T-cell large granular lymphocyte leukemia: Difference between revisions

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{{Infobox_Disease
{{SI}}                                                                 
  | Name          = {{PAGENAME}}
{{CMG}} {{AE}} {{RT}} {{MV}}
  | Image          =  
   
| Caption        =  
{{SK}} LGL leukemia; Tγ-lymphoproliferative disorder; T-cell chronic lymphocytic leukemia; proliferation of large granular lymphocytes (LGLs)
| DiseasesDB    =  
   
| ICD10          =  
==Overview==
| ICD9          =  
 
| ICDO          = 9831/3
T-cell large granular lymphocyte leukemia (also known as T-GLL) is a rare type of [[leukemia]] that exhibits an unexplained, [[Chronic (medical)|chronic]] (> 6 months) elevation in large [[Granule (cell biology)|granular]] [[lymphocytes]] (LGLs) in the [[peripheral blood]]. T-cell large granular lymphocyte leukemia was first discovered by McKenna, in 1977. T-cell large granular lymphocyte leukemia may be [[Classification|classified]] into 2 groups: T-cell large granular lymphocyte leukemia (T-LGL) and [[Natural Killer T cell|natural-killer (NK)]] granular lymphocyte leukemia (NK-LGL). The [[pathogenesis]] of T-cell large granular lymphocyte leukemia is characterized by the involvement of [[Cytotoxic T cell|cytotoxic T cells]]. The postulated [[Cell (biology)|cells]] of origin of T-LGL leukemia are transformed [[CD8+ T cells|CD8+]] [[T cell|T-cells]] with clonal rearrangements of β chain [[T cell receptor|T-cell receptor]] [[Gene|genes]] for the majority of cases and a CD8- [[T cell|T-cell]] with clonal rearrangements of γ chain [[T-cell receptor]] [[Gene|genes]] for a minority of cases. The [[Molecule|molecular]] [[pathogenesis]] of T-cell large granular lymphocyte leukemia is characterized by the disregulation of [[Signal transduction|signaling pathways]], such as: FAS/FAS-L, phosphatidylinositol-3 kinase (PI3K), and mitogen-activated proteinkinase/extracellular signal-regulated kinase (MAPK/ERK). [[Patient|Patients]] of all age groups may develop T-cell large granular lymphocyte leukemia. T-cell large granular lymphocyte leukemia is more commonly observed among middle aged [[Adult|adults]]. [[Laboratory]] findings consistent with the [[diagnosis]] of T-cell large granular lymphocyte leukemia include [[neutropenia]], [[anemia]], [[hypergammaglobulinemia]], and [[lymphocytosis]] (most common). The [[diagnosis]] of T-cell large granular lymphocyte leukemia is made when the following diagnostic criteria is met: clonal rearrangements of the [[T-cell receptor|T-cell receptor (TCR)]] [[gene]], [[chronic]] (> 6 months) elevation in large granular lymphocytes (LGLs) in the [[peripheral blood]], large granular [[lymphocyte]] count greater than 2.0 × 109/L, and [[lymphocytosis]] (typically 2-20x109/L). The mainstay of [[therapy]] for T-cell large granular lymphocyte leukemia is [[Chemotherapy|targeted-chemotherapy]]. Initial [[therapy]] for [[Patient|patients]] with T-cell large granular lymphocyte leukemia includes [[Corticosteroid|corticosteroids]] and [[methotrexate]]. [[Alemtuzumab]] and [[tipifarnib]] are the treatment of choice for [[Patient|patients]] with [[refractory]] T-cell large granular lymphocytic leukemia.
| OMIM          =  
 
