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Troussard X, Maître E, Paillassa J. Hairy cell leukemia 2024: Update on diagnosis, risk-stratification, and treatment-Annual updates in hematological malignancies. Am J Hematol 2024; 99:679-696. [PMID: 38440808 DOI: 10.1002/ajh.27240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 03/06/2024]
Abstract
DISEASE OVERVIEW Hairy cell leukemia (HCL) and HCL-like disorders, including HCL variant (HCL-V) and splenic diffuse red pulp lymphoma (SDRPL), are a very heterogenous group of mature lymphoid B-cell disorders characterized by the identification of hairy cells, a specific genetic profile, a different clinical course and the need for appropriate treatment. DIAGNOSIS Diagnosis of HCL is based on morphological evidence of hairy cells, an HCL immunologic score of 3 or 4 based on the CD11c, CD103, CD123, and CD25 expression, the trephine biopsy which makes it possible to specify the degree of tumoral bone marrow infiltration and the presence of BRAFV600E somatic mutation. RISK STRATIFICATION Progression of patients with HCL is based on a large splenomegaly, leukocytosis, a high number of hairy cells in the peripheral blood, and the immunoglobulin heavy chain variable region gene mutational status. VH4-34 positive HCL cases are associated with a poor prognosis, as well as HCL with TP53 mutations and HCL-V. TREATMENT Patients should be treated only if HCL is symptomatic. Chemotherapy with risk-adapted therapy purine analogs (PNAs) are indicated in first-line HCL patients. The use of chemo-immunotherapy combining cladribine (CDA) and rituximab (R) represents an increasingly used therapeutic approach. Management of relapsed/refractory disease is based on the use of BRAF inhibitors (BRAFi) plus R, MEK inhibitors (MEKi), recombinant immunoconjugates targeting CD22, Bruton tyrosine kinase inhibitors (BTKi), and Bcl-2 inhibitors (Bcl-2i). However, the optimal sequence of the different treatments remains to be determined.
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Affiliation(s)
| | - Elsa Maître
- Laboratoire Hématologie, CHU Côte de Nacre, Caen Cedex, France
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Troussard X, Maitre E. Untangling hairy cell leukaemia (HCL) variant and other HCL-like disorders: Diagnosis and treatment. J Cell Mol Med 2024; 28:e18060. [PMID: 38095234 PMCID: PMC10844692 DOI: 10.1111/jcmm.18060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 02/08/2024] Open
Abstract
The variant form of hairy cell leukaemia (HCL-V) is a rare disease very different from hairy cell leukaemia (HCL), which is a very well-defined entity. The 5th WHO edition (Leukemia, 36, 2022 and 1720) classification (WHO-HAEM5) introduced splenic lymphomas/leukaemias including four different entities: (1) HCL, (2) splenic marginal zone lymphoma (SMZL) with circulating villous cells in the peripheral blood, (3) splenic lymphoma with prominent nucleolus (SLPN), which replaced HCL-V and CD5 negative B-prolymphocytic leukaemia (B-PLL), and (4) splenic diffuse red pulp lymphoma (SDRPL). All these entities have to be distinguished because of a different clinical course and the need for a different treatment. The diagnosis can be challenging because of complex cases and overlap and/or grey zones between all the entities and needs integrating clinical, histologic, immunophenotypic, cytogenetic and molecular data. We review the diagnostic criteria including clinical, immunophenotypic and molecular characteristics of patients with HCL-V and other HCL-like disorders including HCL, SDRPL, SMZL, B-PLL and the Japanese form of HCL. We also discuss the different criteria allowing us to separate these different entities and we will update the recent therapeutic options that have emerged, in particular the advances with chemoimmunotherapy and/or targeted therapies.
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Walewska R, Eyre TA, Barrington S, Brady J, Fields P, Iyengar S, Joshi A, Menne T, Parry-Jones N, Walter H, Wotherspoon A, Linton K. Guideline for the diagnosis and management of marginal zone lymphomas: A British Society of Haematology Guideline. Br J Haematol 2024; 204:86-107. [PMID: 37957111 DOI: 10.1111/bjh.19064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/17/2023] [Accepted: 08/14/2023] [Indexed: 11/15/2023]
Affiliation(s)
- Renata Walewska
- Cancer Care, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Toby A Eyre
- Department of Haematology, Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Barrington
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's Health Partners, Kings College London, London, UK
| | - Jessica Brady
- Guy's Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paul Fields
- Guy's and St Thomas' Hospital, Kings Health Partners, London, UK
| | - Sunil Iyengar
- Department of Haematology, Royal Marsden Hospital and Institute of Cancer Research, London, UK
| | - Anurag Joshi
- All Wales Lymphoma Panel, Department of Cellular Pathology, University Hospital of Wales, Cardiff, UK
| | - Tobias Menne
- Department of Haematology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nilima Parry-Jones
- Department of Haematology, Aneurin Bevan University Health Board, Newport, Wales, UK
| | - Harriet Walter
- The Ernest and Helen Scott Haematological Research Institute, Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Andrew Wotherspoon
- Department of Histopathology, Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Kim Linton
- Division of Cancer Sciences, The Christie NHS Foundation Trust and The University of Manchester, Manchester, UK
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Yap J, Yuan J, Ng WH, Chen GB, Sim YRM, Goh KC, Teo J, Lim TYH, Goay SM, Teo JHJ, Lao Z, Lam P, Sabapathy K, Hu J. BRAF(V600E) mutation together with loss of Trp53 or pTEN drives the origination of hairy cell leukemia from B-lymphocytes. Mol Cancer 2023; 22:125. [PMID: 37543582 PMCID: PMC10403926 DOI: 10.1186/s12943-023-01817-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/04/2023] [Indexed: 08/07/2023] Open
