Review Series

T-CELL MALIGNANCIES

LGL leukemia: from pathogenesis to treatment

Thierry Lamy,1,2 Aline Moignet,1,2 and Thomas P. Loughran Jr3
1
Department of Hematology, Pontchaillou University Hospital, Rennes, France; 2Clinical Investigation Center 1414 INSERM, Rennes, France; and
3
University of Virginia Cancer Center, Charlottesville, VA

Large granular lymphocyte (LGL) leukemia which promotes dysregulation of apoptosis, alpha-induced protein 3 have been demon-
has been recognized by the World Health mainly due to constitutive activation of strated recently in LGL leukemia. Because
Organization classifications amongst ma- survival pathways including Jak/Stat, MapK, these mutations are present in less than half
ture T-cell and natural killer (NK) cell neo- phosphatidylinositol 3-kinase–Akt, Ras– of the patients, they cannot completely

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plasms. There are 3 categories: chronic Raf-1, MEK1/extracellular signal-regulated explain LGL leukemogenesis. A better
T-cell leukemia and NK-cell lymphocytosis, kinase, sphingolipid, and nuclear factor- mechanistic understanding of leukemic
which are similarly indolent diseases char- kB. Socs3 downregulation may also con- LGL survival will allow future consider-
acterized by cytopenias and autoimmune tribute to Stat3 activation. Interleukin 15 ation of a more targeted therapeutic
conditions as opposed to aggressive NK- plays a key role in activation of leukemic approach than the current practice of
cell LGL leukemia. Clonal LGL expansion LGL. Several somatic mutations including immunosuppressive therapy. (Blood.
arise from chronic antigenic stimulation, Stat3, Stat5b, and tumor necrosis factor 2017;129(9):1082-1094)

Introduction
Initially described in 1985, large granular lymphocyte (LGL) leukemia Diagnosis
belongs to the rare chronic mature lymphoproliferative disorders of the T/
natural killer (NK) lineage.1 Two subtypes of LGL disorders were A definite diagnosis of LGL leukemia requires finding evidence of an
proposed in 1993: T-LGL leukemia and aggressive NK-cell leukemia.2 expanded clonal T- or NK-cell LGL population.
The World Health Organization (WHO) recognized this classification
scheme in 2001. Chronic NK-cell lymphocytosis was identified in 2008 as
a provisional entity to differentiate it from the much more aggressive form
of NK-cell leukemia.3,4 The most recent WHO version did not modify this Cytology
classification scheme but did highlight the discovery of Stat mutations
described in 2012 (Table 1).5,6 T-LGL leukemia and chronic NK-cell The first step of diagnosis is based on identification of increased numbers
lymphocytosis share the same clinical and biological presentation, as well of circulating LGL. Initially, an LGL count .2 3 109/L (normal value:
as treatment options.2,7-9 Pathogenesis of the disease is dominated by a ,0.3 3 109/L) was mandatory,2,13 but a lower number may be
clonal expansion of LGL resistant to activation-induced cell death due to compatible with the diagnosis if these cells are clonal and the patient
constitutive survival signaling. This review will describe topics concerning displays other clinical or hematologic features such as rheumatoid
diagnosis, pathogenesis, current, and future therapy of this rare disease. arthritis (RA) or cytopenias. Indeed, it has been found that some patients
with relatively low LGL counts (even ,1 3 109/L) have a clonal
disorder.9,13-15 Leukemic LGL are easily identified on blood smears by
their specific morphology; however, they are not cytologically distinguish-
Epidemiology able from normal reactive cytotoxic lymphocytes. They display a large size
(15-18 m), an abundant cytoplasm containing typical azurophilic granules,
LGL leukemia accounts for 2% to 5% of chronic lymphoproliferative and a reniform or round nucleus with mature chromatin (Figure 1A).
disorders in North America and Europe, and up to 5% to 6% in Asia.2 Blood smears must be examined carefully in cases of normal lymphocyte
Recently, the overall age-standardized incidence based on the national counts, and in rare cases in which the clonal lymphocytes do not present
Dutch registry has been reported as 0.72 per 1 000 000 person-per with typical LGL morphology. LGL excess in bone marrow (BM) (.10%
year.10 The incidence of LGL leukemia does not differ between male LGL) is detected in the majority of cases2 (Figure 1B).
and female. Indolent T-LGL leukemia is the most frequent form of the
disease representing ;85% of the cases, whereas chronic NK-cell
lymphocytosis is estimated at ,10% of cases.
Aggressive NK-LGL leukemia is mainly seen in Asia and Immunophenotyping
comprises ,5% of the LGL disorders. It affects younger patients and
is associated with Epstein-Barr virus infection: the prognosis of this rare T-LGL leukemias show a constitutive mature post-thymic phenotype.
entity is very poor due to refractoriness to chemotherapy.11,12 In the vast majority of cases, T-LGL leukemia shows a CD31, TCR

