Immunophenotypic Analysis of CD103+ Lymphomas

7/30/2019 Immunophenotypic Analysis of CD103+ Lymphomas

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586 Am J Clin Pathol 2009;131:586-595586 DOI: 10.1309/AJCPL13YDUHFKPJU

American Society for Clinical Pathology

Hematopathology / CD103+ B-LymphoproLiferative DisorDers

Immunophenotypic Analysis of CD103+B-Lymphoproliferative Disorders

Hairy Cell Leukemia and Its Mimics

Henry Y. Dong, MD, PhD, James Weisberger, MD,* Zach Liu, MD,* and Sorina Tugulea, MD

Key Words: Hairy cell leukemia; CD103; CD25; CD10; BCL1; Annexin-A1; Flow cytometry

DOI: 10.1309/AJCPL13YDUHFKPJU

A b s t r a c t

CD103 is characteristically expressed in hairycell leukemia (HCL), a B-lymphoproliferative disorderhighly responsive to treatment with purine analogs.Other CD103+ diseases are rare and do not respondwell to the same therapy, including HCL variant(HCLv) and splenic marginal zone B-cell lymphoma(SMZL) variants. We analyzed 215 cases of CD103+B-lymphoproliferative disorders to further delineate

their immunophenotypic features. Flow cytometricanalysis revealed that 78.6% of all cases expressedCD25 and CD103, characteristic of classical HCL.Cases analyzed immunohistochemically werealso invariably positive for annexin-A1; a subsetcoexpressed CD10 (33/169 [19.5%]) or BCL1 (26/65[36.9%]). In contrast, 21.4% of cases lacked CD25,a subset of which was analyzed and was invariablynegative for annexin-A1, CD10, and BCL1. The CD25cases had variable morphologic features ranging fromHCLv and SMZL to prolymphocytic leukemia and

diffuse large B-cell lymphoma. Clinically, patients withCD25 disease tended to be older (P = .001), typicallyhad leukocytosis (P = .014), and did not respond wellto cladribine or pentostatin. We suggest categorizingCD103+ B-lymphoproliferative disorders into 2groups. While HCL coexpresses CD25 and annexin-A1,diseases lacking CD25 and annexin-A1 behaveclinically differently and can be separated fromHCL ondiagnosis.

CD103 is a cell surface glycoprotein of the integrin -7

family,1 initially discovered by raising a monoclonal anti-

body (B-ly7) directly against hairy cell leukemia (HCL).2

Since its discovery, CD103 has been widely used for the

diagnosis of HCL. Despite rare exceptions in the recent

literature,3 CD103 has been detected, together with CD25,4

in every case of HCL in virtually all previous large studies

using flow cytometry.5-7 In contrast, CD103 is not ordinar-

ily detected in other types of B-lymphoproliferative disor-

ders except for rare cases of splenic marginal zone B-celllymphoma (SMZL)8,9 and diffuse large B-cell lymphomas

(DLBCL).10 Only rare entities are known to be frequently

CD103+, namely HCL variant (HCLv)11,12 and splenic

red pulp lymphoma with villous lymphocytes (SRPL).13

Consequently, expression of CD103 has been considered

one of the most useful diagnostic criteria for HCL.

HCL is a rare, chronic B-lymphoproliferative disorder

characterized by distinctive clinical manifestations and

peculiar cytomorphologic features.14 In recent years, treat-

ment with the purine analogs cladribine and pentostatin has

achieved complete response rates of 79% to 95%, overallresponse rates of 96% to 100%, and 5-year disease-free sur-

vival rates of greater than 88%.15-17 Other rare diseases (eg,

HCLv) with frequent CD103 expression and hairy celllike

morphologic features do not respond well to purine ana-

logs.12Therefore, an accurate diagnostic assessment helps to

better stratify patients who will benefit from highly effective

therapy and to avoid unnecessary toxic effects, especially in

the light of a recent concern that patients with HCL might be

at an increased risk of secondary malignancies.18

HCL is traditionally diagnosed by distinct clinical fea-

tures in conjunction with hairy cell morphologic features.


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Am J Clin Pathol 2009;131:586-595 587587 DOI: 10.1309/AJCPL13YDUHFKPJU 587


Hematopathology / originaLartiCLe

Coexpression of CD25 and CD103 identified by flow cytom-

etry has been the most reliable finding at diagnosis.6 A

cytochemical stain for tartrate-resistant acid phosphatase19

may improve diagnostic accuracy. However, expression

of tartrate-resistant acid phosphatase based on immunohis-

tochemical detection seems to be much less specific and

has been found in various subtypes of B-cell lymphoma.20

Hounieu et al21 discovered that DBA.44 was a sensitive anti-

body for diagnosis of HCL by immunohistochemical analysis,

although it also lacks sufficient specificity.22 The variable

immunophenotypes described in the literature, particularly

the lack of CD25 or surface immunoglobulin, have resulted

in a few proposed variants of HCL.12,23-27 The detection of

antigens typical of other types of B-cell lymphoma, such

as BCL128,29 and CD106,7 in HCL, has made the diagnosis

more challenging. Recently, the immunohistochemical stain-

ing of annexin-A130 has been shown to reliably distinguish

HCL from all other B-cell lymphomas, including SMZL and

HCLv. However, annexin-A1 is also strongly expressed inmyeloid cells and, thus, cannot be easily applied for low-level

marrow involvement by HCL.