Abstract
Hairy cell leukemia (HCL) is a B-lymphoma induced by BRAF(V600E) mutation. However, introducing BRAF(V600E) in B-lymphocytes fails to induce hematological malignancy, suggesting that BRAF(V600E) needs concurrent mutations to drive HCL ontogeny. To resolve this issue, here we surveyed human HCL genomic sequencing data. Together with previous reports, we speculated that the tumor suppressor TP53, P27, or PTEN restrict the oncogenicity of BRAF(V600E) in B-lymphocytes, and therefore that their loss-of-function facilitates BRAF(V600E)-driven HCL ontogeny. Using genetically modified mouse models, we demonstrate that indeed BRAF(V600E)KI together with Trp53KO or pTENKO in B-lymphocytes induces chronic lymphoma with pathological features of human HCL. To further understand the cellular programs essential for HCL ontogeny, we profiled the gene expression of leukemic cells isolated from BRAF(V600E)KI and Trp53KO or pTENKO mice, and found that they had similar but different gene expression signatures that resemble that of M2 or M1 macrophages. In addition, we examined the expression signature of transcription factors/regulators required for germinal center reaction and memory B cell versus plasma cell differentiation in these leukemic cells and found that most transcription factors/regulators essential for these programs were severely inhibited, illustrating why hairy cells are arrested at a transitional stage between activated B cells and memory B cells. Together, our study has uncovered concurrent mutations required for HCL ontogeny, revealed the B cell origin of hairy cells and investigated the molecular basis underlying the unique pathological features of the disease, with important implications for HCL research and treatment.
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Affiliation(s)
- Jiajun Yap
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
- Cancer and Stem Cell Program, Duke-NUS Medical School, 8 College Road, 169857, Singapore, Singapore
| | - Jimin Yuan
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
- Cancer and Stem Cell Program, Duke-NUS Medical School, 8 College Road, 169857, Singapore, Singapore
- Department of Urology, The Second Clinical Medical College, The First Affiliated Hospital, Shenzhen People's Hospital, Jinan University, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China
- Geriatric Department, The Second Clinical Medical College, The First Affiliated Hospital, Shenzhen People's Hospital, Jinan University, Southern University of Science and Technology), Shenzhen, 518020, Guangdong, China
| | - Wan Hwa Ng
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
| | - Gao Bin Chen
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
| | - Yuen Rong M Sim
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
| | - Kah Chun Goh
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
| | - Joey Teo
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
| | - Trixie Y H Lim
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
| | - Shee Min Goay
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
| | - Jia Hao Jackie Teo
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
| | - Zhentang Lao
- Department of Hematology, Singapore General Hospital, Blk7 Outram Road, 169608, Singapore, Singapore
| | - Paula Lam
- Cancer and Stem Cell Program, Duke-NUS Medical School, 8 College Road, 169857, Singapore, Singapore
- Department of Physiology, National University of Singapore, 2 Medical Drive, 117597, Singapore, Singapore
- Cellvec Pte. Ltd, 100 Pasir Panjang Road, 118518, Singapore, Singapore
| | - Kanaga Sabapathy
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore
- Cancer and Stem Cell Program, Duke-NUS Medical School, 8 College Road, 169857, Singapore, Singapore
| | - Jiancheng Hu
- Division of Cellular and Molecular Research, National Cancer Centre Singapore, 30 Hospital Boulevard, 168583, Singapore, Singapore.
- Cancer and Stem Cell Program, Duke-NUS Medical School, 8 College Road, 169857, Singapore, Singapore.
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Troussard X, Maître E, Cornet E. Hairy cell leukemia 2022: Update on diagnosis, risk-stratification, and treatment. Am J Hematol 2022; 97:226-236. [PMID: 34710243 DOI: 10.1002/ajh.26390] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022]
Abstract
DISEASE OVERVIEW Hairy cell leukemia (HCL) and HCL-like disorders, including HCL variant (HCL-V) and splenic diffuse red pulp lymphoma (SDRPL), are a very heterogeneous group of mature lymphoid B-cell disorders characterized by the identification of hairy cells, a specific genetic profile, a different clinical course, and the need for appropriate treatment. DIAGNOSIS Diagnosis of HCL is based on morphological evidence of hairy cells, an HCL immunologic score of 3 or 4 based on the CD11C, CD103, CD123, and CD25 expression, the trephine biopsy which makes it possible to specify the degree of tumoral medullary infiltration and the presence of BRAFV600E somatic mutation. RISK STRATIFICATION Progression of patients with HCL is based on a large splenomegaly, leukocytosis, a high number of hairy cells in the peripheral blood, and the immunoglobulin heavy chain variable region gene mutational status. VH4-34-positive HCL cases are associated with a poor prognosis. TREATMENT Patients should be treated only if HCL is symptomatic. Chemotherapy with risk adapted therapy purine analogs (PNAs) are indicated in first-line HCL patients. The use of chemo-immunotherapy combining PNAs and rituximab (R) represents an increasingly used therapeutic approach. Management of relapsed/refractory disease is based on the use of BRAF inhibitors (BRAFi) plus rituximab or MEK inhibitors (MEKi), recombinant immunoconjugates targeting CD22 or Bruton Tyrosine Kinase inhibitors (BTKi). However, the optimal sequence of the different treatments remains to be determined. The Bcl2-inhibitors (Bcl-2i) can play a major role in the future.
