
PLT histogram abnormal cell detection area
 IP message list (PLT message)
IP message Channel
PLT ABNORMAL PLT Abn Distribution PLT
PLT Abn Scattergram RET
Thrombocytopenia PLT, RET
Thrombocytosis PLT, RET
SUSPECT PLT Clumps? WDF
 PLT Abn Distribution
• Dihasilkan dengan perhitungan dan perbandingan ukuran PDW,
PL%, PU%, P-MFV, PLT, P-LCR, MPV

• Recommendation:
Cek morfologi PLT abnormal (large PLT, small
PLT, PLT clumps, fragmented RBC or microcytic RBC)
 “PLT Clumps?”
FSC WDF

FSCW

(FSC-FSCW) digunakan untuk mendeteksi PLT clump dalam

chanel WDF, digunakan di keduanya [CBC] dan [CBC+DIFF]
 FSCW for Platelets
Direction of Sheath Flow
Platelet Normal Large Giant
size

FSC:
denoted by
green
arrow

FSC_W:
Denoted by
yellow
arrow

Note Individual platelets are spherical, therefore FSC and FSC_W signals are similar
 FSCW for Platelets
Direction of Sheath Flow
Platelet Normal Platelet Clumps (1) Platelet Clumps(2)
size

FSC:
denoted
by green
arrow

FSC_W:
Denoted
by yellow
arrow

Note
 FSCW for Platelets
Direction of Sheath Flow
Platelet Normal Platelet Clumps (3) Platelet Clumps(4)
size

FSC:
denoted
by green
arrow

FSC_W:
Denoted
by yellow
arrow

Note
Thank you!