Clinical manifestations and infectious complications of hairy-cell leukaemia

Recommendations for the Management of Patients with Hairy-Cell Leukemia and Hairy-Cell Leukemia-like Disorders: A Work by French-Speaking Experts and French Innovative Leukemia Organization (FILO) Group

INTRODUCTION

Hairy-cell leukemia (HCL) is a rare B-cell chronic lymphoproliferative disorder (B-CLPD), whose favorable prognosis has changed with the use of purine nucleoside analogs (PNAs), such as cladribine (CDA) or pentostatin (P). However, some patients eventually relapse and over time HCL becomes resistant to chemotherapy. Many discoveries have been made in the pathophysiology of HCL during the last decade, especially in genomics, with the identification of the BRAFV600E mutation and cellular biology, including the importance of signaling pathways as well as tumor microenvironment. All of these new developments led to targeted treatments, especially BRAF inhibitors (BRAFis), MEK inhibitors (MEKis), Bruton's tyrosine kinase (BTK) inhibitors (BTKis) and recombinant anti-CD22 immunoconjugates.

RESULTS

The following major changes or additions were introduced in these updated guidelines: the clinical relevance of the changes in the classification of splenic B-cell lymphomas and leukemias; the increasingly important diagnostic role of BRAFV600E mutation; and the prognostic role of the immunoglobulin (IG) variable (V) heavy chain (H) (IGHV) mutational status and repertory. We also wish to insist on the specific involvement of bones, skin, brain and/or cerebrospinal fluid (CSF) of the disease at diagnosis or during the follow-up, the novel targeted drugs (BRAFi and MEKi) used for HCL treatment, and the increasing role of minimal residual disease (MRD) assessment.

CONCLUSION

Here we present recommendations for the diagnosis of HCL, treatment in first line and in relapsed/refractory patients as well as for HCL-like disorders including HCL variant (HCL-V)/splenic B-cell lymphomas/leukemias with prominent nucleoli (SBLPN) and splenic diffuse red pulp lymphoma (SDRPL).

Long-term results of the sequential combination of cladribine and rituximab in Hairy cell leukemia

We report on the long-term efficacy and safety of a phase 2 trial of sequential cladribine and rituximab in hairy cell leukemia (HCL). One-hundred and thirty-nine patients were enrolled: 111 in the frontline setting, 18 in first relapse, and 10 with variant HCL (HCLv). A complete response (CR) was achieved in 133 of 137 evaluable participants (97%) with measurable residual disease (MRD) negativity in 102 (77%). MRD status was not associated with significant differences in event-free survival (EFS) or overall survival (OS). With a median follow-up of 7.8 years (range: 0.40-18.8), eight patients have experienced disease relapse (5.8%), 4/111 with newly diagnosed HCL (3·6%) and 4/10 with HCLv (40%) (p = 0.002). The 10-year EFS and OS rates were 86.7% and 91.1%, respectively. Grade 3 adverse events were observed in 28 participants (20·1%), mostly due to infections. Treatment of HCL with sequential cladribine followed by rituximab is associated with excellent efficacy and safety results both in the frontline and relapsed settings.

