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Persistent Large Granular Lymphocyte Clonal Expansions: “The Root of Many Evils”—And of Some Goodness. Cancers (Basel) 2022; 14:cancers14051340. [PMID: 35267648 PMCID: PMC8909662 DOI: 10.3390/cancers14051340] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Large granular lymphocyte leukemia (LGLL) is a chronic disorder of either mature T or NK lymphocytes. As clonal expansions of the immune system cells, difficulties in the distinction between a true neoplasia and a physiological reactive process have been common since its description. We review here the different conditions associated with persistent clonal LGL expansions and discuss their potential origin and whether they can modulate the clinical features. Abstract Large granular lymphocyte leukemia (LGLL) is a chronic disease of either mature phenotype cytotoxic CD3+ T lymphocytes or CD3- NK cells. LGLL diagnosis is hampered by the fact that reactive persistent clonal LGL expansions may fulfill the current criteria for LGLL diagnoses. In addition to the presence of characteristic clinical and hematological signs such as anemia or neutropenia, LGLL/LGL clonal expansions have been associated with an array of conditions/disorders. We review here the presence of these persistent clonal expansions in autoimmune, hematological disorders and solid neoplasms and after hematopoietic stem cell transplantation. These associations are a unique translational research framework to discern whether these persistently expanded LGL clones are causes or consequences of the concomitant clinical settings and, more importantly, when they should be targeted.
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T-cell large granular lymphocyte leukemia in solid organ transplant recipients: case series and review of the literature. Int J Hematol 2019; 110:313-321. [PMID: 31250283 DOI: 10.1007/s12185-019-02682-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 10/26/2022]
Abstract
T-cell large granular lymphocyte (T-LGL) leukemia is a rare clonal proliferation of cytotoxic lymphocytes rarely described in solid organ transplant (SOT). We reviewed records from 656 kidney transplant recipients in follow-up at our Center from January 1998 to July 2017. In addition, we researched, through PubMed, further reports of T-LGL leukemia in SOT from March 1981 to December 2017. We identified six cases of T-LGL leukemia in our cohort of patients and 10 in the literature. This lymphoproliferative disorder was detected in one combined liver-kidney, one liver and 14-kidney transplant recipients. Median age at presentation was 46.5 years (IQR 39.2-56.9). The disease developed after a median age of 10 years (IQR 4.9-12) from transplantation. Anemia was the most common presentation (62.5%) followed by lymphocytosis (43.7%) and thrombocytopenia (31.2%). Splenomegaly was reported in 43.7% of the patients. Eight patients (50%) who experienced severe symptoms were treated with non-specific immunosuppressive agents. Six of them (75%) had a good outcome, whereas two (25%) remained red blood cell transfusion dependent. No cases progressed to aggressive T-LGL leukemia or died of cancer at the end of follow-up. These results suggest that T-LGL leukemia is a rare but potentially disruptive hematological disorder in the post-transplant period.
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Abstract
Post-transplant lymphoproliferative disorders (PTLD) represent a heterogeneous group of diseases that occur following transplantation. Large granular lymphocytic (LGL) lymphocytosis is one type of PTLD, ranging from reactive polyclonal self-limited expansion to oligo/monoclonal lymphocytosis or even to overt leukaemia. LGL lymphocytosis in transplant recipients may present as a relatively indolent version of the condition and may be more common than reported, but its natural history and clinical course have not been well described, and the lack of a reliable classification system has limited studies on this disease. Patients with unexplained cytopenias, autoimmune manifestations, or unexpected remissions may be mislabelled. The purpose of this review was to evaluate the clinical features, immunophenotypes, etiopathogenesis, diagnosis, outcomes and treatment of post-transplantation LGL lymphocytosis. In conclusion, LGL lymphocytosis is a frequent occurrence after transplantation that correlates with certain procedural variables and post-transplant events. LGL lymphocytosis should be considered in patients with unexplained lymphocytosis or when pancytopenia develops after transplantation. The diagnosis of LGL lymphocytosis requires a demonstration of monoclonality, but clonality does not indicate malignancy. Additional studies are necessary to further delineate the potential effects of large granular lymphocytes in the long-term prognosis of post-transplant patients.
