Updated: 7/18/2017

Hairy Cell Leukemia (HCL)

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Snapshot
  • A 50-year-old man presents to his primary care physician for an annual visit. He has no complaints. His past medical history includes hypertension, hypercholesterolemia, and rheumatoid arthritis. He goes for routine blood tests today, which reveals marked pancytopenia. A peripheral blood smear is done, showing cells with hair-like projections.
Introduction
  • Indolent leukemia of mature B-cells with infiltration of bone marrow and spleen
  • Epidemiology
    • median onset 50-55 years of age
    • male > female 4.5x
  • Associated conditions
    • autoimmune conditions
  • Characteristics
    • “hairy cells” with filamentous, hair-like projections
    • tartrate-resistant acid phosphatase (TRAP) + 
  • Prognosis
    • good prognosis, especially with good response to purine analogs
Presentation
  • Symptoms
    • pancytopenia from infiltration of bone marrow
      • fatigue
      • infections
      • bleeding
      • anemia
  • Physical exam
    • splenomegaly from infiltration of spleen
    • no lymphadenopathy
Evaluation
  • Peripheral blood smear
    • B-cells with hairy projections
    • + TRAP stain (tartrate-resistant acid phosphatase)
  • Flow cytometry
    • CD11c+ and CD2+
    • CD5- and CD10-
  • Bone marrow aspirate
    • dry tap due to marrow fibrosis
  • CBC
    • anemia
    • thrombocytopenia
    • leukopenia
Differential Diagnosis
  • Non-Hodgkin lymphoma
  • Mantle cell lymphoma
Treatment
  • Purine analogs
    • first line: cladribine (2-CDA)
    • pentostatin
    • both inhibit adenosine deaminase
    • recall this is the same enzyme deficiency seen in SCID leading to B-cell dysfunction
Complications
  • Complications
    • infections
    • increased risk of malignancy

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Questions (2)
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(M1.ON.14.23) A 66-year old man presents to your clinic with a complaint of abdominal fullness and six months of worsening fatigue, weakness, and easy bruising. On physical exam, vital signs are stable, but you note marked splenomegaly and scattered ecchymoses. Labs are noteworthy for a hematocrit of 25%, total white blood cell count of 3000/uL, and platelet count of 35,000/uL. A peripheral blood smear is shown in Figure A; a tartrate-resistant acid phosphatase (TRAP) assay comes back positive. On further diagnostic workup, a bone marrow aspirate does not yield a sample due to extensive fibrosis. Which of the following is the first-line agent for the treatment of this condition?

QID: 104663
FIGURES:
1

Vincristine

11%

(16/142)

2

Rituximab

14%

(20/142)

3

Cyclophosphamide

15%

(22/142)

4

Cladribine

50%

(71/142)

5

Methotrexate

7%

(10/142)

M 2 E

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