A population-based study of hairy cell leukemia over a period of 20 years

There are limited population-based studies of hairy cell leukemia (HCL), a rare chronic lymphoproliferative disorder of B-cells. We conducted a population-based study that included all patients diagnosed with HCL between 1996 and 2016 in Western Normandy. Recorded data focused on medical history, clinical presentation, biological results, treatment modalities in the first line and in relapsed/refractory patients and the occurrence of secondary malignancies. One hundred and twenty-three HCL patients were registered in the database. HCL represented 0.7% of all malignant hematological disorders and 3.0% of all leukemia. The overall age-standardized incidence ratio (SIR) was 0.39/100,000 inhabitants in men and 0.09/100,000 in women, and it remained stable over the 20-year period analyzed. One hundred and seven patients (88%) received first-line treatment, 33 patients (27%) received at least 2 lines of treatment and 14 patients (11%) received more than 2 lines. Cladribine used as first-line treatment induced a high hematological complete response (HCR) rate of 92%. The median overall survival (OS) was over 15 years, with 5-year and 10-year survival rates of 84% and 70.5%. No significant differences in OS were observed between men and women, between the calendar periods studied or between patients who received a single line treatment with IFN-α or PNA. The risk of relapse was higher with IFN-α treatment, requiring subsequent treatments in that patients. The time to next treatment (TTN) tends to be longer for PNAs compared to IFN-α even if difference is not significant. Secondary cancers were observed in 9/123 patients (7.3%) with solid tumors in 8 patients and hematological malignancy in one patient. Our data confirm in real life that single courses of cladribine administered to patients with HCL induce high response rates, the majority of which are HCR. Relapses seem less frequent than with IFN-α and the administration schedule is less restrictive for the patients. The emergence of chemo-immunotherapy and the development of effective new drugs such as recombinant immunotoxins and BRAF targeting will offer new possibilities in the management of HCL patients.

Disseminated Histoplasmosis with Concurrent Hairy Cell Leukemia

Histoplasmosis is an endemic fungal infection that can lead to disseminated disease, especially in immunosuppressed patients. Hairy cell leukemia is a rare, slow-growing hematological malignancy. Concurrence of histoplasmosis and hairy cell leukemia is extremely rare. We describe a 69-year-old male who presented with fever, dry cough, pancytopenia, multiple pulmonary nodules, and massive splenomegaly. Histoplasma urinary antigen was positive and disease was confirmed by biopsy of lung lesions. Peripheral smear showed 'hairy cells', and bone marrow biopsy revealed findings of hairy cell leukemia. The patient was treated with intravenous amphotericin, followed by oral itraconazole. After the initial treatment of infection, treatment for hairy cell leukemia was started with cladribine. We will discuss the principles of treating disseminated histoplasmosis in the setting of immunosuppression, and hairy cell leukemia with coexisting infection.

Laboratory evaluation of the IFN-γ circuit for the molecular diagnosis of Mendelian susceptibility to mycobacterial disease

The integrity of the interferon (IFN)-γ circuit is necessary to mount an effective immune response to intra-macrophagic pathogens, especially Mycobacteria. Inherited monogenic defects in this circuit that disrupt the production of, or response to, IFN-γ underlie a primary immunodeficiency known as Mendelian susceptibility to mycobacterial disease (MSMD). Otherwise healthy patients display a selective susceptibility to clinical disease caused by poorly virulent mycobacteria such as BCG (bacille Calmette-Guérin) vaccines and environmental mycobacteria, and more rarely by other intra-macrophagic pathogens, particularly Salmonella and M. tuberculosis. There is high genetic and allelic heterogeneity, with 19 genetic etiologies due to mutations in 10 genes that account for only about half of the patients reported. An efficient laboratory diagnostic approach to suspected MSMD patients is important, because it enables the establishment of specific therapeutic measures that will improve the patient's prognosis and quality of life. Moreover, it is essential to offer genetic counseling to affected families. Herein, we review the various genetic and immunological diagnostic approaches that can be used in concert to reach a molecular and cellular diagnosis in patients with MSMD.

Listeria monocytogenes Infection in Hairy Cell Leukemia: A Case Report and Literature Review

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.

Hairy Cell Lymphoma: A Potentially Under-Recognized Entity

Hairy cell leukemia (HCL) is a low grade B-cell lymphoproliferative disorder that typically presents with splenomegaly, cytopenias, and diffuse bone marrow infiltration. There have been few cases in the literature of HCL presenting as lymphomas in extra-nodal locations, such as soft tissues and bones without circulating leukemic cells, splenomegaly, or iliac crest bone marrow involvement. We present an additional case presenting as a thoracic mass, and discuss potential diagnostic pitfalls and management of these rare cases.

