The vast majority of cases of T cell large granular lymphocyte (T-LGL) leukemia have a CD3+, CD4−, CD8+ phenotype and express the αβ T cell receptor. Whether the rare γδ variant should be included in the same diagnostic category is currently unclear. Two well-characterized cases of γδ T-LGL leukemia were identified by our laboratory in 2007. These two cases and other reports of γδ T-LGL leukemia were compared with the common αβ variant. Other than more often being negative for both CD4 and CD8 (in about 35% to 40% of cases), the γδ variant of T-LGL leukemia is similar to the common αβ type in virtually all respects and should be included in the general category of T-LGL leukemia. However, it is important to exclude other more aggressive γδ T cell lymphoproliferative disorders

AS Bourgault-Rouxel

CS Scott

DP O’Malley

F Pandolfi

Gene R. Shaw

H Makishima

K Morikawa

KP McCarthy

N Ichikawa

N Osuji

R Lundell

R Willemze

T Lamy

T Saito

Vinay S. Naik

WC Chan

WG Morice

Y Mizuno

Y Sandberg

English

PubMed

Springer - Publisher Connector

The γδ variant of T cell large granular lymphocyte leukemia is very similar to the common αβ type: report of two cases

CASE REPORT
The γδ variant of T cell large granular lymphocyte leukemia
is very similar to the common αβ type: report of two cases
Gene R. Shaw & Vinay S. Naik
Received: 25 April 2008 /Accepted: 28 July 2008 /Published online: 23 August 2008
# Springer-Verlag 2008
Abstract The vast majority of cases of T cell large granular
lymphocyte (T-LGL) leukemia have a CD3+, CD4−, CD8+
phenotype and express the αβ T cell receptor. Whether the
rare γδ variant should be included in the same diagnostic
category is currently unclear. Two well-characterized cases
of γδ T-LGL leukemia were identified by our laboratory in
2007. These two cases and other reports of γδ T-LGL
leukemia were compared with the common αβ variant.
Other than more often being negative for both CD4 and
CD8 (in about 35% to 40% of cases), the γδ variant of T-
LGL leukemia is similar to the common αβ type in
virtually all respects and should be included in the general
category of T-LGL leukemia. However, it is important to
exclude other more aggressive γδ T cell lymphoprolifer-
ative disorders.
Keywords Large granular lymphocytes .γδ lymphocytes .
Tcell leukemia
T cell large granular lymphocyte (T-LGL) leukemia is a
clonal lymphoproliferative disorder of cytotoxic T cells
often associated with cytopenias but having a relatively
indolent course [1, 2]. The vast majority of cases have a
CD3+, CD4−, CD8+ phenotype and express the αβ T cell
receptor (TCR). However, there are rare variants including
cases that express the γδ TCR. The CD4 and CD8
expression pattern of these cases is not well-established;
some may be CD4− and CD8− like most normal γδ
lymphocytes [3]. Since many types of γδ leukemias or
lymphomas have a more aggressive clinical course, there is
some controversy whether such cases should be included in
the general T-LGL leukemia category [4]. Herein are
described two cases of γδ T-LGL leukemia that presented
in an indolent fashion very similar to the common αβ
variant.
Report of two cases
Clinical histories
Case 1 An 88-year-old woman presented with a history of
frequent urinary tract infections along with relatively stable
leukopenia and mild anemia that had been present for over
10 years. During the previous 6 years, the platelet count had
become borderline low. At the time of this evaluation in
June 2007, the white blood count (WBC) was 2,500/μL
with 95% lymphocytes and 5% monocytes, hemoglobin
10.7 g/dL, mean corpuscular volume (MCV) 90.8 fL, and
platelets 161,000/μL. On physical exam, there was no
palpable lymphadenopathy or hepatosplenomegaly. The
patient was treated with methotrexate (10 mg orally every
week) and the absolute neutrophil count (ANC) had risen to
1,300/μL 7 months later. She did have a Klebsiella
pneumoniae urinary tract infection in April 2008 when the
ANC was 1,000/μL.
Case 2 A 69-year-old man with a 30-year history of
rheumatoid arthritis was first noted to have neutropenia
2 years before this evaluation. The patient had no recurrent
sinopulmonary infections, but for the previous 6 months he
had a persistent staphylococcal infection of his left foot. At
presentation in April 2007, the WBC was 2,000/μL with
3% bands, 12% segmented neutrophils, 1% eosinophils,
68% lymphocytes, and 16% monocytes. Hemoglobin was
J Hematopathol (2008) 1:139–143
DOI 10.1007/s12308-008-0016-6
G. R. Shaw (*) :V. S. Naik
Department of Pathology, Marshfield Clinic,
1000 North Oak Avenue,
Marshfield, WI 54449, USA
e-mail: shaw.gene@marshfieldclinic.org
16.4 g/dL, MCV 87.1 fL, and platelets 204,000/μL. There
was no palpable organomegaly or lymphadenopathy, but
ultrasound showed mild to moderate hepatosplenomegaly.
The patient was treated with cyclophosphamide (50 mg
orally every day, decreased to 25 mg after 2 months) and
the ANC had risen to 2,300/μL 3 months later. He was
hospitalized for a right upper lobe pneumonia at that time.