Submitted 9 August 2016; accepted 27 November 2016. Prepublished online © 2017 by The American Society of Hematology
as Blood First Edition paper, 23 January 2017; DOI 10.1182/blood-2016-08-
692590.

1082 BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9

BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9 LGL LEUKEMIA: OVERVIEW 1083

Table 1. Classification of LGL leukemia according to the WHO classification

WHO (2001) WHO (2008) WHO (2016)
Mature T- and NK-cell neoplasms Mature T- and NK-cell neoplasms Mature T- and NK-cell neoplasms
T-cell LGL leukemia T-cell LGL leukemia T-cell granular lymphocytic leukemia
Aggressive NK-cell leukemia Chronic lymphoproliferative disorder of NK cells* Aggressive NK-cell leukemia
Aggressive NK-cell leukemia Chronic lymphoproliferative disorder of NK cells*
Modifications:
New subtypes recognized with
clinicopathological manifestations
Stat3 and Stat5b mutations in a subset; latter
associated with more clinically aggressive disease

*Provisional entity.

ab1, CD42, CD5dim, CD81, CD161, CD272, CD282, CD45R02, 30% to 48% of NK-LGL lymphocytosis6,41-43 (Figure 2D). These

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CD45RA1, and CD571 phenotype, which represents a constitutively differences may be due to the sequencing technique and the selection of
activated T-cell phenotype (Figure 2A).16-18 CD31/CD561 T-LGL patients. Detection of identical Stat3 mutations in both T- and NK-
leukemias may have a more aggressive behavior associated with Stat5b subtypes suggests a unifying pathogenesis for these similar disorders.44
mutations.19,20 A rare subset of LGL leukemia is CD41 with or without Mutations are primarily located in exons 20 and 21 encoding the Src
coexpression of CD8. Patents with this LGL leukemia subtype almost homology 2 domain, which drives the dimerization and activation of
never have cytopenias, splenomegaly, or autoimmune phenomena,21,22 the Stat protein. D661 and Y640 account for two-thirds of mutations.42
and clonal LGL seem to be driven by cytomegalovirus.23 Recently, it Activating mutations outside the Src homology 2 domain are rarely
was found that Stat5b mutations are frequent in this LGL subtype.24
T-LGL leukemic cells are characterized by a terminal-effector
memory phenotype defined by the expression of CD45RA and lack of
CD62L expression.25 Leukemic LGL constitutively express interleukin
2 (IL-2) Rb (p75, CD122) and perforin, but not IL-2 Ra (p55,
CD25).26,27 Few cases are TCR gd1/CD4/CD8.28,29
NK-LGL leukemia and NK-LGL lymphocytosis are characterized
by the following phenotype: CD21/sCD32/CD3e1/TCRab2/CD42/
CD81/CD161/CD561 (Figure 2B).13 Fas (CD95) and Fas-ligand
(Fas-L) (CD178) are strongly expressed in LGL leukemia.30,31
Restricted killer immunoglobulin-like receptor (KIR) expression is
often seen in both in T- and NK-LGL leukemia.18,32