We have continuously observed that HCL and HCLv are

often used as interchangeable terms in practice because of

their coexpression of CD103. Our study is aimed at updating

the immunophenotype of all CD103+B-lymphoproliferative

disorders. To this end, we characterized 215 cases of

CD103+B-lymphoproliferative disorders by flow cytometry

and immunohistochemical analysis in an attempt to provide

further aid in diagnosis and subsequent patient care.

Materials and Methods

A total of 215 consecutive cases of CD103+

B-lymphoproliferative disorders in a 3-year period were

analyzed for their immunophenotypic profiles. In all cases,

a final diagnosis was established by immunophenotyping

in conjunction with the available clinical impression and

cytomorphologic and histologic findings. The specimens

consisted of bone marrow (69.3%), peripheral blood

(27.0%), spleen (1.9%), and lymph nodes (1.9%). Thepercentage of clonal B cells in the specimens ranged from

8% to 90% (median, 20%). The diagnosis in all cases with

fewer than 5% of leukemic cells by initial flow cytomet-

ric analysis, typically in peripheral blood specimens, was

further confirmed by subsequent evaluation of a bone mar-

row biopsy specimen, which always had more extensive

involvement.

We performed 4-color flow cytometry according to

standard procedures. The details of the antibody combina-

tions and the method for direct immunofluorescent staining

have been previously published.31Antibodies in the routine

lymphoma or leukemia panels (Beckman Coulter, Miami,

FL) included CD10, CD11c, CD19, CD20, CD22, CD23,

CD38, , (B-cell antigens), CD2, CD3, CD4, CD5,

CD7, CD8, and CD56 (T- and NK-cell antigens). Staining

for CD25 (clone M-A251, BD Biosciences Pharmingen,

San Jose, CA) and CD103 (clone B-ly7, IQ Product,

Groningen, the Netherlands) was performed as a part of

the routine panel for the lymphoma workup during the

first year of the study period but was later used only when

HCL was suspected. A minimum of 10,000 total events

was required for each analysis; 20,000 events were rou-

tinely acquired. Data were analyzed on the FACSCalibur

with CellQuest Pro software (BD Biosciences, San Jose,

CA). The expression levels of individual antigens were

categorized as strong (bright), moderate, and weak (dim)

based on the fluorescence intensity over isotype controls

of greater than 1.5 logs, between 1 and 1.5 logs, and below

1 log, respectively.

Immunohistochemical staining was performed byusing a labeled streptavidin-biotin (LSAB) procedure in a

TechMate 500 automatic immunostainer (Ventana Medical

Systems, Tucson, AZ) as described previously.31 Only a

subset of cases had biopsy tissue for immunohistochemical

study, and only immunohistochemical results for antigens

that were not analyzed by flow cytometry will be discussed.

These included BCL1 (clone DCS-6, NeoMarkers, Fremont,

CA), BCL-2 (clone 124, DAKO, Carpinteria, CA), CD43

(clone L60, DAKO), DBA.44 (DAKO), and annexin-A1

(clone 29, BD Transduction Laboratories, San Jose, CA).

Unequivocal nuclear staining was necessary for positiveBCL1 immunoreactivity. Staining of annexin-A1 (antibody

titer, 1:100) was performed in a subset of cases in parallel

with CD20 staining in each case.

Results

Immunophenotypic Analysis of CD103+

B-Lymphoproliferative Disorders Identified Two Major

Groups With Distinct FeaturesAll 215 cases displayed strong expression of CD11c,

CD20, and CD22, a hallmark phenotypic profile for CD103+

diseases. In addition, they typically lacked expression of

CD5, CD23, and CD38, which were detected in only a sub-

set of cells by flow cytometry, in 2.3%, 4.7%, and 8.8% of

cases, respectively. Strong coexpression of CD5 and CD23,

characteristic of chronic lymphocytic leukemia, was never

observed. The overall results of immunophenotype analysis

by flow cytometry are summarized in zTable 1z.

Based on flow cytometry, 169 cases (78.6%) were

classical HCL with coexpression of CD25. These cases


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Dong et al / CD103+ B-LymphoproLiferative DisorDers

consistently presented a distinct lymphoid population in

the monocyte gate zImage 1Az on analysis of CD45 vs side

scatter and forward scatter vs side scatter. The remaining 46

cases (21.4%) lacked CD25 and were typically composedof small B cells in the normal lymphocyte gate zImage

1Bz. Three cases of CD103+DLBCL and prolymphocytic

leukemia had immunophenotypic features identical to other

CD25 cases except for increased forward scatter, correlat-

ing to increased cell size.