| MedlinePlus    =
==Historical Perspective==
| eMedicineSubj  =  
*T-cell large granular lymphocyte leukemia was first discovered by McKenna, in 1977.<ref name="pmid22830400">{{cite journal |vauthors=Leblanc F, Zhang D, Liu X, Loughran TP |title=Large granular lymphocyte leukemia: from dysregulated pathways to therapeutic targets |journal=Future Oncol |volume=8 |issue=7 |pages=787–801 |year=2012 |pmid=22830400 |pmc=3464048 |doi=10.2217/fon.12.75 |url=}}</ref>
| eMedicineTopic =
==Classification==
| MeshID        = D054066
T-cell large granular lymphocyte leukemia may be [[Classification|classified]] into 2 groups:<ref name="lam1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12876667&query_hl=10&itool=pubmed_ExternalLink]
}}
Lamy T, Loughran TP Jr. "Clinical features of large granular lymphocyte leukemia." '''Semin Hematol'''. 2003 Jul;40(3):185-95. PMID: 12876667</ref>
{{SI}}
* T-cell large granular lymphocyte leukemia (T-LGL)
{{CMG}}; {{AE}} {{RT}}
* [[Natural-killer]] (NK) granular lymphocyte leukemia (NK-LGL)
 
==Pathophysiology==
*The [[pathogenesis]] of T-cell large granular lymphocyte leukemia is characterized by the involvement of [[Cytotoxic T cell|cytotoxic T cells]].
*The postulated [[Cell (biology)|cells]] of origin of T-LGL leukemia are transformed [[Cytotoxic T cell|CD8+ T-cell]] with clonal rearrangements of β chain [[T-cell receptor]] [[Gene|genes]] for the majority of cases and a CD8- [[T cell|T-cell]] with clonal rearrangements of γ chain [[T-cell receptor]] [[Gene|genes]] for a minority of cases.<ref name="lam1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12876667&query_hl=10&itool=pubmed_ExternalLink]
Lamy T, Loughran TP Jr. "Clinical features of large granular lymphocyte leukemia." '''Semin Hematol'''. 2003 Jul;40(3):185-95. PMID: 12876667</ref>
*The [[leukemia]] [[Cell (biology)|cells]] of T-cell large granular lymphocyte leukemia can be found in [[peripheral blood]], [[bone marrow]], [[spleen]], and [[liver]]. [[Lymph node|Nodal]] involvement is rare.
*The [[Molecule|molecular]] [[pathogenesis]] of T-cell large granular lymphocyte leukemia is characterized by the disregulation of [[Signal transduction|signaling pathways]], such as:
:*FAS/FAS-L
:*[[Phosphoinositide 3-kinase|Phosphatidylinositol-3 kinase (PI3K)]],
:*[[Mitogen-activated protein kinase]]/[[Extracellular signal-regulated kinases|extracellular signal-regulated kinase]] ([[Mitogen-activated protein kinase|MAPK]]/[[Extracellular signal-regulated kinases|ERK]])
*The increased expression of [[STAT3]] has been associated with the development of T-cell large granular lymphocyte leukemia, involving the [[janus kinase]] family pathway.


{{SK}}  LGL leukemia; Tγ-lymphoproliferative disorder; T-cell chronic lymphocytic leukemia; Proliferation of large granular lymphocytes (LGLs)
*On [[microscopic]] [[Histopathology|histopathological]] [[analysis]], characteristic findings of T-cell large granular lymphocyte leukemia include:
:*[[Cancer|Neoplastic]] [[Lymphocyte|lymphocytes]] (large in size)  
:*Presence of [[azurophilic granules]] (contains [[Protein|proteins]] involved in [[Lysis|cell lysis]] such as [[perforin]] and [[granzyme B]])
:*[[Bone marrow]] involvement in this [[disease]] is often present, but to a variable extent
:*The [[Lymphocyte|lymphocytic]] infiltrate is usually [[interstitial]], but a [[nodular]] pattern rarely occurs
*On [[immunohistochemistry]], characteristic findings of T-cell large granular lymphocyte leukemia include:
:*Positive [[perforin]]
:*Positive [[TIA-1]]
:*Positive [[granzyme B]]