Autoimmune disorders in patients with hairy cell leukemia: are they more common than previously thought?

BACKGROUND

For a number of decades, hairy cell leukemia (HCL) has been linked with polyarthritis, vasculitis, symptomatic cytopenias and thrombosis in the medical literature. Notwithstanding, the significance of these associations has not been well understood. Therefore, we have decided to analyze them further.

METHODS

We provide herein a comprehensive literature review of the prevalence of autoimmune disorders in patients with HCL. Most relevant publications were identified through searching the PubMed/Medline database for articles published from inception to February 2014.

FINDINGS

Perhaps due to the rarity of HCL, scientific literature on autoimmune conditions in patients with HCL consists mainly of published case series and isolated reports. Our analysis identified increased prevalence of various autoimmune conditions in patients with HCL, including various vasculitides, immune cytopenias and antiphospholipid antibody syndrome (APS) among others.

CONCLUSIONS

Presence of certain autoimmune disorders should increase the suspicion of HCL in an appropriate clinico-laboratory context. Conversely, the diagnosis of HCL should prompt early recognition of certain autoimmune disorders if clinical suspicion exists. While some of these autoimmune diseases are thought to be secondary to the dysfunctional immune response associated with underlying malignant process, others could be primary and might even play a role in the HCL pathogenesis. The autoimmune complications can pose important clinical problems for the HCL patients. Therefore, a catalogue of these problems is important for alerting physicians to watch for them and diagnose them promptly.

Two cases of q-Fever in hairy cell leukemia

Hairy cell leukemia (HCL) is a rare B-cell lymphoproliferative disorder accounting for about 2% of all leukemias. The clinical course is indolent, however HCL patients are particularly susceptible to infections. Here we report two cases of Q-fever as first manifestation of disease in two patients affected by HCL. Both patients described in this report showed an unusually sluggish clinical response to the antibiotic treatment with ciprofloxacin probably because of the marked immunodeficiency. However, treatment of HCL with cladribine administered soon after the resolution of QF pneumonitis was uneventful and led to a complete remission in both cases. Most probably the association of Coxiella burnetii (CB) infection and HCL that we observed in two patients is due to chance. However, a hairy cell resembling transformation of freshly isolated human peripheral blood lymphocytes upon CB has been showed. We think that the possibility of CB infection in febrile HCL patient should be always taken in mind, especially in endemic areas. In addition the potential for such infections to become chronic in HCL patients should not be overlooked and the reporting of further cases should be encouraged.

[Auto-immune diseases and cancers. Second part: auto-immune diseases complicating cancers and their treatment]

Autoimmune diseases may reveal or occur during the course of a neoplasia or its treatment. Autoimmune cytopenia, especially haemolytic anaemia, is common in lymphoproliferative disorders such as chronic lymphoid leukemia. The link between cancer and myositis is well established. Dermatomyositis is associated with an increased relative risk of cancer of 3.4 to 4.4. A combination of detection of antibodies against p155 and TEP-computed tomography may be the best approach to ascertain the presence of occult malignancy in patients with dermatomyositis. A cutaneous or a systemic vascularitis may reveal a cancer, most often a haematological malignancy such as hairy cell leukemia. Paraneoplastic polyarthritis have been described in particular with adenocardinoma of the lungs. Underlying neoplasia should be considered in male smokers patients with new onset polyarthritis and poor health status. The prevalence of autoimmune conditions in myelodysplastic syndromes is 10 to 30%. Vasculitis and relapsing polychondritis are the most commonly reported manifestations. Immune manifestations can also be related to treatment. The most common treatment complications are autoimmune haemolytic anaemia with fludarabine and thyroiditis related to interferon and cervical radiotherapy.