Significant differences were observed between the

CD25+HCL and CD25 cases. Classical HCL displayed

homogeneous expression of CD10 in 19.5% (33/169) of the

cases at expression levels comparable to those of follicular

lymphoma zImage 2z. In contrast, none of the CD25 cases

had detectable CD10 (P =.001). HCL was slightly pre-dominant (/, 0.9:1), whereas the CD25 cases displayed

more frequent surfaceexpression (/, 1.6:1) and tended

to have more frequent low-level or undetectable surface light

chain (20.9% [9/43]) compared with classical HCL (4.1%

[7/169]) (P =.02 ).

Based on immunohistochemical results zTable 2z, all 79

tested CD103+cases expressed DBA.44 and BCL-2; none

of the 79 had detectable CD43. All 28 tested classical HCL

cases were invariably positive for annexin-A1. About 36.9%

of classical HCL cases (24/65) also had overexpression of

BCL1 (Image 2), although the intensity of BCL1 stainingwas highly variable. In contrast, expression of annexin-A1

was never detected in any of the stained CD25 cases, nor

was BCL1 (0/14) (P =.04).

It is worth noting that, as a whole, the expression of

CD20, CD22, and CD11c was distinctively brighter in

CD103+B-lymphoproliferative disorders than in normal B

cells and most other subtypes of B-lymphoproliferative dis-

orders. This profile often allowed detection of a very small

number of abnormal cells (as few as 0.1% of total cells) in

a polyclonal background zImage 1Cz during screening, a

feature useful for monitoring low-level disease.

CD103+B-L ymphoproliferative Disorders With or

Without CD25 Differ in Morphologic Features

Cytologically, classical HCL cells were medium-sized

with eccentric nuclei, reticular chromatin, ruffled cytoplas-mic borders, and irregular surface projections (Image 2).

The presence of prominent nucleoli was also noted in a few

cases. In contrast, the morphologic features of CD25 cases

were more variable. These cells were typically small to

medium-sized with more condensed, coarse chromatin and

fine cytoplasmic projections. The presence of a prominent

nucleolus was noted in at least some cells in all cases, even

though cells with varying morphologic features coexisted in

most cases zImage 3z. Histologically, classical HCL char-

acteristically displayed an extensive interstitial infiltrate in

marrow trephine biopsy specimens without aggregation. Theleukemic cells typically displayed abundant pale cytoplasm

in a fried egg appearance (Image 2). In contrast, the cases

lacking CD25 displayed a patchy infiltrate or distinct clus-

ters of small lymphocytes in the marrow (9/14 cases), even

though they were often inconspicuous on the H&E-stained

section (Image 3). The infiltrate often displayed an exclusive

intrasinusoidal infiltration best seen on CD20 and CD34

staining (6/14 cases).

The CD25 group included 1 case with large cell and 2

cases with large prolymphocytic histologic features in tissue

sections (Image 3). The large B-cell lymphoma was identifiedin a lymph node biopsy specimen from a patient with a history

of HCLv diagnosed 3 years earlier. The immunophenotypic

profile of the large cells was identical to that at the initial

diagnosis of HCLv, suggesting large cell transformation of

the initial disease. The neoplastic cells in this case displayed

enlarged cell size, irregular nuclear contours, and vesicular

chromatin. The other 2 cases manifested as de novo splenic

lymphoma, both of which were composed of predominantly

prolymphocytes/paraimmunoblasts (2- to 3-fold larger than

normal lymphocytes) with a single prominent nucleolus in a

diffuse growth pattern effacing architecture.

zTable 1zImmunophenotype of CD103+B-Lymphoproliferative Disorders Analyzed by Flow Cytometry*

/ No sIg Dim sIg CD5 CD10 CD11c CD23 CD38 CD25 CD103

Total (n = 215) 105/106 (1.0:1) 4 (1.9) 12 (5.6) 5 (2.3) 33 (15.3) 215 (100.0) 10 (4.7) 19 (8.8) 169 (78.6) 215 (100.0)CD25+ (n = 169

[78.6%]) 78/89 (0.9:1) 2 (1.2) 5 (3.0) 4 (2.4) 33 (19.5) 169 (100.0) 10 (5.9) 16 (9.5) 169 (100.0) 169 (100.0)CD25

Small cells (n = 43 25/16 (1.6:1) 2 (5) 7 (16) 1 (2) 0 (0) 43 (100) 0 (0) 3 (7) 0 (0) 43 (100)[20.0%])

Large cells (n = 3 2/1 (1.5:1) 0 (0) 0 (0) 0 (0) 0 (0) 3 (100) 0 (0) 0 (0) 0 (0) 3 (100)[1.4%])

P .017 .001

sIg, surface immunoglobulin.* Except for the/ratio, data are given as number (percentage). Detected only as partial expression at low intensities.


