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Updated: Apr 23, 2026
An Automated Microscopic Scoring Method for the γ-H2AX Foci Assay in Human Peripheral Blood Lymphocytes
Published on: December 25, 2021
Do the flags related to immature granulocytes reported by the Sysmex XE-5000 warrant a microscopic slide review?
Heidi Eilertsen1, Tor-Arne Hagve2
1From the Division of Diagnostics and Technology, Akershus University Hospital, Lørenskog, Norway; Faculty of Health Sciences, Oslo, and Akershus University College of Applied Sciences, Oslo, Norway; and eilertsen@hioa.no.
Objectives:
The Sysmex XE-5000 instruments (Sysmex, Kobe, Japan) count immature granulocytes (IGs) and use the "Imm Gran?" flag to signal unreliable results. This study investigated the usefulness of the "Imm Gran?" flag and the analytical and diagnostic performance of the IG measurements in a side-by-side evaluation.
Methods:
In total, 408 samples were analyzed on three XE-5000 instruments. The IG count and the "Imm Gran?" flag reports from all three instruments were used for reproducibility studies. The diagnostic performance of the automated IGs and the "Imm Gran?" flag were studied by comparing the XE-5000 results with the results of the manual differential.
Results:
The reproducibility of the "Imm Gran?" flagging between instruments was poor (қ, 0.75-0.80). The most significant contributor to the report of the "Imm Gran?" flag was bands, and the flag played a minor role in detecting blasts. The interinstrument reproducibility of the IG counts was high (intraclass correlation, 0.99). The IG count reported by XE-5000s was higher than the manual IG count (36%-55%), and the difference and the variability tended to increase with increasing levels of IGs.
Conclusions:
The "Imm Gran?" flag has a poor analytical quality and gives no substantial information on the presence of blasts in the sample. We therefore suggest reporting the automated IG count without initial microscopic slide review.
Insights
The Sysmex XE-5000 "Imm Gran?" flag shows poor reliability for immature granulocytes (IGs). Automated IG counts are reproducible but higher than manual counts, suggesting reporting without initial slide review.
Area of Science:
- Hematology
- Clinical Chemistry
- Laboratory Medicine
Background:
- Automated hematology analyzers like the Sysmex XE-5000 provide immature granulocyte (IG) counts.
- The "Imm Gran?" flag is intended to signal potentially unreliable IG results.
Purpose of the Study:
- To evaluate the clinical utility of the "Imm Gran?" flag on Sysmex XE-5000 instruments.
- To assess the analytical and diagnostic performance of automated immature granulocyte (IG) measurements.
Main Methods:
- Analyzed 408 samples across three Sysmex XE-5000 instruments.
- Assessed reproducibility of IG counts and "Imm Gran?" flag reports.
- Compared automated IG counts and flag data against manual differential counts.
Main Results:
- "Imm Gran?" flag reproducibility between instruments was poor (κ = 0.75–0.80).
- Bands were the primary cause of the "Imm Gran?" flag; its role in blast detection was minimal.
- Interinstrument reproducibility for IG counts was high (ICC = 0.99).
- Automated IG counts were consistently higher (36%–55%) than manual counts, with increasing variability at higher IG levels.
Conclusions:
- The "Imm Gran?" flag exhibits poor analytical quality and offers limited value in identifying blasts.
- Automated IG counts demonstrate high reproducibility.
- Recommended reporting automated IG counts directly, bypassing initial microscopic review.