Clonality
Evidence of T-LGL clonality is routinely assessed using TCR g-poly-
merase chain reaction analyses. Deep sequencing of TCR has
demonstrated a restricted diversity of TCR repertoire.33 Vb TCR gene
repertoire analysis can also be ascertained using FCM and serves as
presumptive evidence for clonality34,35 (Figure 2C). The current Vb mAbs
panel covers 75% of the Vb spectrum with a high correlation between Vb
FCM and TCRg-polymerase chain reaction results. Fluctuations in clonal
dominance, as determined by complementarity determining region 3
(CDR3) sequencing, are seen in up to one-third of patients.36
It is difficult to assess the clonality of NK-LGL because these cells
do not express TCR. Restricted expression of activating isoforms of
KIR has been used as a surrogate marker for a monoclonal expansion
(Figure 2B).32,37-39
Clonal chromosomal abnormalities have been reported in a few
cases of LGL leukemia.1

Molecular findings
Figure 1. LGLs on blood and marrow smears. (A) A typical LGL on blood smear.
(Wright-Giemsa stain: original magnification 31000; Caméra RETIGA 2000). (B) BM
Constitutive activation of Stat3 in all LGL leukemia patients was first
smear showing numerous LGL with a basophilic neutrophil. (Wright-Giemsa stain:
discovered in 2001.40 In 2012, common somatic gain-of-function Stat3 original magnification 31000; Caméra RETIGA 2000). Image courtesy of Beatrice
mutations were demonstrated in 28% to 75% of T-LGL leukemia and Ly-Sunnaram (Rennes University Hospital, Rennes, France).
1084 LAMY et al BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9

A
[LY] CD3ECD / CD8PC7 [LY] CD8PC7 / CD5 APC APC
103 103

102 102

CD8

CD5
101 101

100 100

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100 101 102 103 100 101 102 103
CD3 CD8
B
[LY] CD3ECD / CD4A700 [LY] CD5 APC APC / CD16A750 [LY] CD3ECD / CD56PC5.5
3 103 103
10

102 102
102
CD4A700

CD56
CD16

101 101 101

00
10 100 100

100 101 102 103 100 101 102 103 100 101 102 103
CD3 CD5 CD3

[NK-cells] CD161PE [NK cells] NKB1- PE

15 20

15
10
Count
Count

10
5
5

0 0
0 100 101 102 103 0 101 102 103
CD161PE NKB1- PE

Figure 2. FCM and TCR g gene rearrangement analysis in LGL leukemia. (A) FCM analysis of a typical case of T CD3 1 LGL leukemia showing CD31 /CD5dim /CD8 1
(dark green). (B) FCM analysis of a case of NK CD3 2 LGL leukemia showing a CD32 /CD8 2 /CD16 1 /CD56 1 phenotype (pink). KIR monotypic expression using
CD161 and NkB1. (C) Clonality assessment: specific Vb mAbs showing restricted expression of Vb13.1 .90% (left); detection of clonal TCR g gene recombination
by gene scanning analysis, showing single peak in green (right). (D) Stat 3 mutation detection in a case of T-LGL leukemia using Sanger sequencing. FCM, flow
cytometry; WT, wild-type.

detected.45 Such mutations are located in the DNA-binding and coiled- but this mutation is not frequent (2%).19 The N642H mutation in
coil domain of Stat3. Utilization of deep sequencing has demonstrated particular was associated with more aggressive disease and an unusual
the presence of multiple subclones containing different Stat3 mutations CD31CD561 phenotype.48
in distinct LGL populations in individual patients.46 These findings
suggest a potential need for sequencing the entire Stat3 gene. Whether
or not Stat3 mutations are correlated with specific clinico-biological
features remains uncertain and is the subject of ongoing research. The Marrow features
Eastern Cooperative Oncology Group prospective clinical trial
suggested that a particular Stat3 mutation, Y640F, predicted response The diagnosis of LGL leukemia as discussed earlier is readily
to initial therapy with methotrexate (MTX).47 The first evidence of established using blood studies, so that marrow aspirate/biopsy is not
Stat5b mutations in human disease was discovered in LGL leukemia, routinely recommended as part of the initial evaluation. However,
BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9 LGL LEUKEMIA: OVERVIEW 1085