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CD103+B-Lymphoproliferative Disorders With or Without

CD25 Were Correlated With Different Clinical Manifestations

The study included a total of 173 men and 42 women

(M/F, 4.2:1). The patients with CD25 disease were sig-

nificantly older (median, 79 years) than patients with classical

HCL (median, 59 years) (P


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follow-up data available (range, 9-62 months), the complete

response (CR) rate was 14% (1/7) and the overall response

rate was 57% (4/7). The only patient who achieved CR had

a relapse 48 months later but achieved the second CR after

additional cladribine therapy. Of the 3 patients who achieved

a partial response, 1 subsequently achieved CR with ritux-

imab. One had a partial response to fludarabine plus rituximab

on disease progression. The third patient died of the disease

104

100

100 101

CD11cFITC

CD20 APC

102 103 104

101

102

103

104

100

100 101

CD11cFITC

CD20 APC

102 103 104

101

102

103

104

100

100 101

CD20APC

CD5 APC

102 103 104

101

102

103

104

100

100 101

CD10FITC

CD20 APC

102 103 104

101

102

103

GFE

DCB

A

zImage 2z Morphologic and antigenic variation of hairy cell leukemia (HCL). A, Flow cytometry demonstrates that classical HCL

cells (CD11c bright, blue) may express cohesive CD10 and occasionally weak CD5. B, Typical hairy cells have reticular chromatin

and a moderate amount of cytoplasm with irregular cytoplasmic projections (Wright-Giemsa, 1,000). C, Prominent nucleoli

may also be present (Wright-Giemsa, 1,000). D, In bone marrow trephine biopsy specimens, HCL displays a characteristic

interstitial infiltrate (H&E, 400). E, F, and G, HCL may display unequivocal nuclear staining of BCL1 (E, 400) and is positive for

annexin-A1 in all cases (F, 400) and CD10 in a subset of cases (G, 400).


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zTable 2zImmunophenotype of CD103+B-Lymphoproliferative Disorders Analyzed by Immunohistochemical Studies*

DBA.44 (n =79) Annexin-A1 (n =42) CD43 (n =79) BCL1 (n =79) BCL-2 (n =79)

CD25+ 65/65 (100) 28/28 (100) 0/65 (0) 24/65 (37) 65/65 (100)CD25 14/14 (100) 0/14 (0) 0/14 (0) 0/14 (0) 14/14 (100)P .014

* Data are given as number/total (percentage).

FD

CBA

E

zImage 3z Morphologic features of CD25, CD103+ B-lymphoproliferative disorders. A and B, The neoplastic cells have more

condensed chromatin, compared with hairy cell leukemia, and fine cytoplasmic projections. Prominent nucleoli are common.

Cells with diverse morphologic features often coexist in a given case (Wright-Giemsa, 1,000). C and D, The bone marrow

histologic features tend to show lymphoid aggregates or patchy clusters (C, H&E, 400), as highlighted by CD20 staining (D,

400). E and F, In rare cases, a diffuse large cell proliferation (E, lymph node) or overwhelming prolymphocytic features (F,

spleen) were evident compared with normal small lymphocytes as the internal control (H&E, 1,000).


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The specific expression of annexin-A1 in classical HCL

was initially discovered by gene expression profiling.33 It was

subsequently validated to be 100% sensitive and specific for

HCL in an immunohistochemical study30 with 500 cases of

B-cell malignancies. In particular, it was positive in all cases

of classical HCL and negative in all cases of SMZL and

HCLv. Our experience has been in agreement with the pub-

lished data. However, annexin-A1 is also strongly expressed

in normal myeloid cells and, therefore, is best used for HCL

with extensive marrow involvement or with extramedullary

disease. A parallel CD20 stain should always be performed

to distinguish HCL cells from nonlymphoid elements in the

marrow. In accordance with gene expression profiling data,33

HCL cases also exhibited unequivocal BCL1 overexpression

detectable by immunohistochemical analysis. The expres-

sion level of BCL1 was variable, which may account for the

wide range of detection rates in the literature (7%-90%).28,29

Nevertheless, expression of BCL1 in HCL is not related to

the BCL1 translocation,34 and its clinical implication is yet tobe determined.

Consistent with others who had reported CD10 expres-

sion in 10% to 26% of HCL cases,3,6,35 we found expression

of CD10 in 19.5% of HCLs. However, it does not seem to have

any known clinical impact.35 In practice, a small or crushed

specimen with limited immunophenotyping may give rise to

an impression of mantle cell lymphoma (BCL1+) or follicular

lymphoma (CD10+). Awareness of the common phenotypic

profiles instead of relying on a single antigen should help rec-

ognize different entities. Of note, neither t(11;14) nor t(14;18)

has been detected in HCL.Apart from classical HCL, about 21.4% of all CD103+

B-lymphoproliferative disorders lacked CD25, annexin-A1,

CD10, and BCL1. This phenotypic profile is identical to most

cases of HCLv and SRPL, both of which lack CD123 seen in

classical HCL as well.36

despite continued treatment with pentostatin plus rituximab.