==Overview==
==Causes==
'''T-cell large granular lymphocyte leukemia''' is a disease that exhibits a unexplained, chronic (> 6 months) elevation in large granular [[lymphocytes]] (LGLs) in the peripheral [[blood]].<ref name="who1"> [http://www.iarc.fr/WHO-BlueBooks/BBwebsite/bb3.html] Jaffe E.S., Harris N.L., Stein H., Vardiman J.W. (eds): '''World Health Organization Classification of Tumors. Pathology and Genetics of Tumours of Haemopoietic and Lymphoid Tissues.''' IARC Press: Lyon 2001 </ref>
Common causes of T-cell large granular lymphocyte leukemia include:<ref name="pmid22830400">{{cite journal |vauthors=Leblanc F, Zhang D, Liu X, Loughran TP |title=Large granular lymphocyte leukemia: from dysregulated pathways to therapeutic targets |journal=Future Oncol |volume=8 |issue=7 |pages=787–801 |year=2012 |pmid=22830400 |pmc=3464048 |doi=10.2217/fon.12.75 |url=}}</ref>
* [[Autoimmune disorders]] such as:
** [[Systemic lupus erythematosus|Systemic lupus erythematosus (SLE or lupus)]]
** [[Hashimoto's Thyroiditis|Hashimoto’s thyroiditis]]
** [[Sjogren’s syndrome]]


==Pathology==
==Differentiating T-cell Large Granular Lymphocyte Leukemia from Other Diseases==
The postulated cells of origin are a transformed CD8+ [[T-cell]] with clonal rearrangements of β chain [[T-cell receptor]] [[gene]]s for the majority of cases and a CD8- [[T-cell]] with clonal rearrangements of γ chain [[T-cell receptor]] genes for a minority of cases.<ref name="who1"/>
*T-cell large granular lymphocyte leukemia must be differentiated from other [[Disease|diseases]] that cause recurrent [[Infection|infections]], [[fatigue]], and night [[fever]], such as:
:*Precursor T lymphoblastic leukemia/[[lymphoma]]
:*[[Mycosis fungoides]]
:*[[HIV AIDS]]
:*[[Burkitt's lymphoma|Burkitt lymphoma]]


===Genetics===
==Epidemiology and Demographics==
Clonal rearrangements of the [[T-cell receptor]] (TCR) genes are a necessary condition for the diagnosis of this disease. The gene for the β chain of the TCR is found to be rearranged more often than the γ chain. of the TCR.<ref name="vie1">
*  T-cell large granular lymphocyte leukemia is a rare form of [[leukemia]], comprising 2 - 3% of all cases of [[Chronic (medical)|chronic]] [[lymphoproliferative disorders]].
[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=2546620&query_hl=30&itool=pubmed_ExternalLink]
Vie H, Chevalier S, Garand R, Moisan JP, Praloran V, Devilder MC, Moreau JF, Soulillou JP.
===Age===
"Clonal expansion of lymphocytes bearing the gamma delta T-cell receptor in a patient with large granular lymphocyte disorder." '''Blood'''. 1989 Jul;74(1):285-90. PMID: 2546620</ref>
*[[Patients]] of all age groups may develop T-cell large granular lymphocyte leukemia.
*T-cell large granular lymphocyte leukemia is more commonly observed among middle aged [[Adult|adults]].<ref name="cha1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3490288&query_hl=6&itool=pubmed_ExternalLink]
Chan WC, Link S, Mawle A, Check I, Brynes RK, Winton EF. "Heterogeneity of large granular lymphocyte proliferations: delineation of two major subtypes." '''Blood'''. 1986 Nov;68(5):1142-53. PMID: 3490288</ref>


===Gross Pathology===
===Gender===
The leukemic cells of T-LGL can be found in peripheral [[blood]], [[bone marrow]], [[spleen]], and [[liver]]. Nodal involvement is rare.<ref name="who1"/><ref name="lam2"/>
*T-cell large granular lymphocyte leukemia affects [[Male|men]] and [[Female|women]] equally.


===Microscopic Pathology===
===Race===
====Peripheral blood====
*There is no racial predilection for T-cell large granular lymphocyte leukemia.
The neoplastic lymphocytes seen in this disease are large in size with azurophilic granules that contains proteins involved in cell lysis such as [[perforin]] and [[granzyme B]].<ref name="sem1">
[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=8978299&query_hl=28&itool=pubmed_ExternalLink]
Semenzato G, Zambello R, Starkebaum G, Oshimi K, Loughran TP Jr. "The lymphoproliferative disease of granular lymphocytes: updated criteria for diagnosis." '''Blood'''. 1997 Jan 1;89(1):256-60. PMID: 8978299</ref>