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Kataria A, Cohen E, Saad E, Atallah E, Bresnahan B. Large granular lymphocytic leukemia presenting late after solid organ transplantation: a case series of four patients and review of the literature. Transplant Proc 2014; 46:3278-81. [PMID: 25240311 DOI: 10.1016/j.transproceed.2014.05.083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 05/27/2014] [Indexed: 10/24/2022]
Abstract
Post-transplantation lymphoproliferative disorder (PTLD) is a significant complication of solid organ transplantation. Most PTLD is of the B-cell subtype, although T-cell subtype PTLD uncommonly occurs. T-cell PTLDs are usually aggressive neoplasms and shorten patient and allograft survivals significantly. We present a single-center case series of 4 patients who developed T-cell large granular lymphocytic (LGL) leukemia, a rare T-cell PTLD characterized by large granular lymphocytes that have characteristic azurophilic granules and a highly variable clinical course.
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Affiliation(s)
- A Kataria
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - E Cohen
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Medicine, Veterans Administration Zablocki Medical Center, Milwaukee, Wisconsin
| | - E Saad
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - E Atallah
- Division of Hematology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - B Bresnahan
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Herreman A, Dierickx D, Morscio J, Camps J, Bittoun E, Verhoef G, De Wolf-Peeters C, Sagaert X, Tousseyn T. Clinicopathological characteristics of posttransplant lymphoproliferative disorders of T-cell origin: single-center series of nine cases and meta-analysis of 147 reported cases. Leuk Lymphoma 2013; 54:2190-9. [PMID: 23402267 DOI: 10.3109/10428194.2013.775436] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
T-cell or natural killer (NK)-cell posttransplant lymphoproliferative disorder (T-PTLD) is a rare but severe complication after transplant. Here we present the clinicopathological features of a single-center series of nine cases. Additionally, we summarize the clinicopathological findings of 147 cases of T/NK-cell PTLD reported in the literature in an attempt to define subtype-specific characteristics. T/NK-cell PTLD occurs in patients of all ages, usually extranodally, and most frequently after kidney transplant. Organ specific incidence, however, is highest following heart transplant. Approximately one-third of T-cell PTLDs are Epstein-Barr virus (EBV)-related, with peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS) being the most prevalent EBV-associated T-cell PTLD. A male predominance is observed, which is most striking in the EBV(+) group, particularly in PTCL, NOS. With a median posttransplant interval of 72 months, T-cell PTLDs are among the late-occurring PTLDs. Of the most common T-cell PTLDs, anaplastic large cell lymphoma (ALCL) has the best prognosis, whereas PTCL, NOS and hepatosplenic T-cell lymphoma (HSTCL) have the worst prognosis. EBV(+) cases seem to have a longer survival than EBV(-) cases, suggesting a different pathogenetic mechanism.