Subsequent ANCs for the next 6 months were highly
variable ranging between 160 and 900/μL.
Microscopic, immunophenotypic, and genetic findings
Case 1 The peripheral blood smear showed a majority of
large granular lymphocytes. The bone marrow aspirate
showed nearly 80% erythroid precursors and only rare
myeloid cells. The biopsy had 50% cellularity with
occasional small lymphoid aggregates and a subtle
interstitial increase in small lymphocytes. Immunohisto-
chemical staining showed a significant increase in small
CD3+, CD8+ T cells mainly in an interstitial pattern. In
the few small lymphoid aggregates, CD3 and CD20 each
marked about half the lymphocytes with CD4+ cells
exceeding CD8+ cells by roughly three to one. There
were only rare interstitial B cells. A G&S stain showed
some areas with a slight increase in reticulin fibrosis.
Flow cytometry performed on the bone marrow aspirate
showed 64% lymphocytes with over 90% T cells
expressing CD2, CD3, CD5, and CD7 without aberrancy.
The CD4:8 ratio was 1.1. Nearly half the T cells were
CD4−, CD8− and the majority expressed TCR γδ along
with CD57 (Fig. 1); CD16 and CD56 were negative. TCR
gene rearrangement studies by polymerase chain reaction
(PCR) were performed on a subsequent peripheral blood
sample and showed clonal γ and β patterns. Cytogenetics
were normal.
Case 2 Increased large granular lymphocytes were noted
on the peripheral smear. The bone marrow aspirate showed
40% erythroid precursors with a low G/E ratio of 1.0:1.2
along with 20.0% lymphs and 3.4% mature plasma cells.
The biopsy had 50% cellularity with an interstitial and
nodular infiltrate of small lymphocytes. The interstitial
population was highlighted with CD3. The large majority
of these expressed CD8 and not CD4 (Fig. 2). Rare
scattered B cells marked with CD20. In the lymphoid
aggregates, the majority of cells were CD3+, but CD4+
cells exceeded CD8+ cells by roughly five to one with only
occasional CD20+ B cells. A G&S stain showed some
areas with a slight increase in reticulin fibrosis. Flow
cytometry on the aspirate showed about 40% of marrow
nucleated cells in the lymphocyte region with about 95% T
cells. The CD4:8 ratio was 0.6. About half the T cells
coexpressed CD57. CD16 and CD56 were negative while
roughly a fourth of the T cells had loss of CD5. About two-
thirds of the lymphocytes lacked both CD4 and CD8. A
similar proportion of the lymphocytes (presumably the
same population) expressed TCR γδ. PCR studies showed
clonal rearrangements of both TCR γ and β (Fig. 3).
Cytogenetics were normal.
Comment
TCR γδ T cells normally comprise only 0.5% to 5% of
peripheral blood lymphocytes [5]. However, they are highly
prevalent in certain peripheral tissues such as the skin,
intestinal tract, and mammary ducts where they play a
central role in the early response to infections. Expansions
of γδ T cells have been described with Epstein–Barr virus
infection, human immunodeficiency virus infection, and
congenital immunodeficiency syndromes [6].
Fig. 1 Case 1—flow cytometry performed on bone marrow aspirate.
a Sixty-one percent of CD3+ T cells coexpressed CD57. b Sixty-nine
percent of CD3+ T cells expressed T cell receptor γ/δ. c Thirty-one
percent of CD3+ T cells expressed T cell receptor α/β. Forty-seven
percent of CD3+ T cells lacked both CD4 and CD8 (not shown)
140 J Hematopathol (2008) 1:139–143
Similar to their representation in the peripheral blood,
the γδ variant of T-LGL leukemia probably accounts for
less than 5% of T-LGL leukemia cases [7]. Most inves-
tigators report that the vast majority of circulating and bone
marrow γδ lymphocytes are CD4− and CD8−, but at least
one study found that nearly half are CD4−, CD8+ [8]. The
immunophenotype of γδ T-LGL leukemia is variable. Both
patients in this report were CD4−, CD8−, CD57+, CD16−,
and CD56−. About 35% to 40% of γδ T-LGL leukemia cases
are CD4−, CD8− [7, 9]. The remaining cases are CD4−,
CD8+ with CD8 expression often dim. Note, however, that
the CD4−,CD8− immunophenotype is not entirely specific
for γδ lymphoid proliferations. Rare cases of αβ T-LGL
leukemia being CD4−, CD8− have been reported [10, 11].
Similar to αβ T-LGL leukemia where over 95% of cases
express CD57, the vast majority of γδ cases express CD57
(86% in the series by Sandberg [7]). Also, like the common
αβ variant, CD16 and CD56 expression is more variable.
Based on Sandberg’s series and other case reports, CD16
and CD56 are each expressed in nearly half of the γδ T-
LGL leukemia cases. Perhaps 20% and 60% of αβ T-LGL
leukemia cases express CD56 and CD16, respectively;
rarely are all three NK markers coexpressed [2].
The bone marrow findings in our two cases conformed to
the general pattern described by Osuji et al. for the common
αβ variant [12]. That group described the bone marrow
histology in 38 cases of T-LGL leukemia. Ninety-seven
percent of cases had an interstitial infiltration of CD3+ cells
that were CD8+ in all but one instance. Nonparatrabecular
lymphoid nodules were seen in 55% of cases and were