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Affiliation(s)
- Xavier Troussard
- Laboratoire Hématologie CHU Côte de Nacre Caen Cedex France
- Université Caen Normandie Caen Cedex France
| | - Elsa Maître
- Laboratoire Hématologie CHU Côte de Nacre Caen Cedex France
- Université Caen Normandie Caen Cedex France
| | - Edouard Cornet
- Laboratoire Hématologie CHU Côte de Nacre Caen Cedex France
- Université Caen Normandie Caen Cedex France
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Maitre E, Cornet E, Troussard X. Hairy cell leukemia: 2020 update on diagnosis, risk stratification, and treatment. Am J Hematol 2019; 94:1413-1422. [PMID: 31591741 DOI: 10.1002/ajh.25653] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022]
Abstract
DISEASE OVERVIEW Hairy cell leukemia (HCL) and HCL-like disorders, including HCL variant (HCL-V) and splenic diffuse red pulp lymphoma (SDRPL), are a very heterogeneous group of mature lymphoid B-cell disorders. They are characterized by the identification of hairy cells, a specific genetic profile, a different clinical course and the need for appropriate treatment. DIAGNOSIS Diagnosis of HCL is based on morphological evidence of hairy cells, an HCL immunologic score of three or four based on the CD11C, CD103, CD123, and CD25 expression. Also, the trephine biopsy which makes it possible to specify the degree of tumoral medullary infiltration and the presence of BRAF V600E somatic mutation. RISK STRATIFICATION Progression of patients with HCL is based on a large splenomegaly, leukocytosis, a high number of hairy cells in the peripheral blood and the immunoglobulin heavy chain variable region gene mutational status. The VH4-34 positive HCL cases are associated with poor prognosis. TREATMENT Risk adapted therapy with purine nucleoside analogs (PNA) are indicated in symptomatic first line HCL patients. The use of PNA followed by rituximab represents an alternative option. Management of progressive or refractory disease is based on the use of BRAF inhibitors associated or not with MEK inhibitors, recombinant immunoconjugates targeting CD22 or BCR inhibitors.
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Affiliation(s)
- Elsa Maitre
- Laboratoire Hématologie CHU Côte de Nacre Caen Cedex France
| | - Edouard Cornet
- Laboratoire Hématologie CHU Côte de Nacre Caen Cedex France
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Clinicopathologic and molecular features in hairy cell leukemia-variant: single institutional experience. Mod Pathol 2018; 31:1717-1732. [PMID: 29955146 DOI: 10.1038/s41379-018-0093-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/05/2018] [Accepted: 05/06/2018] [Indexed: 12/13/2022]
Abstract
Hairy cell leukemia-variant is rare. Only a small number of cases have been reported in the literature with little cytogenetic or molecular data available. In this study, we describe the clinicopathologic and genetic features of 23 patients with hairy cell leukemia-variant (16 men and 7 women) with a median age of 70 years. Most patients had splenomegaly (90%), leukocytosis (77%), and lymphocytosis (82%); no patients had monocytopenia. Histologically, the bone marrow biopsy specimens showed a mixed pattern of predominantly interstitial and lesser intrasinusoidal infiltration by leukemic cells. In bone marrow aspirate smears most cells had villous cytoplasmic features and a small nucleolus. We describe unusual sites of hairy cell leukemia-variant involvement in 4 patients, including brain, omentum, terminal ileum, and skin at the time of initial presentation. Immunophenotyping showed monotypic B-cells positive for pan B-cell antigens, CD11c, and CD103, and negative for CD25 and annexin A1. Conventional cytogenetic or fluorescence in situ hybridization analysis showed deletions of 17p13/TP53 and 11q22/ATM gene in 5/12 (42%) and 2/9 (22%) cases, respectively. Sequencing of the variable region of IGVH showed mutations (>2% deviation from germline) in 40% of the cases assessed. MAP2K1 mutation (p.C121S) was seen in 1 of 14 (7%) patients tested. No BRAF V600E mutations were detected. The patients were treated in a heterogeneous manner, but most often with therapies designed for classical hairy cell leukemia and the 5-year overall survival was 84%. In summary, hairy cell leukemia-variant exhibits a heterogeneous spectrum of clinical, morphologic, immunophenotypic, and genetic features that may overlap with classic hairy cell leukemia and other hairy cell-like B-cell neoplasms. A subset of patients can have an aggressive clinical course. In our experience MAP2K1 mutations are uncommon in this disease.