Of the 3 patients who had no response to cladribine, 1

achieved CR after splenectomy. The other 2 patients elected

to have no additional treatment. Of note, 1 patient initially

treated with fludarabine also had a CR zTable 3z.32

Discussion

In this study, we analyzed 215 cases of CD103+

B-lymphoproliferative disorders, including 169 cases charac-

teristic of classical HCL (56 cases per year). The number of

the classical HCL cases was equivalent to 2.6% of the adult

leukemia cases (56/2,187) and 1.1% of the cases of lympho-

proliferative disorders (56/5,189) seen annually at our institu-

tion. These numbers are in keeping with the current literature,

eg, HCL constituted 2% of all adult leukemia14 and 1% of

lymphoproliferative disorders.32

We demonstrated that CD103+ B-lymphoproliferative

disorders, as a whole, consistently had a distinct phenotypicprofile, ie, bright CD11c, CD20, and CD22. This observa-

tion was especially verified by our initial unbiased data when

CD103 and CD25 were universally used for all cases of lym-

phoma workup during the first year of this study. Of all cases,

78.6% were consistent with classical HCL that invariably

expresses CD25 and annexin-A1. However, exceedingly rare

cases of HCL lacking CD103 expression have been reported

in the literature.3 We have also seen 2 such cases during

past years. One was a relapsed HCL and was the only case

observed in our institution that exhibited the loss of CD103

during the disease course. The other was a de novo HCL withcharacteristic morphologic features and clinical manifesta-

tions. In both cases, the distinct profile of bright CD11c, CD22,

and CD22 provided the initial diagnostic clue, and both cases

retained expression of CD25 and annexin-A1. The de novo

case was also BCL1+.

zTable 3zSummary of Clinical Information for Patients With CD25, CD103+Splenic B-Cell Lymphoma, Unclassifiable*

Case No./ WBC Count Lymphocyte Hepato- Initial Response Secondary Follow-upSex/Age (y) (10

9

/L) Count (%) splenomegaly AdenopathyTherapy (mo) Relapse Therapy (mo)1/M/76 47.8 35 No No Cladribine CR (48) Yes Cladribine NED (14)2/M/75 4.9 52 Yes No Cladribine PR (7) Rituximab NED (13)3/M/78 8.7 56 Yes No Cladribine PR (22) Cladribine, rituximab, AWD (28)

fludarabine4/M/76 26.0 80 Yes Yes Pentostatin PR (6) Pentostatin, DOD (10)

rituximab5/F/59 12.0 86 Yes No Cladribine NR None AWD (9)6/M/72 14.8 56 Yes No Cladribine NR None AWD (13)7/M/73 18.4 84 Yes No Cladribine NR Splenectomy NED (36)8/M/74 13.0 67 Yes No Fludarabine CR (12) No NED (12)9/F/82 7.7 43 Yes No Rituximab PR (6) None AWD (6)

AWD, alive with disease; CR, complete response; DOD, died of disease; NED, no evidence of disease; NR, no response; PR, partial response.* According to Swerdlow et al.32 Values for the WBC count are given in Systme International (SI) units; to convert to conventional units (/L), divide by 0.001; lymphocyte

values are given in conventional units; to convert to SI units (proportion of 1.0), multiply by 0.01.


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and an intrasinusoidal infiltrate in the spleen or marrow repre-

sented more than 20% of cases in the largest series of HCLv,43

7 of 10 cases in a more recent report,44 all marrow biopsies of

SRPL cases,13and 43% of our cases. The occasional CD103+

prolymphocytic leukemia and DLBCL cases in our study and

described in the literature have always lacked CD25 expres-

sion, further deviating from classical HCL.

There has been only a handful of clinical studies on

HCLv reported in the literature; most articles are case reports.

The CD25, CD103+B-lymphoproliferative disorder in our

study constituted approximately 0.5% of all adult leukemia

or 0.2% of lymphoproliferative disorders. The rarity of these

cases makes any clinical studies with significant statistical

power exceedingly difficult. When compared with HCL, the

patients tend to be older and typically have moderate leuko-

cytosis and peripheral lymphocytosis without monocytopenia.

These features are reminiscent of HCLv43and SMZL. Despite

the fact that only a small number of our CD25 cases had rel-

evant follow-up data, our findings still represent a significantaddition to the current literature (Table 4).

Collectively, a low response rate to standard treatment

for HCL has been observed in all published reports on HCLv,

with CR rates consistently no better than 25%. In addition,

there was essentially no response to interferon-alfa.11,26 For

the benefit of clinical management, classical HCL ought to be

clearly separated from other CD103+B-lymphoproliferative

disorders that lack CD25 expression, such as HCLv, SRPL,

and SMZL, as well as prolymphocytic leukemia. Despite their

variable expression of CD103 and variable hairy cytoplasm,

most of these cases may be better considered villous (hairy)cell variants of marginal zone lymphoma rather than a variant

of true HCL, especially because the nondiscriminative use of

Earlier studies also revealed the phenotypic distinctions

between HCL and HCLv and similarities between HCLv and

SMZL. In a study using a scoring system with 4 antigens

(CD11c, CD25, CD103, and HC2) each counting as 1 point,

98% of classical HCLs scored 3 or 4 points and none scored 0

or 1.37 In contrast, 88% of HCLv and 77% of SMZL scored 1

or 2 points, but none scored 3 or 4.37 The tendency to display

low levels of surface immunoglobulin in a subset of CD25

cases is also reminiscent of the so-called Japanese variant of

HCL.27,38 Based on the multiple antigen profiles further sup-

ported by recent data for gene expression profiling (eg, annex-

in-A1 and BCL1), it seems that HCL is sufficiently different

from all other CD103+ B-lymphoproliferative disorders.