predominantly CD4+ T cells surrounding CD20+ collec-
tions of B cells. A reliable distinction between reactive
lymphoid infiltrates and T-LGL leukemia in bone marrow
biopsies is difficult. Interstitial clusters of six or more T
cells expressing CD8, TIA-1, or granzyme B reportedly
favor an LGL leukemia (either T cell or NK cell) [13].
Interestingly, in both our cases, interstitial CD8+ T cells
were slightly increased even though the neoplastic γδ T
cells were CD8− by flow cytometry on the marrow aspirate.
Since γδ T cells often weakly express CD8, perhaps this
observation reflects the different monoclonal antibodies
used in flow cytometry (SK117; BD Biosciences) versus
immunohistochemistry (C8/144B; Dako) in our laboratory
or different sensitivities by the two techniques. Alternative-
ly, the interstitial CD8+ T cells could be an immune
Fig. 3 Case 2—T cell receptor gamma PCR 6% polyacrylamide gel.
Patient bone marrow sample in lane 3 (from left) shows a discrete
clonal band. Lane 1 has marker bands. Lanes 1, 4, and 5 have
polyclonal patterns. Lane 6 is a positive control. T cell receptor beta
reaction was also clonal (not shown). PCR primers described by
McCarthy et al. [18, 19]
Fig. 2 Case 2—immunohistochemistry performed on the bone marrow biopsy (×10). a Increased interstitial CD8+ T cells. b Predominantly CD4+ T
cells in a lymphoid aggregate with relatively few interstitially
J Hematopathol (2008) 1:139–143 141
epiphenomenon and not part of the neoplastic population as
has been described by Morice for NK-LGL leukemia [14].
Both cases had severe neutropenia with the ANC 300/μL
or less. Like the common αβ variant, neutropenia is
commonly associated with γδ T-LGL leukemia with an
ANC below 1,500/μL in 50% to 70% of cases [7, 9]. Pure
red cell aplasia has been described in about 5% of cases
similar to the common αβ T-LGL leukemia [5, 7, 9].
One of our two patients had rheumatoid arthritis. A
history of rheumatoid arthritis has been described in about
20% of γδ T-LGL leukemia cases [7, 9, 10] compared with
about 25% of αβ cases [1].
Whether the type of TCR (γδ versus αβ) should be a
pivotal diagnostic criterion for T cell lymphoproliferative
disorders is unclear. Hepatosplenic T cell lymphoma was
originally restricted to γδ cases, but subsequent reports
described an essentially indistinguishable αβ subtype. In
contrast, the γδ subtype of subcutaneous panniculitis-like T
cell lymphoma is purported to have a significantly worse
prognosis than its αβ counterpart, thus generating a
separate provisional entity [15]. Saito et al. reported an
aggressive clinical course for 10 of 11 γδ T cell neoplasms,
but interestingly the one indolent case was a T-LGL
leukemia that was CD4−, CD8− and after 4 years of
follow-up, the patient had no progression of disease without
treatment [16].
Recent reviews are reluctant to place the γδ subtype of
T-LGL leukemia in the general T-LGL leukemia diagnostic
category largely based on concerns regarding the aggressive
clinical behavior of many γδ T cell lymphoproliferative
disorders [1, 3, 4]. However, our two cases and a review of
the literature on this topic suggest that γδ T-LGL leukemia
is usually indolent and rarely may even spontaneously
regress [17].
Conclusion
In summary, it is proposed that the γδ variant of T-LGL
leukemia be included in the general diagnostic category of T-
LGL leukemia. Other than often being CD4 and CD8
“double negative” (in 35% to 40% of cases), it is essentially
indistinguishable from the common αβ variant in terms of
cytology, immunophenotype, bone marrow morphology,
clinical presentation, and prognosis. As a cautionary note,
however, when a γδ lymphoproliferative disorder is encoun-
tered, it is crucial to exclude more aggressive disorders (e.g.,
hepatosplenic T cell lymphoma and peripheral T cell
lymphoma) and also transient reactive γδ expansions (e.g.,
infection-related). This requires full evaluation of the
morphology, immunophenotype, genetic data, and clinical
presentation. Further studies with more patients are needed
to confirm these findings and recommendations.
Acknowledgement We thank Marshfield Clinic Research Foundation
for its support through the assistance of Alice Stargardt and Marie
Fleisner in the preparation of this manuscript.
Ethical standards All research involving human subjects conducted
at Marshfield Clinic with the approval of the Marshfield Clinic
Research Foundation Investigational Review Board (IRB) is per-
formed in accordance with the ethical standards laid down in the 1964
Declaration of Helsinki. The Marshfield Clinic Research Foundation’s
IRB has determined that a case series involving only individuals who
are or who have been under the care of the proposed author do not
meet the research definition.
Conflict of interest The authors declare that they have no conflict of
interest.
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BeiskeK,RandenU etal(2007) Characteristicappearances of the bone marrow in T-cell large granular lymphocyte leukaemia.