====Bone marrow====
==Risk Factors==
[[Bone marrow]] involvement in this disease is often present, but to a variable extent. The lymphocytic infiltrate is usually [[interstitial]], but a [[nodular]] pattern rarely occurs.<ref name="who1"/>
*The most common [[risk factor]] in the development of T-cell large granular lymphocyte leukemia is exposure to [[Radiation therapy|radiation]].<ref name="cha1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3490288&query_hl=6&itool=pubmed_ExternalLink]
Chan WC, Link S, Mawle A, Check I, Brynes RK, Winton EF. "Heterogeneity of large granular lymphocyte proliferations: delineation of two major subtypes." '''Blood'''. 1986 Nov;68(5):1142-53. PMID: 3490288</ref>


==Epidemiology and Demographics==
== Natural History, Complications and Prognosis==
T-LGL is a rare form of [[leukemia]], comprising 2-3% of all cases of small lymphocytic leukemias.<ref name="who1"/>
*The majority of [[Patient|patients]] with T-cell large granular lymphocyte leukemia may be initially [[asymptomatic]].
*Early clinical features include [[fever]], [[Sleep hyperhidrosis|night sweats]], and [[weight loss]].
*If left untreated, [[Patient|patients]] with T-cell large granular lymphocyte leukemia may progress to develop [[Infection|infections]].
*Common [[complications]] of T-cell large granular lymphocyte leukemia include:<ref name="cha1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3490288&query_hl=6&itool=pubmed_ExternalLink]
Chan WC, Link S, Mawle A, Check I, Brynes RK, Winton EF. "Heterogeneity of large granular lymphocyte proliferations: delineation of two major subtypes." '''Blood'''. 1986 Nov;68(5):1142-53. PMID: 3490288</ref>
:*[[Bone marrow suppression|Bone marrow failure]] [[Disorder (medicine)|disorders]]
:*[[Myelodysplastic syndrome]]
:*[[Aplastic anemia]]
:*[[Paroxysmal nocturnal hemoglobinuria]]
*[[Prognosis]] is generally good, and the 5 year survival rate of [[patients]] with T-cell large granular lymphocyte leukemia is approximately 89%.<ref name="lam1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12876667&query_hl=10&itool=pubmed_ExternalLink]
Lamy T, Loughran TP Jr. "Clinical features of large granular lymphocyte leukemia." '''Semin Hematol'''. 2003 Jul;40(3):185-95. PMID: 12876667</ref>
 
== Diagnosis ==
===Diagnostic Study of Choice===
The [[diagnosis]] of T-cell large granular lymphocyte leukemia is made when the following diagnostic criteria is met:<ref name="cha1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3490288&query_hl=6&itool=pubmed_ExternalLink]
Chan WC, Link S, Mawle A, Check I, Brynes RK, Winton EF. "Heterogeneity of large granular lymphocyte proliferations: delineation of two major subtypes." '''Blood'''. 1986 Nov;68(5):1142-53. PMID: 3490288</ref>
* Clonal rearrangements of the [[T-cell receptor|T-cell receptor (TCR)]] [[gene]]
* [[Chronic (medical)|Chronic]] (> 6 months) elevation in large granular lymphocytes (LGLs) in the [[peripheral blood]]
* Large [[Granule (cell biology)|granular]] [[lymphocyte]] count greater than 2.0 × 109/L
* [[Lymphocytosis]] (typically 2-20x109/L)


==Natural History, Complications ans Prognosis==
=== Symptoms ===
* This disease is known for an indolent clinical course and incidental discovery.<ref name="who1"/>
*T-cell large granular lymphocyte leukemia may be initially [[asymptomatic]].
* The 5 year survival has been noted as 89% in at least one study from France of 201 patients with T-LGL leukemia.<ref>{{cite journal|pmc=2930955|title=Analysis of a French cohort of patients with large granular lymphocyte leukemia: A report on 229 cases|year=2010|volume=95|issue=9|pmid=20378561|last1=Bareau|first1=B|last2=Rey|first2=J|last3=Hamidou|first3=M|last4=Donadieu|first4=J|last5=Morcet|first5=J|last6=Reman|first6=O|last7=Schleinitz|first7=N|last8=Tournilhac|first8=O|last9=Roussel|first9=M|pages=1534–41|doi=10.3324/haematol.2009.018481|journal=Haematologica}}</ref>
*[[Symptom|Symptoms]] of T-cell large granular lymphocyte leukemia may include the following:<ref name="cha1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3490288&query_hl=6&itool=pubmed_ExternalLink]
Chan WC, Link S, Mawle A, Check I, Brynes RK, Winton EF. "Heterogeneity of large granular lymphocyte proliferations: delineation of two major subtypes." '''Blood'''. 1986 Nov;68(5):1142-53. PMID: 3490288</ref>
** Generalized weakness and [[Fatigue (physical)|fatigue]]
** [[Anorexia]]
**[[Arthralgia|Joint pain]]
** [[Sleep hyperhidrosis|Night sweats]]
** [[Epistaxis]]
** [[Bone pain]]
** [[Dyspnea|Difficulty breathing]]