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Affiliation(s)
- An Herreman
- KU Leuven, Translational Cell and Tissue Research , Leuven , Belgium
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Risk Factors and Prognosis in T-Cell Posttransplantation Lymphoproliferative Diseases. Transplantation 2013; 95:479-88. [DOI: 10.1097/tp.0b013e3182762e07] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Large Granular Lymphocyte Expansion after Allogeneic Hematopoietic Stem Cell Transplant Is Associated with a Cytomegalovirus Reactivation and Shows an Indolent Outcome. Biol Blood Marrow Transplant 2012; 18:1765-70. [DOI: 10.1016/j.bbmt.2012.07.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 07/09/2012] [Indexed: 11/19/2022]
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Kwong YL, Au WY, Leung AYH, Tse EWC. T-cell large granular lymphocyte leukemia: an Asian perspective. Ann Hematol 2010; 89:331-9. [PMID: 20084380 PMCID: PMC7102052 DOI: 10.1007/s00277-009-0895-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 12/22/2009] [Indexed: 11/24/2022]
Abstract
To characterize T-cell large granular leukemia in Asia, 22 Chinese patients from a single institute were reported, together with an analysis of 88 Asian and 272 Western patients identified from the literature. In our cohort, anemia due to pure red cell aplasia (PRCA) occurred in 15/22 (68%) of cases, being the most common indication for treatment. Neutropenia was only found in 8/22 (36%) cases, and recurrent infections, the most important clinical problem in Western patients, were not observed. None of our cases presented with rheumatoid arthritis. These clinical features were consistently observed when compared with the 88 other Asian patients. Combined data from our cohort and other Asian cases showed that Asian patients, compared with Western patients, had more frequent anemia (66/110, 60% versus 113/240, 47%; p=0.044), attributable to a much higher incidence of PRCA (52/110, 47% versus 6/143, 4%; p<0.001). However, Western patients presented more frequently than Asian patients with neutropenia (146/235, 62% versus 33/110, 30%; p<0.001) and splenomegaly (99/246, 40% versus 16/110, 15%; p< 0.001). Notably, Western patients were about eight to ten times more likely than Asian patients to have rheumatoid arthritis (73/272, 27% versus 4/106, 4%; p<0.001) and recurrent infections (81/272, 30% versus 3/107, 3%; p<0.001). These clinicopathologic differences have important implications on disease pathogenesis and treatment.
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Affiliation(s)
- Yok-Lam Kwong
- Department of Medicine, University of Hong Kong, Hong Kong, Special Administrative Region, People's Republic of China.
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Abstract
Session 9 of the 2005 Society for Hematopathology/European Association for Haematopathology Workshop focused on large granular lymphocyte (LGL) leukemias and related disorders. T-cell LGL (T-LGL) leukemias, discussed herein, account for 2% to 3% of cases of small lymphocytic leukemia. T-LGL diseases cover a heterogeneous spectrum of disorders that include reactive conditions, typically associated with autoimmune disease, to outright leukemia. These disorders are found in older people, with an average age at initial examination of approximately 60 years and a median survival of more than 10 years in T-LGL leukemia. Systemic symptoms and neutropenia are common at initial examination. Lymphocytosis, composed of small mature lymphocytes with increased cytoplasm, is common. The spleen and bone marrow are involved in T-LGL leukemia, although morphologic findings may be subtle. The immunophenotype is typically that of CD3+/CD8+ cytotoxic T cells. Some cases may be due to chronic immune stimulation, with subsequent clonal escape and proliferation of a neoplastic population of lymphocytes.
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Abstract
Posttransplantation lymphoproliferative disorders (PTLDs) of T-cell or natural killer (NK)-cell origin are an uncommon heterogeneous group of lymphoid proliferations that fulfill the criteria for one of the T- or NK-cell lymphomas/leukemias. This report summarizes 130 T/NK-cell PTLDs reported in the literature or presented at the Society for Hematopathology/European Association for Haematopathology Workshop on T/NK-cell malignancies. The T/NK-cell PTLDs occur at a median of 66 months following transplantation and are usually extranodal. The most common types reported are peripheral T-cell lymphoma, unspecified, and hepatosplenic T-cell lymphoma. Approximately one third are Epstein-Barr virus (EBV)+. The median survival is 6 months. EBV+ cases have a significantly longer survival than EBV- cases, even when indolent T-cell large granular lymphocytic leukemias are included among the EBV- cases. Many T/NK-cell PTLDs have been treated with chemotherapy, often together with decreased immunosuppression, but there are infrequent patients who have done well without chemotherapy or radiation.
