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Leukemia and Lymphoma

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Biclonal T-cell receptor γδ+ large granular lymphocyte leukemia associated with rheumatoid arthritis

Monika Prochorec-Sobieszek ab; Monika Chełstowska c; Grzegorz Rymkiewicz d; Mirosław Majewski c; Krzysztof Warzocha c; Renata Maryniak a a Department of Pathomorphology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland b Department of Pathology, Institute of Rheumatology, Warsaw, Poland c Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland d

Department of Pathology, The Maria Sk odowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland First Published on: 15 February 2008 To cite this Article: Prochorec-Sobieszek, Monika, Chełstowska, Monika, Rymkiewicz, Grzegorz, Majewski, Mirosław, Warzocha, Krzysztof and Maryniak, Renata (2008) 'Biclonal T-cell receptor γδ+ large granular lymphocyte leukemia associated with rheumatoid arthritis', Leukemia and Lymphoma, 49:4, 828 — 831 To link to this article: DOI: 10.1080/10428190801895337 URL: http://dx.doi.org/10.1080/10428190801895337

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Leukemia & Lymphoma, April 2008; 49(4): 828 – 831

LETTER TO THE EDITOR

Biclonal T-cell receptor g dþ large granular lymphocyte leukemia associated with rheumatoid arthritis

MONIKA PROCHOREC-SOBIESZEK1,2, MONIKA CHEŁSTOWSKA3, GRZEGORZ RYMKIEWICZ4, MIROSŁAW MAJEWSKI3, KRZYSZTOF WARZOCHA3, & RENATA MARYNIAK1 1

Department of Pathomorphology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland, 2Department of Pathology, Institute of Rheumatology, Warsaw, Poland, 3Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland, and 4Department of Pathology, The Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland (Received 25 November 2007; revised 19 December 2007; accepted 5 January 2008)

T-cell large granular lymphocyte (T-LGL) leukemia is a rare disorder of mature activated cytotoxic T lymphocytes with monoclonal T-cell receptor (TCR) genes rearrangements. T-LGL leukemias usually express CD3þ/CD47/CD8þ/CD57þ/TCRabþ although other variants like: CD3þ/CD4þ/CD87/ TCRabþ or CD3þ/CD4þ/CD8þ/TCRabþ have also been observed [1]. TCRgdþ LGL leukemias represent a rare (about 5%) subset of CD3þ T-LGL leukemias with a clinical presentation similar to TCRabþ LGL leukemia. The clinical course is indolent, associated with cytopenias (mainly neutropenia), autoimmune disorders and less often, splenomegaly. The most common phenotype of leukemic cells is CD2þ/CD3þ/CD47/CD5þ/CD7þ/CD8þ/ CD57þ and a variable expression of CD16, CD56, CD11b, CD11c [2,3]. Two large series of patients with gdþ T-LGL leukemia have recently been published [2,3], but to our knowledge only one case of a well documented biclonal T-LGL leukemia was reported [4]. We present a case of T-LGL leukaemia associated with long-lasting rheumatoid arthritis and proliferation of two immunophenotypically slightly different populations of T-cells (CD3þ/ CD47/CD8þweaker and CD3þ/CD47/CD87) detected by flow cytometry (FCM) as well as the presence of distinct TCRG and TCRD genes rearrangements.

A 58-year-old female was referred to the Department of Hematology, Institute of Hematology and Transfusion Medicine for investigation of mild leucocytosis and lymphocytosis persisting for 1 year. The patient had a 32-year history of rheumatoid arthritis with severe changes in numerous joints and positive rheumatoid factor, anticyclic citrullinated peptide antibodies and antinuclear antibodies. The medical history included bilateral hip and right knee replacement surgery and autoimmune thyroiditis. The patient has been treated with Meloxicam 15 mg and Methylprednisolone 6 mg daily as well as 7.5 mg Methotrexate once a week. Blood counts were as follows: white blood cells 9.2 6 109/L, lymphocytes 6.6 6 109/L, neutrophils 1.7 6 109/L, hemoglobin 13.4 g/dL and platelets 230 6 109/L. In peripheral blood smear majority of lymphocytes had abundant cytoplasm and azurophilic granules consistent with LGLs. There was no hepatosplenomegaly or lymphadenopathy on physical examination and ultrasonography. Biochemical markers were normal except for polyclonal hypergammaglobulinemia. The patient was seronegative for EBV, CMV, HBV, HCV, HIV and HTLV-I. Bone marrow was normocellular in histopathological evaluation of trephine biopsy. Immunohistochemical stainings revealed subtle interstitial clusters and intrasinusoidal linear infiltrations of small