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Listeria monocytogenes Infection in Hairy Cell Leukemia: A Case Report and Literature Review. Case Rep Hematol 2018; 2018:5616898. [PMID: 29651349 PMCID: PMC5831943 DOI: 10.1155/2018/5616898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/01/2017] [Accepted: 12/18/2017] [Indexed: 11/18/2022] Open
Abstract
Listeria monocytogenes infections have been described in patients with diverse types of malignancy, especially leukemia. We report the case of a 65-year-old man with previously untreated hairy cell leukemia characterized by CD5 positivity and trisomy 12 (3% of blood lymphocytes) who developed bacteremia due to L. monocytogenes serotype 1/2b. We summarize clinical features and treatment of this patient and five previously reported patients with hairy cell leukemia who also had L. monocytogenes infections. All six patients were men. Their mean age at infection diagnosis was 70 y. Three men had undergone splenectomy 4–11 y before they developed L. monocytogenes infection. The central nervous system was the primary site of infection in four men. Bacteremia alone occurred in two other men. At diagnosis of infection, one man was receiving antileukemia chemotherapy and another man was receiving treatment for Kaposi's sarcoma. Two other patients had other comorbid conditions. All six men recovered from their infections.
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Azoulay D, Sonkin V, Akria L, Rozano Gorelick A, Trakhtenbrot L, Hershkovitz D, Shaoul E, Rozen S, Dementiev E, Cohen HI, Suriu C, Braester A. Hairy cell leukemia-variant without typical morphology and with near-tetraploid DNA content. CYTOMETRY PART B-CLINICAL CYTOMETRY 2017; 94:169-171. [DOI: 10.1002/cyto.b.21503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/04/2016] [Accepted: 12/12/2016] [Indexed: 11/08/2022]
Affiliation(s)
- David Azoulay
- Department of Hematology; Galilee Medical Center; Nahariya Israel
| | - Vadim Sonkin
- Department of Pathology; Galilee Medical Center; Nahariya Israel
| | - Luiza Akria
- Department of Hematology; Galilee Medical Center; Nahariya Israel
| | | | | | - Dov Hershkovitz
- Department of Pathology; Rambam Health Care Campus; Haifa Israel
| | - Ety Shaoul
- Department of Hematology; Galilee Medical Center; Nahariya Israel
| | - Simona Rozen
- Department of Hematology; Galilee Medical Center; Nahariya Israel
| | - Eugene Dementiev
- Department of Pathology; Galilee Medical Center; Nahariya Israel
| | - Hector I Cohen
- Department of Pathology; Galilee Medical Center; Nahariya Israel
| | - Celia Suriu
- Department of Hematology; Galilee Medical Center; Nahariya Israel
| | - Andrei Braester
- Department of Hematology; Galilee Medical Center; Nahariya Israel
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Behdad A, Bailey NG. Diagnosis of Splenic B-Cell Lymphomas in the Bone Marrow: A Review of Histopathologic, Immunophenotypic, and Genetic Findings. Arch Pathol Lab Med 2014; 138:1295-301. [DOI: 10.5858/arpa.2014-0291-cc] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Splenic B-cell lymphomas are a heterogeneous group of diseases comprising several entities that exhibit overlapping features. Diagnosis of these lymphomas has been reliant on the histopathologic examination of the spleen. However, with advances in diagnostic modalities and therapy, splenectomy is not commonly performed, and diagnosis and subclassification must be rendered based on the blood and bone marrow findings. In this brief review, we summarize the morphologic, immunophenotypic, and genetic findings of splenic B-cell lymphomas in the blood and bone marrow.
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Affiliation(s)
- Amir Behdad
- From the Department of Pathology, University of Michigan Medical School, Ann Arbor
| | - Nathanael G. Bailey
- From the Department of Pathology, University of Michigan Medical School, Ann Arbor
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Grey zone lymphoid neoplasms with features overlapping between splenic marginal zone lymphoma and hairy cell leukaemia: splenic B-cell lymphoma/leukaemia, unclassifiable. J Hematop 2011. [DOI: 10.1007/s12308-011-0092-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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12
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Robak T. Hairy-cell leukemia variant: recent view on diagnosis, biology and treatment. Cancer Treat Rev 2010; 37:3-10. [PMID: 20558005 DOI: 10.1016/j.ctrv.2010.05.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 05/20/2010] [Accepted: 05/25/2010] [Indexed: 10/19/2022]
Abstract
Hairy-cell leukemia variant (HCl-V) is a district clinico-pathological entity with intermediate features between classical HCl (HCl-C) and B-cell prolymphocytic leukemia. HCl-V is now included in the World Health Organization (WHO) classification as a provisional entity. It is an uncommon disorder accounting for approximately 0.4% of chronic lymphoid malignancies and 10% of all HCl cases. In contrast to HCl-C, HCl-V is a more aggressive disease and according to the new WHO classification it is no longer considered to be biologically related to HCl-C. Patients with HCl-V have an elevated white blood count, easy-to-aspirate bone marrow and weak reactivity to tartrate - resistant acid phosphatase (TRAP). Immunophenotypically, HCl-V cells are positive for CD103 and CD11c and negative for CD25. The HCl-V cells express also the B-cell antigens, CD19, CD20 and CD22. The HCl-V patients have frequently an unmutated Ig gene configuration. Currently, the principles of therapy for this rare disease derive from uncontrolled single institutional studies, or even single case reports. In contrast to HCl-C, the HCl-V response to purine nucleoside analogs (PNA) is limited to partial responses in approximately 50% of patients. However, complete responses were observed in patients treated with rituximab and anti-CD22 immunotoxins. In Japan, a distinct subtype of HCl known as HCl-Japanese variant (HCl-JV) has been identified. As with HCl-V, patients with HCl-JV have leukocytosis, weak TRAP activity in leukemic cells, and lack of CD25 antigen. In this review, the biology, diagnostic criteria, and current therapeutic options in HCl-V and HCl-JV are presented.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Copernicus Memorial Hospital, 93-510 Lodz, Ul. Ciolkowskiego 2, Poland.