==Diagnosis==
=== Physical Examination ===
===Symptoms===
*[[Patient|Patients]] with T-cell large granular lymphocyte leukemia usually appear [[Pallor|pale]] and [[Malnutrition|malnourished]].
* [[B symptoms]] are seen in a third of cases - [[fever]], [[night sweat]]s, and [[weight loss]]
*[[Physical examination]] may be remarkable for:<ref name="lam2">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10761014&query_hl=22&itool=pubmed_ExternalLink]
* Symptoms of [[anemia]] - [[shortness of breath]], [[fatigue]], [[palpitations]]
* Abdominal discomfort
* Recurrent [[infections]] due to the associated neutropenia are seen in almost half of cases.<ref name="lam2">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10761014&query_hl=22&itool=pubmed_ExternalLink]
Lamy T, Loughran TP. "Large Granular Lymphocyte Leukemia." '''Cancer Control'''. 1998 Jan;5(1):25-33. PMID: 10761014</ref><ref name="cha1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3490288&query_hl=6&itool=pubmed_ExternalLink]
Lamy T, Loughran TP. "Large Granular Lymphocyte Leukemia." '''Cancer Control'''. 1998 Jan;5(1):25-33. PMID: 10761014</ref><ref name="cha1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3490288&query_hl=6&itool=pubmed_ExternalLink]
Chan WC, Link S, Mawle A, Check I, Brynes RK, Winton EF. "Heterogeneity of large granular lymphocyte proliferations: delineation of two major subtypes." '''Blood'''. 1986 Nov;68(5):1142-53. PMID: 3490288</ref><ref name="pan1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=2403836&query_hl=8&itool=pubmed_ExternalLink]
Chan WC, Link S, Mawle A, Check I, Brynes RK, Winton EF. "Heterogeneity of large granular lymphocyte proliferations: delineation of two major subtypes." '''Blood'''. 1986 Nov;68(5):1142-53. PMID: 3490288</ref><ref name="pan1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=2403836&query_hl=8&itool=pubmed_ExternalLink]
Pandolfi F, Loughran TP Jr, Starkebaum G, Chisesi T, Barbui T, Chan WC, Brouet JC, De Rossi G, McKenna RW, Salsano F, ''et al.'' "Clinical course and prognosis of the lymphoproliferative disease of granular lymphocytes. A multicenter study." '''Cancer'''. 1990 Jan 15;65(2):341-8. PMID: 2403836</ref><ref name="lam1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12876667&query_hl=10&itool=pubmed_ExternalLink]
Pandolfi F, Loughran TP Jr, Starkebaum G, Chisesi T, Barbui T, Chan WC, Brouet JC, De Rossi G, McKenna RW, Salsano F, ''et al.'' "Clinical course and prognosis of the lymphoproliferative disease of granular lymphocytes. A multicenter study." '''Cancer'''. 1990 Jan 15;65(2):341-8. PMID: 2403836</ref><ref name="lam1">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12876667&query_hl=10&itool=pubmed_ExternalLink]
Lamy T, Loughran TP Jr. "Clinical features of large granular lymphocyte leukemia." '''Semin Hematol'''. 2003 Jul;40(3):185-95. PMID: 12876667</ref>
Lamy T, Loughran TP Jr. "Clinical features of large granular lymphocyte leukemia." '''Semin Hematol'''. 2003 Jul;40(3):185-95. PMID: 12876667</ref>
* Joint pains - [[rheumatoid arthritis]] is commonly observed in patients with T-LGL, leading to a clinical picture similar to [[Felty's syndrome]].
:*[[Heart murmur|Cardiac flow murmur]]
:*High-grade [[fever]]
:*[[Hepatomegaly]]
:*[[Splenomegaly]]