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Affiliation(s)
- Steven H Swerdlow
- Department of Pathology, Division of Hematopathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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Minami R, Izutsu K, Miyamura T, Yamamoto M, Suematsu E. [A case of systemic lupus erythematosus accompanied with pure red cell aplasia]. NIHON RINSHO MEN'EKI GAKKAI KAISHI = JAPANESE JOURNAL OF CLINICAL IMMUNOLOGY 2006; 29:148-53. [PMID: 16819263 DOI: 10.2177/jsci.29.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pure red cell aplasia (PRCA) is a rare cause of anemia associated with SLE. We herein report a case presenting with SLE and PRCA. A 33-year-old woman, who had been suffering from photosensitivity, proteinuria, and pancytopenia, was diagnosed to have SLE. She showed normochromatic normocytic anemia. The serum level of haptoglobin was <10 mg/dl, and Direct Coombs' test was negative. Her reticulocyte count was 0.8%. Her clinical and laboratory features, except for anemia, had recovered in response to 50 mg/day of prednisolone. The serum level of haptoglobin had normalized, but the reticulocyte count remained low. The bone marrow findings revealed erythroid hypoplasia, and she was diagnosed to have PRCA complicated with SLE. No viral DNA of human parvovirus B19 in her bone marrow was detected. The anemia gradually improved following the further use of 50 mg/day prednisolone. In order to disclose the mechanism of PRCA in this patient, we examined the effects of her peripheral T lymphocytes on erythrogenesis, using erythroid colony-forming cells (ECFC) in her peripheral blood. When we co-cultured peripheral T cells and ECFC, her T cells inhibited erythroid colony formation in a dose dependent manner. Several reports have shown the presence of inhibitory factors in SLE patients' serum such as antibodies against erythroid progenitors or erythropoietin, while other reports have shown abnormal T cells that inhibit the growth of erythroid progenitors. Our study suggests that these inhibitory T cells may therefore have played an important role in the pathogenesis of this patient.
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Affiliation(s)
- Rumi Minami
- Division of Rheumatology and Connective Tissue Diseases, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center
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Go RS, Lust JA, Phyliky RL. Aplastic anemia and pure red cell aplasia associated with large granular lymphocyte leukemia. Semin Hematol 2003; 40:196-200. [PMID: 12876668 DOI: 10.1016/s0037-1963(03)00140-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aplastic anemia (AA) and pure red cell aplasia (PRCA) are two of the various types of immune-mediated cytopenias that can be associated with large granular lymphocyte (LGL) leukemia. We review the experience on LGL leukemia-associated AA and PRCA in the published literature. In the setting of LGL leukemia, AA is found rarely, while PRCA is frequent. However, the diagnosis of LGL leukemia in the presence of pancytopenia is very challenging. In general, the clinical findings and treatment outcome are similar to the idiopathic or primary forms of AA and PRCA. Serial trials of immunosuppressive agents usually result in relatively durable remissions. In refractory cases, studies using newer immunosuppressive agents active against T cells and natural killer (NK) cells are necessary. There are many similarities in the currently known pathophysiologic mechanisms among these three disorders. As LGL leukemia is underdiagnosed, it is interesting to speculate that perhaps a significant proportion of idiopathic AA and PRCA may be, in fact, secondary to LGL leukemia.
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MESH Headings
- Anemia, Aplastic/drug therapy
- Anemia, Aplastic/etiology
- Anemia, Aplastic/immunology
- Comorbidity
- Humans
- Immunosuppressive Agents/therapeutic use
- Killer Cells, Natural/immunology
- Killer Cells, Natural/pathology
- Leukemia, Lymphoid/complications
- Leukemia, Lymphoid/drug therapy
- Leukemia, Lymphoid/immunology
- Red-Cell Aplasia, Pure/drug therapy
- Red-Cell Aplasia, Pure/etiology
- Red-Cell Aplasia, Pure/immunology
- T-Lymphocytes, Cytotoxic/immunology
- T-Lymphocytes, Cytotoxic/pathology
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Affiliation(s)
- Ronald S Go
- Gundersen Lutheran Medical Center, La Crosse, WI, USA
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Lee PS, Hwang WS. Pathologic quiz case: chronic anemia with red cell aplasia and lymphocytosis in a middle-aged man. T-cell large granular lymphocyte leukemia. Arch Pathol Lab Med 2002; 126:1549-50. [PMID: 12503585 DOI: 10.5858/2002-126-1549-pqccaw] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Po-Shing Lee
- Department of Pathology, Chi Mei Foundation Medical Center, Yungkang City, Tainan, Taiwan
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