Infections in patients with leukemia and lymphoma

Infectious complications remain a significant issue in the care of patients with hematologic malignancies. Inherent immune defects related to the primary disease process are present in patients with disorders such as chronic lymphocytic leukemia, multiple myeloma, hairy cell leukemia, and Hodgkin lymphoma. Therapy-related immunosuppression is also commonplace in these patients. This includes not only treatment-related neutropenia, but also defects in cell-mediated immunity, such as those that occur with purine analog therapy. In this chapter, we will review the pathogenesis of infection in these disorders, as well as the spectrum of infectious complications seen and suggested strategies for the prevention of infection.

Vasculitides associated with haematological malignancies: a case-based review

Autoimmune phenomena including vasculitis are known to be associated with malignancy, especially those that are haematological in origin. Vasculitis syndromes associated with malignant disease include cutaneous leucocytoclastic vasculitis, polyarteritis nodosa, Churg-Strauss syndrome, microscopic polyangiitis, Wegener's granulomatosis and Henoch-Schönlein purpura. We describe a patient whose initial presentation with vasculitis led to the diagnosis of hairy cell leukaemia.

Management of the cancer patient with infection and neutropenia

Infections are major causes of morbidity and mortality in cancer. The intensity and duration of immunosuppressive chemotherapy determine the risk. Cancer may be associated with immune defects, in particular hematologic malignancies. Predisposing factors include tumor site, intravenous devices, neutropenia due to underlying disease, mucosal lesions, corticosteroids, monoclonal antibodies, splenic dysfunction, and treatment with chemotherapy or radiation therapy. Bacteremia is documented in approximately 25% of people with febrile neutropenia. The drug choice for empiric therapy is influenced by factors related either to the patient or to the institution. Guidelines and general statements should always take local epidemiology into consideration. The therapeutic hematopoietic growth factors should be reserved for patients with fever and neutropenia and those at high risk for infection-associated complications or poor clinical outcomes. The Multinational Association of Supportive Care in Cancer (MASCC) has developed a Risk Index that predicts the risk of medical complications and outcome.

Modern strategies for hairy cell leukemia

Enormous progress in the treatment of hairy cell leukemia over the last five decades has emerged as a result of organized clinical investigations. Although interferon represented one of the initial major therapeutic advances in the management of this disease in 1984, the subsequent introduction of purine nucleoside analogs (pentostatin and cladribine) changed the natural history of this rare disease by achieving a high rate of complete and durable remissions. The disease-free survival after effective therapy has not reached a plateau, suggesting control but not cure of the disease. Identification of minimal residual disease in patients achieving a complete hematologic remission provides insight into the potential source for predicting eventual relapse. Modern strategies of targeted therapies directed against immunophenotypic markers on the leukemic cells provide hope that improved long-term control of the disease is possible. Combined chemoimmunotherapy may hold the highest promise for disease eradication, but the optimal strategy for using this approach is under active investigation. Despite the perception by hematologists that this disease has already been conquered, there are critically important unanswered questions that remain. Investigation of the bone marrow microenvironment and its impact on minimal residual disease may ultimately prevent relapse. Consideration of the median age of patients at diagnosis combined with a substantial relapse rate mandates continued pursuit of improved therapy. The ultimate goal will be to achieve cure rather than simple control of the disease.

Risk of additional cancers in untreated and treated hairy cell leukemia patients

IMPORTANCE OF THE FIELD

One of the feared events encountered in hairy cell leukemia (HCL) survivors is the subsequent development of a malignant neoplasm. The increased incidence of second cancers in HCL has been documented in large epidemiologic studies conducted in various locations on the globe.

AREAS COVERED IN THIS REVIEW

The authors explore the current clinico-epidemiologic evidence, as well as the immune alterations, that link HCL and its therapies to the development of second cancers. Most relevant publications have been identified through the PubMed/Medline database search.