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Functional analysis of clonally expanded CD8, TCR γδ T cells in a patient with chronic T-gamma lymphoproliferative disease.

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Peripheral expansion of V δ 1-J δ 1/J δ 2+ γδ T cells and large granular lymphocytes in a patient with Wiskott–Aldrich syndrome.

Subcutaneous panniculitis-like T-cell lymphoma: definition, classification, and prognostic factors: an EORTC Cutaneous Lymphoma Group Study of 83 cases.

T-cell large granular leukemia and related proliferations.

T-cell large granular lymphocyte leukaemia. In: Jaffe ES, Harris NL, Stein H, Vardiman JW (eds) Pathology and genetics of tumours of haematopoietic and lymphoid tissues, vol 3. World Health Organization Classification of Tumours.

Tcell large granular lymphocyte leukemias have multiple phenotypic abnormalities involving pan-T-cell antigens and receptors for MHC molecules.

TCRγδ+ large granular lymphocyte leukemias reflect the spectrum of normal antigen-selected TCRγδ+ T-cells.

The rapid detection of clonal T-cell proliferations in patients with lymphoid disorders.

Zambello R et al (2008) Clinical spectrum of γδ+ T cell LGL leukemia: analysis of 20 cases.

γδ T-cell neoplasms: a clinicopathological study of 11 cases.

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The γδ variant of T cell large granular lymphocyte leukemia is very similar to the common αβ type: report of two cases

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