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13
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Kanellis G, Mollejo M, Montes-Moreno S, Rodriguez-Pinilla SM, Cigudosa JC, Algara P, Montalban C, Matutes E, Wotherspoon A, Piris MA. Splenic diffuse red pulp small B-cell lymphoma: revision of a series of cases reveals characteristic clinico-pathological features. Haematologica 2010; 95:1122-9. [PMID: 20220064 DOI: 10.3324/haematol.2009.013714] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Splenic diffuse red pulp small B-cell lymphoma is an uncommon B-cell lymphoma, now recognized as a provisional entity in the 2008 update of the WHO Classification. Additional work is required to review this entity and establish its diagnostic features. DESIGN AND METHODS We have retrospectively analyzed the disease features in a highly selected series of 17 patients diagnosed as splenic diffuse red pulp small B-cell lymphoma. RESULTS The median age was 65.5 years (range 40-79 years) and there was a predominance of males (male/female ratio: 2.4). Clinical manifestations were mainly derived from splenomegaly. Splenectomy was the front-line treatment in 11 symptomatic patients; the remaining 6 received chemotherapy initially followed by splenectomy. After a mean follow-up of 72 months, the five-year overall survival was 93%. All cases showed a purely diffuse pattern of splenic infiltration by monomorphous small cells with small round nuclei and pale cytoplasm. All bone marrow biopsies showed tumoral infiltration, with intrasinusoidal infiltration. Peripheral blood cells were small to medium-sized, with clumped chromatin and round nuclear outline and villous cytoplasm. Neoplastic cells had a CD20(+), CD23(-), bcl6(-), Annexin A1- phenotype, with frequent expression of DBA44+ (15/17) and IgG (10/15). FCM data had a B-cell phenotype (CD19(+), CD20(+), CD22(+)) with FMC7 (10/11) and CD11c (5/8) expression. Clonal IgH rearrangement studies in 4 cases showed IgVH mutations in all cases, without VH1.2 usage. CONCLUSIONS Our data suggest that splenic diffuse red pulp small B-cell lymphoma is a distinct entity with morphological and immunophenotypical features that differ from those of other splenic lymphomas.
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Affiliation(s)
- George Kanellis
- Spanish National Cancer Research Centre (CNIO), Madrid, Spain
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14
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Abstract
Progress in the treatment of patients with hairy cell leukemia (HCL) has led to a significant change in the natural history of the disease. With current regimens, the majority of patients achieve a complete remission, and their survival curves are similar to those for appropriate age-matched individuals without the disease. At the same time, new technologies are allowing better understanding of the molecular mechanisms responsible for the pathogenesis of this and other indolent lymphoid neoplasms. Several studies using modern techniques with different sensitivities have demonstrated the persistence of minimal residual disease (MRD) after therapy with nucleoside analogues in majority of patients. However, it is not clear whether such MRD would invariably lead to leukemia recurrence or what level of MRD can predict relapse. The role of monoclonal antibodies, naked or conjugated with toxins, in the management of HCL and their ability to eradicate MRD is under investigation. Whether such strategies of chemoimmunotherapy would lead to further improvements in the outcome of patients with HCL needs to be further investigated.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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Hairy cell leukemias with unmutated IGHV genes define the minor subset refractory to single-agent cladribine and with more aggressive behavior. Blood 2009; 114:4696-702. [PMID: 19667403 DOI: 10.1182/blood-2009-03-212449] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Hairy cell leukemia (HCL) is generally responsive to single-agent cladribine, and only a minority of patients are refractory and with poor prognosis. HCLs generally express mutated (M) and, in a minority, unmutated (UM) IGHV. In a multicenter clinical trial in newly diagnosed HCL, we prospectively investigated clinical and molecular parameters predicting response and event-free survival after single-agent cladribine. Of 58 HCLs, 6 expressed UM-IGHV (UM-HCL) and 52 M-IGHV (M-HCL). Beneficial responses were obtained in 53 of 58 patients (91%), whereas treatment failures were observed in 5 of 58 patients (9%). Failures were associated significantly with UM-IGHV (5 of 5 failures vs 1 of 53 beneficial responses had UM-IGHV, P < .001), leukocytosis (3 of 5 vs 3 of 53, P = .006), and bulky spleen (4 of 5 vs 4 of 53, P < .001). The UM-HCL not benefiting from cladribine characteristically had bulky spleen (4 of 5, 80%), leukocytosis (3 of 5, 60%), and TP53 defects (2 of 5, 40%), and progressed rapidly after first treatment (median event-free survival, 7.5 months). Our data suggest that UM-HCLs identify the minor subgroup failing cladribine treatment and with more aggressive disease. High incidence of TP53 dysfunction indicates a potential mechanism of resistance to cladribine in the UM-HCL group. Overall, our data provide new molecular elements relevant for treatment concerns in HCL.
