Molecular and flow cytometry characterization during the follow-up of three simultaneous lymphoproliferative disorders: Hairy cell leukemia, monoclonal B-cell lymphocytosis, and CD4++/CD8+/−dim T-large granular lymphocytosis-A case report

CD5-negative, CD10-negative low-grade B-cell lymphoproliferative disorders (CD5-CD10-LPD) of the spleen comprise a fascinating group of indolent, neoplastic, mature B-cell proliferations that are essential to accurately identify but can be difficult to diagnose. They comprise the majority of B-cell LPDs primary to the spleen, commonly presenting with splenomegaly and co-involvement of peripheral blood and bone marrow, but with little to no involvement of lymph nodes. Splenic marginal zone lymphoma is one of the prototypical, best studied, and most frequently encountered CD5-CD10-LPD of the spleen and typically involves white pulp. In contrast, hairy cell leukemia, another well-studied CD5-CD10-LPD of the spleen, involves red pulp, as do the two less common entities comprising so-called splenic B-cell lymphoma/leukemia unclassifiable: splenic diffuse red pulp small B-cell lymphoma and hairy cell leukemia variant. Although not always encountered in the spleen, lymphoplasmacytic lymphoma, a B-cell lymphoproliferative disorder consisting of a dual population of both clonal B-cells and plasma cells and the frequent presence of the MYD88 L265P mutation, is another CD5-CD10-LPD that can be seen in the spleen. Distinction of these different entities is possible through careful evaluation of morphologic, immunophenotypic, cytogenetic, and molecular features, as well as peripheral blood and bone marrow specimens. A firm understanding of this group of low-grade B-cell lymphoproliferative disorders is necessary for accurate diagnosis leading to optimal patient management.

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A Unique Hairy Cell Leukemia Variant

Case Reports in Oncology ◽

10.1159/000446696 ◽

2016 ◽

Vol 9 (2) ◽

pp. 312-316

Author(s):

Charles Jian ◽

Cyrus C. Hsia

Keyword(s):

Flow Cytometry ◽

B Cell ◽

Hairy Cell Leukemia ◽

Nucleoside Analogs ◽

B Cell Lymphoma ◽

Purine Nucleoside ◽

Peripheral Blood Flow ◽

Hairy Cell ◽

Cell Leukemia ◽

Normal Peripheral Blood

A 65-year-old woman presented with easy bruising, left upper quadrant pain, decreased appetite, and weight loss. She had splenomegaly and lymphocytosis (lymphocyte count of 11.6 × 109/l), with remarkably abnormal appearing morphology. Her hemoglobin and platelet counts were normal. Peripheral blood flow cytometry revealed a monoclonal B-cell population expressing CD11c, CD25, CD19, CD20, and CD103. An initial diagnosis of hairy cell leukemia (HCL) was made, and the patient was treated with a standard 5-day course of cladribine. However, her lymphocytosis improved transiently, with a relapse 4 months later. There was no improvement in her splenomegaly. An HCL variant (HCL-v) was considered based on her resistance to treatment with a purine nucleoside analog. A subsequent splenectomy improved symptoms. Two years after, the patient suffered a relapse and underwent 6 cycles of CHOP-R (cyclophosphamide, hydroxydaunomycin, oncovin, prednisone, and rituximab), achieving partial remission. While under observation, she progressed with lymphocytosis 6 months later and was treated with pentostatin. There was no significant improvement in her disease, and she died 8 weeks following treatment initiation. HCL-v is a clinically more aggressive mature B-cell lymphoma than HCL with worse splenomegaly, higher lymphocyte counts, and resistance to typical HCL therapy with purine nucleoside analogs. Early recognition of HCL-v in the history, physical examination, and investigations with morphology and flow cytometry is key to patient management. Further, as in our case of HCL-v, cell morphology can be distinctly atypical, with large nucleoli and extremely convoluted nuclei. The distinction between HCL and HCL-v is important as HCL-v patients require more aggressive therapy and closer follow-up.

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Antigenic Variation of Hairy Cell Leukemia Defines a CD25 Negative Variant with a Uniform Immunophenotype and Distinct Clinicopathologic Features.