WHAT THE READER WILL GAIN

Although HCL patients could develop both HCL and secondary malignancies because of a shared genetic predisposition, a common environmental carcinogen, or not yet identified infectious agents, multiple immune defects documented in HCL might play an important role in second carcinogenesis. Furthermore, the 'gold standards' of HCL therapy - cladribine and pentostatin - are associated with profound and prolonged suppression of the CD4(+) T-lymphocyte counts, often in excess of 2 - 3 years. And while there is no clear-cut evidence that pentostatin or interferon-alpha play an established role in generation of an excess of second cancers in HCL, the safety of cladribine, the preferred agent by a majority of clinicians worldwide, in this regard is a still largely unsettled issue.

TAKE-HOME MESSAGE

Therefore, it remains to be seen if the immune deficiencies induced by the HCL therapies and their consequences can be offset by the benefit conferred by controlling the leukemic process.

Autosomal dominant and sporadic monocytopenia with susceptibility to mycobacteria, fungi, papillomaviruses, and myelodysplasia

We identified 18 patients with the distinct clinical phenotype of susceptibility to disseminated nontuberculous mycobacterial infections, viral infections, especially with human papillomaviruses, and fungal infections, primarily histoplasmosis, and molds. This syndrome typically had its onset in adulthood (age range, 7-60 years; mean, 31.1 years; median, 32 years) and was characterized by profound circulating monocytopenia (mean, 13.3 cells/microL; median, 14.5 cells/microL), B lymphocytopenia (mean, 9.4 cells/microL; median, 4 cells/microL), and NK lymphocytopenia (mean, 16 cells/microL; median, 5.5 cells/microL). T lymphocytes were variably affected. Despite these peripheral cytopenias, all patients had macrophages and plasma cells at sites of inflammation and normal immunoglobulin levels. Ten of these patients developed 1 or more of the following malignancies: 9 myelodysplasia/leukemia, 1 vulvar carcinoma and metastatic melanoma, 1 cervical carcinoma, 1 Bowen disease of the vulva, and 1 multiple Epstein-Barr virus(+) leiomyosarcoma. Five patients developed pulmonary alveolar proteinosis without mutations in the granulocyte-macrophage colony-stimulating factor receptor or anti-granulocyte-macrophage colony-stimulating factor autoantibodies. Among these 18 patients, 5 families had 2 generations affected, suggesting autosomal dominant transmission as well as sporadic cases. This novel clinical syndrome links susceptibility to mycobacterial, viral, and fungal infections with malignancy and can be transmitted in an autosomal dominant pattern.

Hairy cell leukemia

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.

Characteristics of common solid liver lesions and recommendations for diagnostic workup

Due to the widespread clinical use of imaging modalities such as ultrasonography, computed tomography and magnetic resonance imaging (MRI), previously unsuspected liver masses are increasingly being found in asymptomatic patients. This review discusses the various characteristics of the most common solid liver lesions and recommends a practical approach for diagnostic workup. Likely diagnoses include hepatocellular carcinoma (the most likely; a solid liver lesion in a cirrhotic liver) and hemangioma (generally presenting as a mass in a non-cirrhotic liver). Focal nodular hyperplasia and hepatic adenoma should be ruled out in young women. In 70% of cases, MRI with gadolinium differentiates between these lesions. Fine needle core biopsy or aspiration, or both, might be required in doubtful cases. If uncertainty persists as to the nature of the lesion, surgical resection is recommended. If the patient is known to have a primary malignancy and the lesion was found at tumor staging or follow up, histology is required only when the nature of the liver lesion is doubtful.

The leukemias of mature lymphocytes

The leukemias of mature B cells and T cells are a limited set of diseases in which blood and bone marrow are the primary sites of involvement. Although they may superficially resemble one another, they have distinct clinical and pathologic features and must be distinguished from one another. In this article, the major clinical, morphologic, phenotypic, and molecular genetic features of the mature B- and T-cell leukemias are reviewed, and differential diagnostic considerations are discussed.