===Physical Examination===
=== Laboratory Findings ===
====Skin====
[[Medical laboratory|Laboratory]] findings consistent with the [[diagnosis]] of T-cell large granular lymphocyte leukemia include:
* [[Pallor]]
*[[Neutropenia]]
*[[Anemia]]
*[[Hypergammaglobulinemia]]
*[[Lymphocytosis]] (most common)
===Imaging Findings===
*There are no specific [[imaging]] findings associated with T-cell large granular lymphocyte leukemia.


====Abdomen====
=== Other Diagnostic Studies ===
* [[Splenomegaly]]
*T-cell large granular lymphocyte leukemia may also be [[Diagnosis|diagnosed]] using the following studies:
 
'''Immunophenotyping'''
===Laboratory Findings===
*The following table demonstrates common [[Immunophenotyping|immunophenotype]] findings.
* Complete blood count and differential count - [[neutropenia]]
*The [[Cancer|neoplastic]] [[Cell (biology)|cells]] of this [[disease]] display a mature [[T-cell]] [[immunophenotype]], with the majority of cases showing a [[CD4]]-/[[CD8]]+ [[T cell|T-cell]] subset [[immunophenotype]] versus other permutations of those markers. Variable expression of [[CD11b]], [[CD56]], and [[CD57]] are observed.
* The requisite [[lymphocytosis]] of this disease is typically 2-20x10<sup>9</sup>/L.
* Immunoglobulin derangements including hypergammaglobulinemia, autoantibodies, and circulating immune complexes are commonly seen.<ref name="lam1"/><ref name="osh1">{{cite journal |author=Oshimi K, Yamada O, Kaneko T, ''et al.'' |title=Laboratory findings and clinical courses of 33 patients with granular lymphocyte-proliferative disorders |journal=Leukemia |volume=7 |issue=6 |pages=782–8 |year=1993 |month=June |pmid=8388971 |doi= |url=}}</ref><ref name="lou1">{{cite journal |author=Loughran TP, Starkebaum G, Aprile JA |title=Rearrangement and expression of T-cell receptor genes in large granular lymphocyte leukemia |journal=Blood |volume=71 |issue=3 |pages=822–4 |year=1988 |month=March |pmid=3345349 |doi= |url=http://www.bloodjournal.org/cgi/pmidlookup?view=long&pmid=3345349}}</ref><ref name="lou2">{{cite journal |author=Loughran TP, Kadin ME, Starkebaum G, ''et al.'' |title=Leukemia of large granular lymphocytes: association with clonal chromosomal abnormalities and autoimmune neutropenia, thrombocytopenia, and hemolytic anemia |journal=Ann. Intern. Med. |volume=102 |issue=2 |pages=169–75 |year=1985 |month=February |pmid=3966754 |doi= |url=}}</ref>
 
====Immunophenotype====
The neoplastic cells of this disease display a mature [[T-cell]] [[immunophenotype]], with the majority of cases showing a [[CD4]]-/[[CD8]]+ T-cell subset [[immunophenotype]] versus other permutations of those markers.<ref name="cha1"/><ref name="pan1"/> Variable expression of [[CD11b]], [[CD56]], and [[CD57]]<ref name="lam1"/> are observed. Immunohistochemisty for [[perforin]], [[TIA-1]], and [[granzyme B]] are usually positive.<ref name="who1"/> 


{| border="1" cellpadding="5" cellspacing="0"
{| border="1" cellpadding="5" cellspacing="0"
Line 81: Line 135:
! Type || Immunophenotype
! Type || Immunophenotype
|-
|-
| rowspan="1"| Common type (80% of cases)
| rowspan="1" | Common type (80% of cases)
| colspan="1" align="center"| [[CD3]]+, [[TCR]]αβ+, [[CD4]]-, [[CD8]]+
| colspan="1" align="center" | [[CD3]]+, [[TCR]]αβ+, [[CD4]]-, [[CD8]]+
|-
|-
| rowspan="3" align="center" | Rare variants  
| rowspan="3" align="center" | Rare variants  
Line 92: Line 146:
|}
|}