On the other hand, CD25 diseases are likely composed of

heterogeneous entities, including HCLv with variable expres-

sion of CD11c (75%-87%) and CD103 (47%-75%) zTable 4z

and other diseases with diverse morphologic features; many

of those diseases have properties comparable to variants of

SMZL and prolymphocytic leukemia.In the current literature, HCLv is described to have a pro-

lymphocyte-like single nucleolus in centrally located nuclei

and villous cytoplasmic projections.11,12,23,24,43 However,

hairy cells with a prominent nucleolus were well documented

in the initial landmark work on HCL14 in 1958. HCLv-like

cases without prominent nucleoli were also described in

recent studies.13,44 The hairy or villous cytoplasm alone may

have a wide spectrum of morphologic variations as summa-

rized recently,13 including artifact, well discussed in the early

studies of hairy cells.45-47

The CD25 cases, HCLv and SMZL, also share histologicfeatures. Instead of the nonaggregating interstitial infiltrate

typical of HCL, lymphoid aggregates are common in all others,

zTable 4zSummary of HCL v-Like Diseases in the Literature*

Response to Cladribine/Diagnosis/Study CD5 CD10 CD11c CD25 CD103 Annexin Pentostatin

HCLvSainati et al,11 1990 (n = 17) 38 (6/16) 18 (2/11) 100 (12/12) 0/17 40 (4/10) ND PR, 1/3; NR, 2/3Matutes et al,37 1994 (n = 25) 8 21 79 0 47 ND NDMatutes et al,12 2003 (n = 48) 0 15 87 6 60 ND PR, 50%; NR, 50%Zinzani et al,26 1990 (n = 7) 71 (5/7) ND 100 (6/6) 71 (5/7) ND ND NDBlasinska-Morawiec,39 1997 (n = 3) ND ND ND ND ND ND PR, 1/3; NR, 2/3Hoffman et al,40 1997 (n = 4) ND ND ND 0/4 ND ND PR, 4/4Tetreault et al,41 1999 (n = 4) 25 (1/4) ND 75 (3/4) 25 (1/4) 75 (3/4) ND CR, 1/4; PR, 2/4; NR, 1/4Robak et al,42 1999 (n = 6) ND ND ND ND ND ND PR, 2/6Cessna et al,44 2005 (n = 10) 0/10 0/10 100 (10/10) 0/10 100 (10/10) ND ND

SRPLTraverse-Glehen et al,13 2008 (n = 37) 14 (5/37) ND 97 (36/37) 3 (1/37) 38 (13/34) 0/12 ND

Splenic BCL, unclassifiablePresent study (n = 43) 2 (1/43) 0/43 100 (43/43) 0/43 100 (43/43) 0/14 CR, 1/7; PR, 3/7; NR, 3/7

BCL, B-cell lymphoma; CR, complete response; HCLv, hairy cell leukemia variant; ND, not determined; NR, no response; PR, partial response; SRPL, splenic red pulplymphoma with villous lymphocytes.

* Data are given as percentage of cases positive (number of cases positive/total tested), except in the Response to Cladribine/Pentostatin column, in which number with response/total receiving treatment or numbers or percentages of cases with a response to treatment are given.


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8. Matutes E, Morilla R, Owusu-Ankomah K, et al. Theimmunophenotype of splenic lymphoma with villouslymphocytes and its relevance to the differential diagnosis withother B-cell disorders. Blood. 1994;83:1558-1562.

9. Isaacson PG, Matutes E, Burke M, et al. The histopathologyof splenic lymphoma with villous lymphocytes. Blood.1994;84:3828-3834.

10. Moller P, Mielke B, Moldenhauer G. Monoclonal antibody

HML-1, a marker for intraepithelial T cells and lymphomasderived thereof, also recognizes hairy cell leukemia and someB-cell lymphomas.Am J Pathol. 1990;136:509-512.

11. Sainati L, Matutes E, Mulligan S, et al. A variant form ofhairy cell leukemia resistant to alpha-interferon: clinicaland phenotypic characteristics of 17 patients. Blood.1990;76:157-162.

12. Matutes E, Wotherspoon A, Catovsky D. The variant formof hairy-cell leukaemia. Best Pract Res Clin Haematol.2003;16:41-56.

13. Traverse-Glehen A, Baseggio L, Bauchu EC, et al. Splenic redpulp lymphoma with numerous basophilic villous lymphocytes:a distinct clinicopathologic and molecular entity? Blood.2008;111:2253-2260.

14. Bouroncle BA, Weisman BK, Doan C. Leukemicreticuloendotheliosis. Blood. 1958;3:609-630.

15. Maloisel F, Benboubker L, Gardembas M, et al. Long-termoutcome with pentostatin treatment in hairy cell leukemiapatients: a French retrospective study of 238 patients.Leukemia. 2003;17:45-51.

16. Goodman GR, Burian C, Koziol JA, et al. Extended follow-upof patients with hairy cell leukemia after treatment withcladribine.J Clin Oncol. 2003;21:891-896.

17. Chadha P, Rademaker AW, Mendiratta P, et al. Treatmentof hairy cell leukemia with 2-chlorodeoxyadenosine (2-CdA):long-term follow-up of the Northwestern University experience.Blood. 2005;106:241-246.