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Cheung KJJ, Horsman DE, Gascoyne RD. The significance ofTP53in lymphoid malignancies: mutation prevalence, regulation, prognostic impact and potential as a therapeutic target. Br J Haematol 2009; 146:257-69. [DOI: 10.1111/j.1365-2141.2009.07739.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Forconi F, Poretti G, Kwee I, Sozzi E, Rossi D, Rancoita PMV, Capello D, Rinaldi A, Zucca E, Raspadori D, Spina V, Lauria F, Gaidano G, Bertoni F. High density genome-wide DNA profiling reveals a remarkably stable profile in hairy cell leukaemia. Br J Haematol 2008; 141:622-30. [PMID: 18397341 DOI: 10.1111/j.1365-2141.2008.07106.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hairy cell leukaemia (HCL) is a rare B-cell neoplasm for which the molecular mechanisms are largely unknown. High-density genome-wide DNA profiling was performed with Affymetrix 250K arrays to analyse copy number (CN) changes and loss of heterozygosity (LOH) in 16 cases of HCL. Four of 16 cases (25%) demonstrated gross non-recurrent CN deletions. Within the affected regions, we identified genes involved in bone marrow fibrosis (FGF12) and response to treatment (TP53) in individual cases. Large regions (> 5 Mb) of LOH without any concomitant DNA CN changes were identified in 5/16 (31%) HCL and were indicative of uniparental disomy UD. The germline origin of UD was demonstrated in one case for which a matched normal sample was available. Overall analysis of LOH showed that identical loci were recurrently targeted in chromosomes 1, 2 and 6. As a whole, however, HCL showed a remarkably stable genome. This finding adds to several other features that are unique to HCL among mature B-cell tumours.
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Abstract
Hairy cell leukemia (HCL) is a unique chronic lymphoproliferative disorder that can mimic or coexist with other clonal hematologic disorders and has been associated with autoimmune disorders. It should be entertained as an alternative diagnosis in patients with cytopenias being assigned the diagnosis of aplastic anemia, hypoplastic myelodysplastic syndrome, atypical chronic lymphocytic leukemia, B-prolymphocytic leukemia, or idiopathic myelofibrosis. Causative etiology or molecular defects remain unclear, although nonspecific chromosomal and molecular changes have been described. The typical presentation is that of a middle-aged man with an incidental finding of pancytopenia, splenomegaly, and inaspirable bone marrow. Treatment with a purine analogue, cladribine or pentostatin, results in extremely high, durable, overall, and complete response rates, although resistance and relapses do occur. A variant subtype exists and is frequently associated with a poor response. Because of its simplified dosing schedule, cladribine is commonly used as the initial therapy. Treatment of relapsed HCL is dictated by the duration of the preceding remission. Relapsed disease after a prolonged remission can often be successfully retreated with the same initial agent. Resistance in typical HCL is treated with the alternate purine analogue. New agents, such as rituximab and BL22, are actively being evaluated and show promising results in both HCL subtypes. This article uses two patients diagnosed with aplastic anemia and recently seen in consultation at our institution as a springboard to discuss the biology, pathogenesis, clinical presentation, diagnostic evaluation, and treatment options of HCL.
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Affiliation(s)
- Sam O Wanko
- Duke University Medical Center, Division of Hematology/Oncology & Bone Marrow Transplant, Durham, North Carolina 27710, USA.
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Chaigne-Delalande B, Deuve L, Reuzeau E, Basoni C, Lafarge D, Varon C, Tatin F, Anies G, Garand R, Kramer I, Génot E. RhoGTPases and p53 are involved in the morphological appearance and interferon-alpha response of hairy cells. THE AMERICAN JOURNAL OF PATHOLOGY 2006; 168:562-73. [PMID: 16436670 PMCID: PMC1606488 DOI: 10.2353/ajpath.2006.050345] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hairy cell leukemia is an uncommon B-cell lymphoproliferative disease of unknown etiology in which tumor cells display characteristic microfilamentous membrane projections. Another striking feature of the disease is its exquisite sensitivity to interferon (IFN)-alpha. So far, none of the known IFN-alpha regulatory properties have explained IFN-alpha responsiveness nor have they taken into account the morphological characteristics of hairy cells. IFN-alpha profoundly alters cytoskeletal organization of hairy cells and causes reversion of the hairy appearance into a rounded morphology. Because cytoskeletal rearrangements are controlled by the Rho family of GTPases, we investigated the GTPase activation status in hairy cells and their regulation by IFN-alpha. Using immunolocalization techniques and biochemical assays, we demonstrate that hairy cells display high levels of active Cdc42 and Rac1 and that IFN-alpha down-regulates these activities. In sharp contrast, RhoA activity was low in hairy cells but was increased by IFN-alpha treatment. Finally, IFN-alpha-mediated morphological changes also implicated a p53-induced response. These observations shed light on the mechanism of action of IFN-alpha in hairy cell leukemia and are of potential relevance for the therapeutical applications of this cytokine.
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Coupland LA, Brun M, Jammu V, D'Rozario JM. A variant chronic B-cell lymphoma characterized by villous cells with novel immunophenotypic and cytogenetic profiles. Leuk Lymphoma 2005; 47:129-34. [PMID: 16321837 DOI: 10.1080/10428190500277126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The less common chronic B-cell lymphomas include hairy cell leukemia, hairy cell leukemia variant and splenic lymphoma with villous lymphocytes. These disease entities can sometimes cause a diagnostic dilemma; however, immunophenotypic markers have been identified as disease specific and scoring systems have been proposed to assist the process. This study reports a case of a chronic B-cell lymphoma with long cytoplasmic projections which does not fit into any of the published disease categories based upon a combination of clinical and morphological features and immunophenotyping. Furthermore, this case featured a combination of cytogenetic abnormalities not previously described in the published literature in association with a B-cell lymphoproliferative disorder.