Treatment options in skeletal localizations of hairy cell leukemia: a systematic review on the role of radiation therapy

Skeletal localizations are a rare complication in hairy cell leukaemia patients, with an estimated incidence of 3%. These lesions, mainly osteolytic, can occur at various sites and are almost always symptomatic. Localized radiation therapy (RT) has been extensively used as effective palliative treatment in such cases, with different total doses and fractionation schedules. In this article, a systematic review of all reported cases with osseous complications is presented, to underline the role of RT and to define the most appropriate approach in this subset of patients.

Acute vasculitis as a first manifestation of hairy cell leukemia

Hairy cell leukemia (HCL) is a lymphoproliferative malignancy characterized by bone marrow, spleen, liver, and occasionally lymph node infiltration with hairy cells, usually accompanied by splenomegaly and pancytopenia. We report an unusual case of HCL in a 53-year-old woman with leukopenia and sudden onset of fever of unknown origin, arthritis, and generalized maculopapular exanthem. Skin biopsy revealed perivascular and/or vessel wall lymphocytic infiltration in the dermis. On the basis of bone marrow biopsy and flow cytometry, the diagnosis of HCL was established. A detailed, retrospective re-evaluation of the skin biopsy helped to identify hairy cells among the cells of the perivascular infiltrations. Small-vessel vasculitis, as an atypical presentation, was found to predate a diagnosis of HCL. Recognition that vasculitis can reflect or antedate lymphoid malignancy may permit early diagnosis and aggressive treatment. A rapid response was obtained with a single course of cladribine.

Pentostatin: impact on outcome in hairy cell leukemia

Major advances in the management of patients who have hairy cell leukemia have been made following the use of purine nucleoside analogs. Pentostatin and cladribine are equally effective, and have impressive long-term effectiveness. Although the degree of myelosuppression may be less with the use of pentostatin, this may reflect differences in the schedule and dose of drug administration between these agents. The gradual, but relentless, improvement in the peripheral blood counts enables out-patient management with pentostatin in most patients. Cladribine affords the convenience of a single course of administration. A direct comparative study with these two agents is unlikely to yield the optimal management of patients who have minimal residual disease following the administration of either agent is warranted in the context of a clinical trial. Patients do relapse, and the overall survival curves have not reached a plateau, which indicates that cure has not been secured. The satisfaction of having improved the outcome for patients who have this previously untreatable leukemia should not give way to complacency for further improvement in the management of this disease. Future studies should be directed to optimizing the therapy for minimal residual disease as well as clearer definition of supportive care.

Eradication of minimal residual disease in hairy cell leukemia

Although the nucleoside analogs cladribine and pentostatin produce high response rates in patients with hairy cell leukemia (HCL), a significant number of patients eventually relapse. Several studies have demonstrated that patients with complete remission (CR) have a longer disease-free survival. Therefore, strategies to improve on the initial response to nucleoside analog therapy are likely to be beneficial, at least for a proportion of patients. We have treated 13 patients with newly diagnosed HCL (n = 11) or after failure of one prior chemotherapy (n = 2) with cladribine (5.6 mg/m(2) given intravenously over 2 hours daily for 5 days) followed by 8 weekly doses of rituximab (375 mg/m(2)). All patients achieved a CR and minimal residual disease (MRD) assessed by consensus primer polymerase chain reaction (PCR) or flow cytometry was eradicated in 11 (92%) of 12 and in 12 (92%) of 13 of patients, respectively. There was no decline in the absolute CD4 and CD8 lymphocyte number after rituximab. We conclude that eradication of MRD in HCL is possible. Whether this leads to a reduced risk of relapse would need to be evaluated in a larger number of patients and with longer follow-up. Disease characteristics may potentially be used to identify patients that are more likely to benefit from such additional therapy.

Chronic lymphoid leukemias other than chronic lymphocytic leukemia: diagnosis and treatment

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.