18. Hisada M, Chen BE, Jaffe ES, et al. Second cancer incidenceand cause-specific mortality among 3104 patients with hairycell leukemia: a population-based study.J Natl Cancer Inst.2007;99:215-222.

19. Yam LT, Li CY, Lam KW. Tartrate-resistant acidphosphatase isoenzyme in the reticulum cells of leukemicreticuloendotheliosis.N Engl J Med. 1971;284:357-360.

20. Went PT, Zimpfer A, Pehrs AC, et al. High specificity ofcombined TRAP and DBA.44 expression for hairy cellleukemia.Am J Surg Pathol. 2005;29:474-478.

21. Hounieu H, Chittal SM, al Saati T, et al. Hairy cell leukemia:diagnosis of bone marrow involvement in paraffin-embeddedsections with monoclonal antibody DBA.44.Am J Clin Pathol.1992;98:26-33.

22. Salomon-Nguyen F, Valensi F, Troussard X, et al. The valueof the monoclonal antibody, DBA44, in the diagnosis of B-lymphoid disorders. Leuk Res. 1996;20:909-913.

23. Cawley JC, Burns GF, Hayhoe FG. A chroniclymphoproliferative disorder with distinctive features: a distinctvariant of hairy-cell leukaemia. Leuk Res. 1980;4:547-559.

24. Catovsky D, OBrien M, Melo JV, et al. Hairy cell leukemia(HCL) variant: an intermediate disease between HCL and Bprolymphocytic leukemia. Semin Oncol. 1984;11:362-369.

25. Diez Martin JL, Li CY, Banks PM. Blastic variant of hairy-cellleukemia.Am J Clin Pathol. 1987;87:576-583.

26. Zinzani PL, Lauria F, Buzzi M, et al. Hairy cell leukemiavariant: a morphologic, immunologic and clinical study of 7cases. Haematologica. 1990;75:54-57.

terms between HCL and HCLv may confuse proper therapy in

clinical settings. In the 2008 World Health Organization clas-

sification of tumors of hematopoietic and lymphoid tissues,

HCLv and SRPL have been listed under an umbrella term

splenic B-cell lymphoma, unclassifiable; HCLv is no lon-

ger considered to be biologically related to HCL.32 Although

patients may be empirically treated with cladribine and pen-

tostatin, it should be recognized that they typically require

additional therapies. Treatment with rituximab,48 BL22,49

and alemtuzumab (Campath-1H)50 may be useful options

owing to the strong expression of CD20, CD22, and CD52.51

Our data also emphasize that expression of CD25 ought to

be evaluated in the routine workup of HCL, especially when

analysis of annexin-A1 expression is not feasible.

We analyzed the largest series of CD103+

B-lymphoproliferative disorders in the literature. While cases

coexpressing CD25 and annexin-A1 are characteristic of

HCL, cases lacking CD25 and annexin-A1 seem to deviate

from HCL and more closely relate to variants of SMZL.Although a precise diagnosis depends on a multimodal

approach, separating the 2 groups should provide useful guid-

ance in improving patient care.

FromGenzyme Genetics, New York, NY.

Address reprint requests to Dr Dong: Genzyme Genetics, 521W 57th St, New York, NY 10019.

* Drs Weisberger and Liu were with IMPATH when thisstudy was done and are currently with BioReference Laboratories,Elmwood Park, NJ.

Acknowledgments: We thank Sherrie Perkins, MD, University

of Utah, Salt Lake City, for review of the manuscript and WilliamKirtland for help in data collection.

References

1. Micklem KJ, Dong Y, Willis A, et al. HML-1 antigen onmucosa-associated T cells, activated cells, and hairy leukemiccells is a new integrin containing the beta 7 subunit.Am JPathol. 1991;139:1297-1301.

2. Visser L, Shaw A, Slupsky J, et al. Monoclonal antibodiesreactive with hairy cell leukemia. Blood. 1989;74:320-325.

3. Chen YH, Tallman MS, Goolsby C, et al. Immunophenotypicvariations in hairy cell leukemia.Am J Clin Pathol.

2006;125:1-9.4. Korsmeyer SJ, Greene WC, Cossman J, et al. Rearrangement

and expression of immunoglobulin genes and expression ofTac antigen in hairy cell leukemia. Proc Natl Acad Sci U S A.1983;80:4522-4526.

5. Hassan IB, Hagberg H, Sundstrom C. Immunophenotype ofhairy-cell leukemia. Eur J Haematol. 1990;45:172-176.

6. Robbins BA, Ellison DJ, Spinosa JC, et al. Diagnosticapplication of two-color flow cytometry in 161 cases of hairycell leukemia. Blood. 1993;82:1277-1287.

7. Juliusson G, Lenkei R, Liliemark J. Flow cytometry of bloodand bone marrow cells from patients with hairy cell leukemia:phenotype of hairy cells and lymphocyte subsets after treatmentwith 2-chlorodeoxyadenosine. Blood. 1994;83:3672-3681.


10/10

Am J Clin Pathol 2009;131:586-595 595 American Society for Clinical Pathology


40. Hoffman MA, Janson D, Rose E, et al. Treatment of hairy-cellleukemia with cladribine: response, toxicity, and long-termfollow-up.J Clin Oncol. 1997;15:1138-1142.