Blood ◽

10.1182/blood.v104.11.1102.1102 ◽

2004 ◽

Vol 104 (11) ◽

pp. 1102-1102

Author(s):

Henry Y. Dong

Keyword(s):

Flow Cytometry ◽

Hairy Cell Leukemia ◽

Standard Therapy ◽

Overall Response Rate ◽

Response Rate ◽

Complete Response ◽

Hairy Cell ◽

Cell Leukemia ◽

Overall Response

Abstract Classical hairy cell leukemia (HCL) coexpressing both CD25 and CD103 is highly responsive to the treatment with cladribine and pentostatin (complete response rate, 75–95%; overall response rate, 86–100%). HCL variant in the literature is characterized by HCL-like morphology, lack of CD25 coexpression, and variable immunophenotypes indistinguishable from those of splenic marginal zone B cell lymphoma (Matutes, et al. Leukemia2001; 15:184). Importantly, HCL variant is associated with a poor response to standard therapy. It is unclear if HCL cases lacking CD25 but otherwise phenotypically identical to classical HCL belong to HCL or HCL variant, and if the standard therapy is effective in these patients. To further delineate features of HCL and its variants, we analyzed immunophenotyping data, by flow cytometry or immunohistochemistry, or by both when feasible, in 260 consecutive patients with HCL (Dong, et al. Mod Pathol2003; 16:230A). The diagnosis was established by hairy cell morphology together with coexpression of strong CD20 and CD22, bright CD11c, and CD103. Clinical data were obtained for a subset of cases in which expression of CD25 was distinctly absent. Our results were consistent with the literature in that HCL has a consistent and unique immunophenotypic profile, which allowed detection of residual HCL by flow cytometry at levels as low as 0.1% of total cells. In addition, approximately 20% and 37% of classical HCL coexpressed CD10 and BCL-1 respectively, which may significantly confuse the diagnosis in an incomplete work-up. Interestingly, there were 43 cases (20% of all CD103+ cases) that lacked CD25 but were otherwise identical to classical HCL in their uniform phenotypic profiles. Compared with classical HCL, patients with the CD25- HCL were generally older (medium age: 59yrs vs. 79yrs; p=0.001) and frequently had leukocytosis (medium WBC: 3.0x109/L vs. 24.5x109/L; p=0.014). Among 14 patients with follow up data, 7 were treated with cladribine or pentostatin. The complete response (CR) rate was 14.3% (1/7) and the overall response rate was 57.1% (4/7). Three patients had no response. One patient who had an initial partial response (PR) to pentostatin died of the disease 10 months after the diagnosis. Of others, an additional two patients achieved CR and PR upon initial treatment with fludarabine and Rituxamab respectively. Four patients were untreated and were alive with disease (follow up, 21–41 months). One patient died of the disease in 2 years and treatment for this patient was unknown. These clinical features overlapped with those of HCL variant in the literature. However, unlike the HCL variant that has significant phenotypic heterogeneity, including lack of CD11c and CD103 in a substantial number of cases, the CD25- HCL was remarkably uniform in phenotype and can be easily identified by immunophenotyping. In conclusion, these results suggest that lack of CD25 in HCL defines a clinically distinct chronic lymphoproliferative disorder, which appears to require different clinical management.

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Bendamustine and Rituximab for the Treatment of Multiply Relapsed Hairy Cell Leukemia,

Blood ◽

10.1182/blood.v118.21.3909.3909 ◽

2011 ◽

Vol 118 (21) ◽

pp. 3909-3909

Author(s):

Robert J. Kreitman ◽

Maryalice Stetler-Stevenson ◽

Wyndham H. Wilson ◽

Sapolsky Jeffrey ◽

Laura Roth ◽

...

Keyword(s):