Correspondence: Monika Prochorec-Sobieszek, Department of Pathomorphology, Institute of Hematology and Transfusion Medicine, I. Gandhi 14, Warsaw, Poland. Tel/Fax: þ48-22-3496456. E-mail: [email protected] ISSN 1042-8194 print/ISSN 1029-2403 online Ó 2008 Informa UK Ltd. DOI: 10.1080/10428190801895337

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Figure 1. Biclonal TCRgdþ large granular leukemia. (A) Dot plots illustrating the main phenotypic features of two populations of leukemic cells (thin and thick arrows) in comparison with normal residual T lymphocytes (cells outlined in oval). (B) Ethidium bromide-stained polyacrylamide gel showing PCR products, derived from TCR genes rearrangements. Lane 1 – standard 50 bp; Lane 2 – TCRB genes rearrangement negative (tube A); Lane 3 – TCRB genes rearrangement negative (tube B); Lane 4 – TCRB genes rearrangement biclonal bands 200 bp (1) and 290 bp (2) in tube C; Lane 5 – TCRG genes rearrangement biclonal bands 180 – 220 bp (3, 4) in tube A; Lane 6 – TCRG genes rearrangement negative – polyclonal smear (tube B); Lane 7 – TCRD genes rearrangement biclonal bands 170 – 220 bp (5, 6).

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Letter to the Editor

lymphocytes (15% of cells). They expressed CD3þ, CD47, CD87, CD57þ/7 and granzyme Bþ/7. Moreover, reactive intertrabecular lymphoid nodules composed of B (CD20þ) and T (CD3þ, CD4þ, CD8þ) cells were noted. Three-color FCM analysis of peripheral blood leucocytes performed with a panel of monoclonal antibodies revealed two abnormal TCRgdþ T-cell populations: CD3þ/CD47/CD8þweaker (24% of all lymphocytes) [Figure 1(A)-thin arrows] and CD3þ/ CD47/CD87 (48% of all lymphocytes) [Figure 1(A)-thick arrows]. The former was positive for CD57 and CD5weaker, while the later was negative for both antigens. Additionally, both populations of T-LGL leukemia cells showed varied intensity of expression of CD167/þ, CD16&CD56þ/7, CD567/þ and were positive for CD45, CD45RA, CD2, CD7, CD43, CD44, CD52, HLA-DR but negative for CD45RO, CD25, CD27, CD62L, CD69, CD71, CD95, TCRab proteins. Leukemic cells expressed slightly weaker level of CD2 and CD7 as well as slightly higher level of CD3 than normal CD8þ and CD4þ T lymphocytes [Figure 1(A)-cells outlined in oval]. Molecular studies of bone marrow performed by multiplex polymerase chain reaction (PCR) with heteroduplex analysis according to BIOMED-2 protocol [5] revealed biclonal TCR genes rearrangements in the following regions: Db1, Db2-Jb, VgIf, Vg10-Jg, Vd, Dd2-Jd, Dd3 [Figure 1(B)]. Biclonal TCRgdþ T-LGL leukemia diagnosis was based on morphological and immunophenotypical features of the blood and bone marrow and confirmed by molecular evidence of TCR genes rearrangements. The previous treatment was continued and the disease remains stable for the 7 months of follow-up, with no anemia and infections, but also with no significant improvement of blood cell counts. In this case morphology of lymphocytes, histopathological and immunophenotypical features as well as clinical presentation and disease course were typical for T-LGL leukemia, but the dual-phenotype and biclonality were quite unusual. Biclonality in Tcell leukemias/lymphomas is a rare phenomenon described in sporadic cases [6,7]. So far it has been mainly reported in B-cell lymphoproliferative disorders, where true biclonality means coexistence of two unrelated B-cell clones that differ phenotypically and cytogenetically [8]. In some patients different clones occur within the same diagnostic entity, in others they appear as coexistence of distinct types of leukemia/lymphoma [8]. Moreover, there is evidence of intraclonal diversity of lymphoma cells representing different stages of single clone evolution. It means a monoclonal expansion of two populations of

cells with a similar phenotype but with different morphology, cell size and distinct DNA contents [8,9]. Although, in the presented case two populations of T-cells within the same diagnostic entity were morphologically identical with only a slight difference in expression of a similar panel of antigens in FCM, the molecular analysis revealed two independent clones. Therefore our case represents a true biclonal disease, not intraclonal diversity. Moreover, this case does not correspond to oligoclonal expansion of T cells. Langerak et al. [10] detected a single dominant and several additional weak gene products in Vb transcripts in numerous cases of T-LGL leukemia. Some authors [11] postulate that T-LGL leukemia may develop from a polyclonal or oligoclonal expansion as a consequence of chronic abnormal stimulation of immune system by autoantigens in the course of autoimmune processes. The observed coexistence of autoimmune disease and proliferation of T-cells mainly expressing CD3þ, CD47, CD87, CD577, CD567/þ required ruling out of autoimmune lymphoproliferative syndrome [12]. However, this syndrome caused by mutations in FAS (TNFRSF6) gene and defective FAS induced apoptosis has a different clinical presentation and in contrast to our T-LGL leukemia proliferating CD47/CD87 cells are TCRab positive. Clonal expansion of gdþ T-LGLs may also occur in viral infections [13], but that possibility has been excluded in our patient.