41. Tetreault SA, Robbins BA, Saven A. Treatment of hairycell leukemia-variant with cladribine. Leuk Lymphoma.1999;35:347-354.

42. Robak T, Blasinska-Morawiec M, Blonski J, et al.2-Chlorodeoxyadenosine (cladribine) in the treatment of hairy

cell leukemia and hairy cell leukemia variant: 7-year experiencein Poland. Eur J Haematol. 1999;62:49-56.

43. Matutes E, Wotherspoon A, Brito-Babapulle V, et al. Thenatural history and clinico-pathological features of the variantform of hairy cell leukemia. Leukemia. 2001;15:184-186.

44. Cessna MH, Hartung L, Tripp S, et al. Hairy cell leukemiavariant: fact or fiction.Am J Clin Pathol. 2005;123:132-138.

45. Babusikova O, Mesarosova A, Kusenda J, et al. Immunephenotype and some enzyme patterns in phorbol esterinduced chronic lymphocytic leukemia cells.Neoplasma.1995;42:221-226.

46. Visser L, Poppema S. Induction of B-cell chronic lymphocyticleukaemia and hairy cell leukaemia like phenotypes by phorbolester treatment of normal peripheral blood B-cells.

Br JHaematol. 1990;75:359-365.

47. Schrek R, Donnelly WJ. Hairy cells in blood inlymphoreticular neoplastic disease and flagellated cells ofnormal lymph node. Blood. 1966;27:199-211.

48. Narat S, Gandla J, Dogan A, et al. Successful treatment ofhairy cell leukemia variant with rituximab. Leuk Lymphoma.2005;46:1229-1232.

49. Kreitman RJ, Wilson WH, Bergeron K, et al. Efficacy of theanti-CD22 recombinant immunotoxin BL22 in chemotherapy-resistant hairy-cell leukemia.N Engl J Med. 2001;345:241-247.

50. Sasaki M, Sugimoto K, Mori T, et al. Effective treatmentof a refractory hairy cell leukemia variant with splenicpre-irradiation and alemtuzumab.Acta Haematol.

2008;119:48-53.51. Quigley MM, Bethel KJ, Sharpe RW, et al. CD52 expression

in hairy cell leukemia.Am J Hematol. 2003;74:227-230.

27. Machii T, Tokumine Y, Inoue R, et al. Predominance of adistinct subtype of hairy cell leukemia in Japan. Leukemia.1993;7:181-186.

28. Bosch F, Campo E, Jares P, et al. Increased expression of thePRAD-1/CCND1 gene in hairy cell leukaemia. Br J Haematol.1995;91:1025-1030.

29. Zukerberg LR, Yang WI, Arnold A, et al. Cyclin D1expression in non-Hodgkins lymphomas: detection by

immunohistochemistry.Am J Clin Pathol. 1995;103:756-760.30. Falini B, Tiacci E, Liso A, et al. Simple diagnostic assay for

hairy cell leukaemia by immunocytochemical detection ofannexin A1 (ANXA1). Lancet. 2004;363:1869-1870.

31. Dong HY, Gorczyca W, Liu Z, et al. B-cell lymphomaswith coexpression of CD5 and CD10.Am J Clin Pathol.2003;119:218-230.

32. Swerdlow SH, Campo E, Harris NL, et al. WHO Classificationof Tumours of Haematopoietic and Lymphoid Tissues. 4th ed.Lyon, France: IARC Press; 2008.

33. Basso K, Liso A, Tiacci E, et al. Gene expression profiling ofhairy cell leukemia reveals a phenotype related to memoryB cells with altered expression of chemokine and adhesionreceptors.

J Exp Med.2004;199:59-68.

34. de Boer CJ, Kluin-Nelemans JC, Dreef E, et al. Involvementof the CCND1 gene in hairy cell leukemia.Ann Oncol.1996;7:251-256.

35. Jasionowski TM, Hartung L, Greenwood JH, et al.Analysis of CD10+ hairy cell leukemia.Am J Clin Pathol.2003;120:228-235.

36. Del Giudice I, Matutes E, Morilla R, et al. The diagnostic valueof CD123 in B-cell disorders with hairy or villous lymphocytes.Haematologica. 2004;89:303-308.

37. Matutes E, Morilla R, Owusu-Ankomah K, et al. Theimmunophenotype of hairy cell leukemia (HCL): proposal fora scoring system to distinguish HCL from B-cell disorders withhairy or villous lymphocytes. Leuk Lymphoma. 1994;14:57-61.

38. Yamaguchi M, Machii T, Shibayama H, et al.Immunophenotypic features and configuration ofimmunoglobulin genes in hairy cell leukemia-Japanese variant.Leukemia. 1996;10:1390-1394.

39. Blasinska-Morawiec M, Robak T, Krykowski E, et al. Hairy cellleukemia-variant treated with 2-chlorodeoxyadenosine: a reportof three cases. Leuk Lymphoma. 1997;25:381-385.

Immunophenotypic Analysis of CD103+ Lymphomas

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