C
[CD8]
VB 8- 13.6 / VB 13.1 - 13.6 50 90 130 170 210 250 290
103
β13.1
Vβ 8000
92% 7000
102
VB 13.1 - 13.6

6000
5000
101 4000
3000
100 2000
1000
0
100 101 102 103

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VB 8- 13.6
D
G A A C C A T A C A C A A A G C A

STAT3
wt

2051 A>T

STAT3
mutated
Y640F

Figure 2. (Continued).

marrow evaluation can be helpful when the diagnosis is not straight distribution between dendritic cells and LGL in patient marrow samples
forward (eg, LGL count not increased). Such studies are also of value have been shown, suggesting constant antigen presentation.53 Trilineage
when considering other diseases that are part of the differential, hematopoiesis in BM biopsies of LGL patients is normal or increased in
including myelodysplastic syndrome (MDS) or aplastic anemia, or the majority of cases. Apoptotic figures, increased macrophages, and
when considering the diagnosis of pure red cell aplasia (PRCA) as eosinophilia have been described, suggesting an underlying dysmyelo-
potential etiology of profound anemia in patients with LGL leukemia. poiesis. In neutropenic patients, a typical finding is a decrease in
Individual or small clusters of LGLs may be sometimes identified. granulocyte precursors and left-shift maturation. However, the
They are difficult to identify because they mimick granulocytic or degree of marrow infiltration by LGL does not correlate with the
monocytic precursors. Because LGL infiltration of marrow is often a degree of cytopenia.49 An increase of erythroid precursors is
subtle finding, trephine biopsy with immunohistochemistry is described in 30% to 40% of the cases. Reticulin fibrosis is usually
recommended.7,49-51 A “grey zone” where the diagnosis of LGL present, ranging from grade 2 or 3 in ;50% to 60% of the cases.54
leukemia is not certain, should be considered in cases of low-LGL
count, or even lymphopenia associated with unexplained cytopenia
in which the diagnosis can be easily missed (Figure 3).
Classical histologic features are depicted in Figure 4. Clusters of Clinico-biological features
eight CD81/TiA11 cells or six granzyme B1 lymphocytes are
considered as characteristic histopathologic findings of LGL leukemia, LGL leukemia principally affects elderly people with a median age of
and support this diagnosis in uncertain cases.50,52 Very close topographic 60 years.2,7,8,55-58 Very rare pediatric cases have been reported and
1086 LAMY et al BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9

Clinical or biological context: neutropenia, recurrent infections, anemia,

autoimmune conditions, RA, lymphocytosis

Careful blood smears examination: excess of large granular lymphocytes?

yes

Flow cytometry analysis using CD3/5/4/8/16/56/57, TCRγ rearrangement,

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(Stat 3 mutation: recommended at this stage, Vβ repertoire and KIR phenotyping; if available,)

Grey zone
Polyclonal True clonal LGL expansion
Low LGL count around 0.5-1 x 109/L,
and no blood clonal evidence, stat3 unmutated, T or NK LGL Leukemia
pancytopenia, lymphopenia, Clonal TCRγ
Reactive LGL with clinical evocative context
proliferation

Post-splenectomy,
viral infection (CMV, HIV, EBV) Bone marrow biopsy with
BM/organ Immunohistochemistry yes
transplantation,…

Additional tests (if required

and not done before)
Interstitial and intravascular subtle LGL Stat3-5b/NFKB mutation,
Infiltration of clusters of CD3+/CD8+ Granzyme B/TiA1+ LGL Vβ repertoire, KIR
Lymphoid nodules of B and T CD4 cells phenotyping

Figure 3. Algorithm of the diagnosis of LGL leukemia. EBV, Epstein-Barr virus.