References 1. Chan WC, Catovsky D, Foucar K, Montserrat E. T-cell large granular lymphocyte leukaemia. In: Jaffe ES, Harris NL, Stein H, Vardiman JW, editors. World Health Organization classification of tumors. Pathology and Genetics of Tumors of Haematopoietic and Lymphoid Tissues. Lyon: IARC Press; 2001. pp 197 – 198. 2. Sandberg Y, Almeida J, Gonzalez M, Lima M, Ba´rcena P, Szczepan´ski T, et al. TCR gdþ large granular lymphocyte leukemias reflect the spectrum of normal antigen-selected TCR gdþ T-cells. Leukemia 2006;20:505 – 513. 3. Bourgault-Rouxel AS, Loughran TP Jr, Zambello R, EplingBurnette PK, Semenzato G, Donadieu J, et al. Clinical spectrum of gdþ T cell LGL leukemia: analysis of 20 cases. Leuk Res 2008;32:45 – 48. 4. Richards SJ, Short M, Steed AJ, Scott CS. A biclonal large granular lymphocyte (LGL)/NK-associated (NKa) disorder of CD4þ and CD8þ lymphocyte subpopulations characterized by the simultaneous presence of distinct TCR rearrangements. Br J Haematol 1994;88:629 – 632. 5. van Dongen JJ, Langerak AW, Bruggemann M, Evans PA, Hummel M, Lavender FL, et al. Design and standardization of PCR primers and protocols for detection of clonal immunoglobulin and T-cell receptor gene recombinations in suspect lymphoproliferations: report of the BIOMED-2 concerted action BMH4-CT98-3936. Leukemia 2003;12:2257 – 2317.

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Letter to the Editor 6. Kondo S, Kotani T, Tsumori S, Narahara S, Aratake Y, Kobayashi M, et al. Identification of biclonal (duplex) leukaemic cells expressing either CD4þ/CD87 or CD47/ CD8þ from a patient with adult T-cell leukaemia/lymphoma. Br J Haematol 1995;89:669 – 671. 7. Shibata K, Shimamoto Y, Suga K, Watanabe M, Kikuchi M, Yamaguchi M. Adult T-cell leukemia/lymphoma with two distinct clones in peripheral blood and lymph node. Am J Hematol 1995;48:116 – 119. 8. Sanchez ML, Almeida J, Lopez A, Sayagues JM, Rasillo A, Sarasquete EA, et al. Heterogeneity of neoplastic cells in B-cell chronic lymphoproliferative disorders: biclonality versus intraclonal evolution of a single tumor cell clone. Haematologica 2006;91:331 – 339. 9. Granjo E, Lima M, Lopes JM, Cunha N, Teixeira M-A, Santos F, et al. Intraclonal diversity in a Sezary syndrome with a differential response to 2-deoxycoformycin of the two lymphoma cell populations. Br J Haematol 2002;119:629 – 633.

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10. Langerak AW, van den Beemd R, Wolvers-Tettero ILM, Boor PPC, van Lochem EG, Hooijkaas H, et al. Molecular and flow cytometric analysis of the Vb repertoire for clonality assessment in mature TCRab T-cell proliferations. Blood 2001;98:165 – 173. 11. O’Keefe CL, Plasilova M, Wlodarski M, Risitano AM, Rodriguez AR, Howe E, et al. Molecular analysis of TCR clonotypes in LGL: a clonal model for polyclonal responses. J Immunol 2004;172:1960 – 1969. 12. Worth A, Thrasher AJ, Gaspar HB. Autoimmune lymphoproliferative syndrome: molecular basis of disease and clinical phenotype. Br J Haematol 2006;133:124 – 140. 13. Horiuchi T, Hirokawa M, Satoh K, Kitabayashi A, Muira AB. Clonal expansion of gd T lymphocytes in an HTLV-I carrier, associated with chronic neutropenia and rheumatoid arthritis. Ann Hematol 1999;78:101 – 104.