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Affiliation(s)
- L A Coupland
- Haematology Department, The Canberra Hospital, Garran, ACT, Australia.
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Ravandi F, O'Brien S. Chronic lymphoid leukemias other than chronic lymphocytic leukemia: diagnosis and treatment. Mayo Clin Proc 2005; 80:1660-74. [PMID: 16342661 DOI: 10.4065/80.12.1660] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The World Health Organization classification divides lymphoid malignancies into precursor B-cell and T-cell neoplasms as well as mature B-cell and T-cell neoplasms. Mature B-cell neoplasms comprise more than 85% of non-Hodgkin lymphomas worldwide and can be further subclassified according to the postulated cell of origin by using specific morphologic, immunophenotypic, and molecular characteristics. Similarly, the more uncommon mature T-cell neoplasms have been better characterized to include numerous distinct entities with widely varying natural histories. The distinction between lymphoma and leukemia is somewhat arbitrary and is based on variable involvement of the bone marrow, peripheral blood, and lymphatic system. In this article, we review the diagnostic and clinical features of mature B-cell and T-cell lymphoproliferative disorders that commonly have a leukemic presentation.
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MESH Headings
- Diagnosis, Differential
- Humans
- Leukemia, Hairy Cell/diagnosis
- Leukemia, Hairy Cell/therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Leukemia, T-Cell/diagnosis
- Leukemia, T-Cell/therapy
- Prognosis
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, The University of Texas M D Anderson Cancer Center, Houston 77030, USA.
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Sun T, Grupka N, Klein C. Transformation of hairy cell leukemia to high-grade lymphoma: a case report and review of the literature. Hum Pathol 2005; 35:1423-6. [PMID: 15668902 DOI: 10.1016/j.humpath.2004.08.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The coexistence of hairy cell leukemia (HCL) and non-Hodgkin's lymphoma is extremely rare. In the few reports demonstrating such coexistence, the relationship between the 2 entities was mostly inconclusive. We report a case of HCL that transformed to large cell lymphoma. This case has been followed for more than 4 years with immunohistochemical, flow cytometric, and molecular genetic studies on multiple bone marrow biopsy specimens, a splenectomy specimen, and a lymph node biopsy. In our case, the immunophenotype and tartrate-resistant acid phosphatase stain confirmed that the large cell lymphoma was of HCL origin. The markedly increased Ki-67 staining (proliferation fraction) in the lymph node biopsy specimen compared to the earlier splenectomy specimen indicated the transformation of a low-grade leukemia to a high-grade lymphoma. The overexpression of p53 in the lymph node implies that p53 mutation was probably involved in the pathogenesis of HCL transformation.
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MESH Headings
- Adult
- Biomarkers, Tumor/metabolism
- Bone Marrow/metabolism
- Bone Marrow/pathology
- Cell Transformation, Neoplastic
- DNA, Neoplasm/analysis
- Humans
- Immunoenzyme Techniques
- Immunophenotyping
- In Situ Hybridization, Fluorescence
- Ki-67 Antigen/metabolism
- Leukemia, Hairy Cell/genetics
- Leukemia, Hairy Cell/metabolism
- Leukemia, Hairy Cell/pathology
- Lymph Nodes/metabolism
- Lymph Nodes/pathology
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/pathology
- Male
- Neoplasms, Second Primary/genetics
- Neoplasms, Second Primary/metabolism
- Neoplasms, Second Primary/pathology
- Spleen/metabolism
- Spleen/pathology
- Tumor Suppressor Protein p53/metabolism
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Affiliation(s)
- Tsieh Sun
- Pathology and Laboratory Medicine Service, Veterans Affairs Medical Center, Denver, CO 80220, USA
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Abstract
Hairy cell leukemia is an indolent, chronic B-cell lymphoproliferative disorder comprising approximately 2 to 3% of all adult leukemias in the United States. Hairy cells are clonal expansions of mature, activated B-cells. They co-express CD11c, CD19, CD20, CD22, CD25, and CD103. Hairy cells possess clonal immunoglobulin gene rearrangements and express monoclonal surface immunoglobulin of either IgG or multiple heavy-chain isotypes. Treatment of hairy cell leukemia should be considered for symptomatic patients. It is indicated in patients with significant neutropenia, anemia, thrombocytopenia, symptomatic splenomegaly, constitutional symptoms due to hairy cell leukemia, or recurrent serious infections. Many treatments exist, including cladribine, pentostatin, interferon-alpha, splenectomy, rituximab (mabthera), and BL-22 immunotoxin.
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Affiliation(s)
- Grant R Goodman
- Division of Hematology/Oncology, Scripps Clinic, La Jolla, California 92037, USA
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Abstract
The evidence that hairy cells are activated clonal late B cells is presented. The largely non-specific (i.e. not confined to hairy-cell leukaemia) chromosome and genetic abnormalities are then described. Next, the features of malignant-cell activation are considered, including the distinctive morphology of hairy cells and their expression of activation-related antigens and activated adhesion receptors. Also, signalling and cytokine production are discussed in the context of malignant-cell activation. It is then demonstrated that many of the distinctive clinicopathological features of hairy-cell leukaemia can be explained in terms of the interaction of the activated malignant cells with other types of cell and tissue matrix. Finally, the biological basis of the hairy cell's unusually high sensitivity to IFN-alpha and nucleoside analogues is discussed.