==Treatment==
'''Peripheral blood smear'''
[[Alemtuzumab]] has been investigated for use in treatment of refractory T-cell large granular lymphocytic leukemia.<ref name="pmid14976065">{{cite journal |author=Rosenblum MD, LaBelle JL, Chang CC, Margolis DA, Schauer DW, Vesole DH |title=Efficacy of alemtuzumab treatment for refractory T-cell large granular lymphocytic leukemia |journal=Blood |volume=103 |issue=5 |pages=1969–71 |year=2004 |month=March |pmid=14976065 |doi=10.1182/blood-2003-11-3951 |url=http://www.bloodjournal.org/cgi/pmidlookup?view=long&pmid=14976065}}</ref>
*Large [[Cancer|neoplastic]] [[Lymphocyte|lymphocytes]]
*[[Azurophil|Azurophilic]] [[Granule (cell biology)|granules]]
 
== Treatment ==
=== Medical Therapy ===
*The mainstay of [[therapy]] for T-cell large granular lymphocyte leukemia is [[Chemotherapy|targeted-chemotherapy]].  
*Initial [[therapy]] for [[Patient|patients]] with T-cell large granular lymphocyte leukemia may include:
:*[[Corticosteroid|Corticosteroids]]
:*[[Methotrexate]]
*[[Alemtuzumab]] and [[tipifarnib]] are the treatment of choice for [[Patient|patients]] with [[refractory]] T-cell large granular lymphocytic leukemia.
 
=== Prevention ===
*There are no [[Prevention (medical)|primary preventive measures]] available for T-cell large granular lymphocyte leukemia.
*Once [[Diagnosis|diagnosed]] and successfully treated, [[Patient|patients]] with T-cell large granular lymphocyte leukemia are followed-up every 3, 6 or 12 months.
*Follow-up [[Test|testing]] includes [[complete blood count]], [[physical examination]], and [[Blood film|peripheral blood smear]].


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [5] Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [6] Maria Fernanda Villarreal, M.D. [7]

Synonyms and keywords: LGL leukemia; Tγ-lymphoproliferative disorder; T-cell chronic lymphocytic leukemia; proliferation of large granular lymphocytes (LGLs)

Overview

T-cell large granular lymphocyte leukemia (also known as T-GLL) is a rare type of leukemia that exhibits an unexplained, chronic (> 6 months) elevation in large granular lymphocytes (LGLs) in the peripheral blood. T-cell large granular lymphocyte leukemia was first discovered by McKenna, in 1977. T-cell large granular lymphocyte leukemia may be classified into 2 groups: T-cell large granular lymphocyte leukemia (T-LGL) and natural-killer (NK) granular lymphocyte leukemia (NK-LGL). The pathogenesis of T-cell large granular lymphocyte leukemia is characterized by the involvement of cytotoxic T cells. The postulated cells of origin of T-LGL leukemia are transformed CD8+ T-cells with clonal rearrangements of β chain T-cell receptor genes for the majority of cases and a CD8- T-cell with clonal rearrangements of γ chain T-cell receptor genes for a minority of cases. The molecular pathogenesis of T-cell large granular lymphocyte leukemia is characterized by the disregulation of signaling pathways, such as: FAS/FAS-L, phosphatidylinositol-3 kinase (PI3K), and mitogen-activated proteinkinase/extracellular signal-regulated kinase (MAPK/ERK). Patients of all age groups may develop T-cell large granular lymphocyte leukemia. T-cell large granular lymphocyte leukemia is more commonly observed among middle aged adults. Laboratory findings consistent with the diagnosis of T-cell large granular lymphocyte leukemia include neutropenia, anemia, hypergammaglobulinemia, and lymphocytosis (most common). The diagnosis of T-cell large granular lymphocyte leukemia is made when the following diagnostic criteria is met: clonal rearrangements of the T-cell receptor (TCR) gene, chronic (> 6 months) elevation in large granular lymphocytes (LGLs) in the peripheral blood, large granular lymphocyte count greater than 2.0 × 109/L, and lymphocytosis (typically 2-20x109/L). The mainstay of therapy for T-cell large granular lymphocyte leukemia is targeted-chemotherapy. Initial therapy for patients with T-cell large granular lymphocyte leukemia includes corticosteroids and methotrexate. Alemtuzumab and tipifarnib are the treatment of choice for patients with refractory T-cell large granular lymphocytic leukemia.