B Cell ◽

Dose Level ◽

Hairy Cell Leukemia ◽

Research Funding ◽

Hairy Cell ◽

Cell Leukemia ◽

Purine Analog ◽

Prospective Phase ◽

Dose Levels

Abstract Abstract 3909 Background: Hairy cell leukemia (HCL) is highly sensitive to purine analogs cladribine (CdA) and pentostatin (DCF), but patients who relapse have decreasing remission rates with each course and can eventually become purine analog-refractory. Bendamustine and rituximab (BR) have been reported as effective with acceptable toxicity in several B-cell malignancies, particularly B-cell lymphomas and chronic lymphocytic leukemia. The structure of bendamustine contains an alkylating group and also part of cladribine, suggesting it might be useful in HCL. In one case report, bendamustine achieved a transient partial response in a patient with relapsed/refractory HCL, but its activity in other patients with this disease is not reported. The combination of DCF and rituximab (DCFR) is reported to achieve high complete remission (CR) rates in HCL in retrospective series, but prospective phase II trials of this combination have not been reported. Methods: To determine the activity of BR relative to DCFR in HCL, a randomized trial was undertaken in multiply relapsed HCL comparing the 2 regimens in which each arm could constitute a prospective phase II trial, with 2-way crossover for lack of response to or relapse from the originally assigned regimen. The primary endpoint is an overall response rate of 65% for each arm and the 2 arms will be compared with respect to response and other secondary endpoints including toxicity, response duration, and eradication of minimal residual disease (MRD). Patients received 6 cycles at 4-week intervals of rituximab 375 mg/m2 days 1 and 15 with either pentostatin at 4 mg/m2 days 1 and 15, or bendamustine days 1 and 2. To test the tolerability of bendamustine prior to randomizing 56 patients between the 2 arms, 12 non-randomized patients received BR using 70 (n=6) or 90 (n=6) mg/m2/dose of bendamustine. Doses of all agents could be delayed but not reduced. Results: A total of 20 patients are so far enrolled and the 12 patients receiving the 2 dose levels of BR are evaluable for response and toxicity. Patients had 1–6 (median 3) prior courses of purine analog and 8 (67%) had prior rituximab. All toxicity was reversible and only 1 patient at 90 mg/m2 required >2-week delay due to prolonged neutropenia and thrombocytopenia. However, this delay was only between cycles 1 and 2 and not between subsequent cycles after responding to BR. Of the 36 cycles of BR administered to each group of 6 patients on the 2 dose levels of bendamustine, 90 vs 70 mg/m2/dose, common grade 3–4 toxicities included lymphopenia (28 vs 22%), leukopenia (19 vs 17%), and thrombocytopenia (14 vs 17%). Febrile neutropenia requiring hospitalization occurred just once in 3 patients at 90 vs 0 patients at 70 mg/m2/dose. Major response was achieved in 10 (83%) of 12 patients. CR was achieved in 3 (50%) of 6 patients at each dose level, while 2 (33%) at 70 and 3 (50%) at 90 mg/m2 achieved clearance of MRD at all sites including bone marrow aspirate by flow cytometry. No patient in CR has relapsed after 8–14 (median 11) months of follow-up. Of 4 patients evaluable by clone-specific real-time PCR, previously reported sensitive to 1 HCL cell in 106 normal, 3 patients at 90 mg/m2/dose were negative. Conclusions: BR can achieve responses including CRs in multiply relapsed HCL, and its safety profile permits comparison of BR with DCFR using the more common dose level of bendamustine, 90 mg/m2 days 1 and 2. Additional patients and follow-up will be required to access durability of response and long-term eradication of MRD, and to compare BR with DCFR (Supported in part by NCI, intramural research program, NIH, Genentech, Inc, and Cephalon, Inc). Disclosures: Kreitman: Cephalon: Research Funding; Genentech: Research Funding. Off Label Use: Use of bendamustine and rituximab for HCL. Arons:Genentech: Research Funding.

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UNUSUAL PRESENTATION OF HAIRY CELL LEUKEMIA: A CASE REPORT

International Journal of Medical and Biomedical Studies ◽

10.32553/ijmbs.v3i6.338 ◽

2019 ◽

Vol 3 (6) ◽

Author(s):

Dr. Vartika Sachdeva ◽

Dr. Mansi Kala ◽

Dr. Sushil Kumar Shukla ◽

Dr. Anuradha Kusum ◽

Dr. Kunal Das

Keyword(s):

Bone Marrow ◽

Case Report ◽

B Cell ◽

Hairy Cell Leukemia ◽

Lymphoproliferative Disorder ◽

Case Reports ◽

Hairy Cell ◽

Cell Leukemia ◽

Prominent Feature ◽

High Level

Hairy cell leukemia is a chronic B cell lymphoproliferative disorder,which is uncommon and constitutes around two percent of hematolymphoid malignancies. HCL commonly involves bone marrow and spleen and rarely peripheral blood . Splenomegaly is a prominent feature and is seen in around 70 to 100% of HCL cases as reported in various case reports. Sometimes the absence of splenomegaly rules out the diagnosis of HCL and is misdiagnosed as aplastic anemia. Thus the aim of our study is to understand the importance and keep a high level of suspicion in such cases. As in present case there was no evidence of splenomegaly clinically or radiology, but the morphologic features on biopsy had suggested HCL which was further confirmed on immunophenotyping. The purpose of this case report is to highlight the importance of the fact that HCL can present even without splenomegaly. Keywords: Hairy cell leukemia, Splenomegaly, Immunohistochemistry

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The BRAF V600E mutation in hairy cell leukemia and other mature B-cell neoplasms

Blood ◽

10.1182/blood-2011-08-368209 ◽

2012 ◽

Vol 119 (1) ◽

pp. 188-191 ◽

Cited By ~ 112

Author(s):

Luca Arcaini ◽

Silvia Zibellini ◽

Emanuela Boveri ◽

Roberta Riboni ◽

Sara Rattotti ◽

...