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Affiliation(s)
- M Zuzel
- Department of Haematology, Royal University of Liverpool Hospital, Duncan Building, Daulby Street, Liverpool L69 3GA, UK
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Abstract
Hairy-cell leukaemia-variant (HCL-variant) is a rare B-cell disorder which accounts for 10% of HCL cases. It affects elderly or middle-aged males. The main features are splenomegaly, lymphocytosis and cytopenias without monocytopenia. The circulating cells have a morphology intermediate between prolymphocytes and hairy cells. The immunophenotype shows a mature B-cell phenotype with expression of the B-cell antigens CD11c and CD103-but unlike typical HCL the cells are CD25- and HC2-negative. The histology of bone marrow and spleen shows a pattern of infiltration similar to that in HCL. There is no recurrent chromosomal abnormality but complex karyotypes and monoallelic p53 deletion by fluorescence in situ hybridization are common. Patients are resistant to alkylating agents and interferon-alpha (IFN-alpha) and only half achieve partial responses to pentostatin and/or cladribine. Splenectomy results in long-lasting partial responses in over two-thirds of the patients and is a good palliative treatment. Despite the lack of response to most therapies, the clinical course of HCL-variant is chronic. The median survival is 9 years and 42% of patients die of unrelated causes. Transformation to large cell is seen in 6% of patients. The inferior survival in HCL-variant compared with typical HCL cases may reflect the chemotherapy resistance.
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Affiliation(s)
- E Matutes
- Academic Department of Haematology and Cytogenetics, The Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK.
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Abstract
The diagnosis of HCL is usually straightforward and is based on the identification of typical HCs in the blood and bone marrow. The suspected diagnosis is confirmed by a combination of TRAP cytochemistry, a distinctive immunophenotype and characteristic BM trephine appearances. Nucleoside treatment is highly effective in inducing prolonged remissions; relapsing patients can usually be successfully retreated with nucleoside. Monoclonal antibody therapy is a promising novel approach to the treatment of resistant disease.
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Affiliation(s)
- D J Allsup
- Department of Heamatology, Royal Liverpool University Hospital, Duncan Building, Daulby Street, L69 3GA Liverpool, UK
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Gruszka-Westwood AM. Abnormalities of the p53 Tumour Suppressor Gene in Mature B-cell Neoplasms. Hematology 2001; 6:241-54. [PMID: 27414843 DOI: 10.1080/10245332.2001.11746577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The p53 gene, located on the short arm of human chromosome 17 at 17p13, codes for a 393 aminoacid phosphoprotein, which acts as a transcription factor and is involved in the control of many different cellular processes. It is the most frequently mutated gene in neoplasia and mutations have been observed in 231 of the 393 codons, including all but one codon of the DNA binding domain. p53 abnormalities in mature B-cell lymphoproliferative disorders (B-LPDs) occur in up to 75% of cases and are mostly detected in patients with advanced clinical stages. B-LPDs encompass a heterogeneous group of clinically important lymphoid malignancies with a complex biology, varying natural history and prognosis that makes their classification and treatment difficult. Despite many publications concerning the role of p53 abnormalities in the development of B-LPDs and the prognostic implications of detecting aberrant p53 function, it is difficult to draw firm conclusions as studies have varied with respect to patient selection and classification and techniques used. This review focuses on the available data pertaining to p53 abnormalities in the different mature B-cell neoplasms and summarises the incidences of abnormalities, the mutation patterns encountered and their clinical significance.
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Affiliation(s)
- A M Gruszka-Westwood
- a Academic Department of Haematology and Cytogenetics , Institute of Cancer Research/Royal Marsden NHS Trust , London , UK
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Chaganti RS, Nanjangud G, Schmidt H, Teruya-Feldstein J. Recurring chromosomal abnormalities in non-Hodgkin's lymphoma: biologic and clinical significance. Semin Hematol 2000; 37:396-411. [PMID: 11071361 DOI: 10.1016/s0037-1963(00)90019-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Non-Hodgkin's lymphomas (NHLs) are a group of clinically important neoplasms with a complex biology that makes their classification and treatment difficult. Their incidence is increasing and they cause significant morbidity and mortality. NHLs result from transformation of B and T/natural killer (NK) cells. Their genetic hallmark is chromosomal translocations resulting from aberrant rearrangements of IG and TCR genes, which lead to inappropriate expression of genes at reciprocal breakpoints that regulate a variety of cellular functions, including gene transcription, cell cycle, apoptosis, and tumor progression. Cytogenetics followed by molecular genetic analysis of some of the recurring translocations continues to provide new insights into lymphomagenesis and cell biology. More recently, chromosomal and gene amplification and gene deletion have been recognized as frequent genetic changes that may play a role in lymphoma progression and clinical behavior. In this review, cytogenetic data pertaining to recurring chromosomal changes on lymphomas are reviewed and examined in relation to their relevance to lymphoma development, classification, and clinical behavior.
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Affiliation(s)
- R S Chaganti
- Department of Human Genetics, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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