Historical Perspective

  • T-cell large granular lymphocyte leukemia was first discovered by McKenna, in 1977.[1]

Classification

T-cell large granular lymphocyte leukemia may be classified into 2 groups:[2]

  • T-cell large granular lymphocyte leukemia (T-LGL)
  • Natural-killer (NK) granular lymphocyte leukemia (NK-LGL)

Pathophysiology

  • The increased expression of STAT3 has been associated with the development of T-cell large granular lymphocyte leukemia, involving the janus kinase family pathway.
  • On immunohistochemistry, characteristic findings of T-cell large granular lymphocyte leukemia include:

Causes

Common causes of T-cell large granular lymphocyte leukemia include:[1]

Differentiating T-cell Large Granular Lymphocyte Leukemia from Other Diseases

  • T-cell large granular lymphocyte leukemia must be differentiated from other diseases that cause recurrent infections, fatigue, and night fever, such as:

Epidemiology and Demographics

Age

  • Patients of all age groups may develop T-cell large granular lymphocyte leukemia.
  • T-cell large granular lymphocyte leukemia is more commonly observed among middle aged adults.[3]

Gender

  • T-cell large granular lymphocyte leukemia affects men and women equally.

Race

  • There is no racial predilection for T-cell large granular lymphocyte leukemia.

Risk Factors

  • The most common risk factor in the development of T-cell large granular lymphocyte leukemia is exposure to radiation.[3]

Natural History, Complications and Prognosis

  • Prognosis is generally good, and the 5 year survival rate of patients with T-cell large granular lymphocyte leukemia is approximately 89%.[2]

Diagnosis

Diagnostic Study of Choice

The diagnosis of T-cell large granular lymphocyte leukemia is made when the following diagnostic criteria is met:[3]

Symptoms

Physical Examination

Laboratory Findings

Laboratory findings consistent with the diagnosis of T-cell large granular lymphocyte leukemia include:

Imaging Findings

  • There are no specific imaging findings associated with T-cell large granular lymphocyte leukemia.

Other Diagnostic Studies

  • T-cell large granular lymphocyte leukemia may also be diagnosed using the following studies:

Immunophenotyping

Type Immunophenotype
Common type (80% of cases) CD3+, TCRαβ+, CD4-, CD8+
Rare variants CD3+, TCRαβ+, CD4+, CD8-
CD3+, TCRαβ+, CD4+, CD8+
CD3+, TCRγδ+, CD4 and CD8 variable

Peripheral blood smear

Treatment

Medical Therapy

Prevention

References

  1. 1.0 1.1 Leblanc F, Zhang D, Liu X, Loughran TP (2012). "Large granular lymphocyte leukemia: from dysregulated pathways to therapeutic targets". Future Oncol. 8 (7): 787–801. doi:10.2217/fon.12.75. PMC 3464048. PMID 22830400.
  2. 2.0 2.1 2.2 2.3 [1] Lamy T, Loughran TP Jr. "Clinical features of large granular lymphocyte leukemia." Semin Hematol. 2003 Jul;40(3):185-95. PMID: 12876667
  3. 3.0 3.1 3.2 3.3 3.4 3.5 [2] Chan WC, Link S, Mawle A, Check I, Brynes RK, Winton EF. "Heterogeneity of large granular lymphocyte proliferations: delineation of two major subtypes." Blood. 1986 Nov;68(5):1142-53. PMID: 3490288
  4. [3] Lamy T, Loughran TP. "Large Granular Lymphocyte Leukemia." Cancer Control. 1998 Jan;5(1):25-33. PMID: 10761014
  5. [4] Pandolfi F, Loughran TP Jr, Starkebaum G, Chisesi T, Barbui T, Chan WC, Brouet JC, De Rossi G, McKenna RW, Salsano F, et al. "Clinical course and prognosis of the lymphoproliferative disease of granular lymphocytes. A multicenter study." Cancer. 1990 Jan 15;65(2):341-8. PMID: 2403836

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