Keyword(s):

Molecular Marker ◽

B Cell ◽

Hairy Cell Leukemia ◽

Lymphoproliferative Disorders ◽

Braf V600e Mutation ◽

Braf V600e ◽

Splenic Marginal Zone Lymphoma ◽

Hairy Cell ◽

Cell Leukemia ◽

Specific Pcr

Abstract The somatically acquired V600E mutation of the BRAF gene has been recently described as a molecular marker of hairy cell leukemia (HCL). We developed an allele-specific PCR for this mutation and studied 62 patients with HCL, 1 with HCL variant, 91 with splenic marginal zone lymphoma, 29 with Waldenström macroglobulinemia, and 57 with B-cell chronic lymphoproliferative disorders. The BRAF V600E mutation was detected in all HCL cases and in only 2 of the remaining 178 patients. These 2 subjects had B-cell chronic lymphoproliferative disorders that did not fulfill the diagnostic criteria for HCL. Despite the positive PCR finding, the mutation could not be detected by Sanger sequencing in these 2 cases, suggesting that it was associated with a small subclone. We conclude that the BRAF V600E mutation is present in all patients with HCL and that, in combination with clinical and morphologic features, represents a reliable molecular marker for this condition.

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Durability of complete remission by moxetumomab pasudotox (HA22 or CAT-8015) assessed by clone-specific real-time quantitative PCR (RQ-PCR).

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.2503 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 2503-2503

Author(s):

Robert J. Kreitman ◽

Evgeny Arons ◽

Jeffrey Sapolsky ◽

Laura Roth ◽

Hong Zhou ◽

...

Keyword(s):

Bone Marrow ◽

Flow Cytometry ◽

Real Time ◽

Quantitative Pcr ◽

Hairy Cell Leukemia ◽

Hairy Cell ◽

Cell Leukemia ◽

Real Time Quantitative Pcr ◽

Recombinant Immunotoxin

2503^ Background: The anti-CD22 recombinant immunotoxin moxetumomab pasudotox, also known as HA22 or CAT-8015, was recently reported in phase I testing to achieve complete remissions (CRs) in 13 (46%) of 28 patients with relapsed/refractory hairy cell leukemia (HCL); 3 of 13 patients have relapsed. Methods: To complete this trial, 20 additional patients received the highest dose level (50 µg/Kg every other day x 3 doses); none of the 48 HCL patients had dose-limiting toxicity (DLT). Results: Of the first 42 patients with >6 mo of follow up off-treatment, 23 (55%) had CRs, with an overall response rate of 88%. Of the 23 CRs, 21 were evaluable for minimal residual disease (MRD) using flow cytometry of blood and immunohistochemistry of the bone marrow biopsy, and 17 (81%) were negative. Of these 17 patients, 11 (65%) were negative by bone marrow aspirate (BMA) flow cytometry. PCR using consensus primers for the heavy chain immunoglobulin (IgH) rearrangement was less specific than flow cytometry of blood, since IgH rearrangements of normal B cells, which recovered rapidly after immunotoxin treatment, were also amplified. For better MRD detection in blood, patient IgH sequences were cloned and sequence specific primers and probes designed for real-time quantitative PCR (RQ-PCR). RQ-PCR of blood was negative in 6 (100%) of 6 patients achieving flow-negativity in both blood and BMA and positive in 3 (100%) of 3 patients flow-negative in blood but not BMA (p=0.01). No relapses from CR have been observed in 10 patients who became RQ-PCR-negative in blood or flow-negative in BMA, with 5-38 (median 11) mo of follow-up. Conclusions: We conclude that clone-specific RQ-PCR is the most sensitive blood test for MRD in our HCL patients after moxetumomab pasudotox, and could be used to assess the possibility of long-term molecular remissions. We believe these results, including durable CRs without DLT, support a pivotal trial in which moxetumomab pasudotox is compared with alternative therapy. Note: this summary contains investigator reported data. This study was funded by MedImmune, LLC, and supported by NCI’s Intramural Research Program and the Hairy Cell Leukemia Research Foundation.

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