,25% of adult patients are younger than 50 years old. About one- a2, monocyte chemoattractant protein-1 (an attractive factor of
third of patients are asymptomatic at the time of diagnosis. Initial monocytes, T, and NK cells to sites of inflammation), epidermal
presentation is mainly related to neutropenia and includes recurrent oral growth factor, IL-6, IL-8, and IL-18.47,61,62 High b2 microglobulin
aphthous ulcerations, fever secondary to bacterial infections. These level is observed in 70% of cases. Rheumatoid factor and antinuclear
infections typically involve skin, oropharynx, and perirectal areas, but antibody are detected in 60% and 40% of patients, respectively.15
severe sepsis may occur. However, some patients may have profound Serum protein electrophoresis usually shows polyclonal hypergamma-
and persistent neutropenia without any infections over a very long globulinemia due to increased immunoglobulin G (IgG) and/or IgA
period of time. The frequency of recurrent infections varies in different subclasses. Defects in downregulation of Ig secretion in LGL leukemia
series from 15% to 39%. Fatigue and B symptoms are observed in 20% could partly explain the development of autoantibodies and clonal
to 30% of cases. Splenomegaly is reported with a frequency varying B-cell malignancies observed in this disease.63
from 20% to 50% and lymphadenopathy is rare.15 Half of the patients The associated comorbid conditions are reported in Table 2. RA is
present with lymphocyte counts between 4 3 109/L and 10 3 109/L, the most common associated disease, occurring in 10% to 18% of
and the LGL count usually ranges from 1 to 6 3 109/L. A lower LGL patients.7,8,17,64 Systemic lupus erythematosus, Sjogren syndrome,
count (0.5 to 1 3 109/L) may be observed in 7% to 36% of cases. Severe autoimmune thyroid disorders, coagulopathy, vasculitis with cryoglo-
neutropenia (,0.5 3 109/L) and moderate neutropenia (,1.5 3 109/L) bulinemia, and inclusion body myositis have occasionally been
are observed in 16% to 48% and 48% to 80% of cases, reported.64-67 Pulmonary artery hypertension has been observed.68
respectively. Anemia is frequent; transfusion-dependent patients Association with myeloid malignancies and BM failure syndromes, ie,
are observed in 10% to 30% of cases. PRCA occurs in 8% to 19% aplastic anemia (AA), paroxysmal nocturnal hemoglobinuria, and
of the cases and moderate thrombocytopenia is observed in ,25% MDS, is also reported.69-71 Recurrent Stat3 mutations in de novo AA
of patients.59 and MDS suggest similar pathogenesis.41 Efficacy of immunosuppres-
Although not routinely performed, increased soluble Fas-L (sFas-L) sive treatments directed against T-lymphocyte–mediated immune
is a good surrogate marker of LGL leukemia.60 We and others showed response is a strong argument for a common role of autoreactive T cells
that LGL leukemia patients had increased serum levels of interferon- in all of these diseases.
BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9 LGL LEUKEMIA: OVERVIEW 1087

Figure 4. BM features of LGL leukemia. (A)

Hematoxylin and eosin staining (HES) of marrow
biopsy reveals a slightly hypercellular marrow with a
subtle increase in interstitial lymphocytes. (B) CD3 A B
staining reveals the LGL interstitial infiltration. (C)
Immunoperoxydase staining for CD8 demonstrates
clusters of at least 8 cytotoxic lymphocytes CD81. (D)
Linear array of intravascular LGL demonstrated by
Granzyme B (GzB) staining. (E) CD57 staining reveals
the LGL interstitial infiltration. Original magnifications 34
(A), 340 (B), 320 (C), 3100 (D), and 320 (E). Images
courtesy of Philippe Gaulard (Department of Pathology,
Henri Mondor Hospital, Assistance Publique–Hôpitaux
de Paris, Creteil, France) and Patrick Tas (Department
of Pathology, Rennes University Hospital, Rennes, HES
France).

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CD3 x 40

CD8 x 20

CD57 x 20 GzB x 100

a larger clone size in LGL leukemia patients.47 Disease manifestations

Pathogenesis of LGL leukemia such as cytopenias and autoimmune diseases then result from the
production of proinflammatory cytokines mediated by STAT 3 regula-
A model of LGL leukemia pathogenesis is shown in Figure 5. LGL tion, as well as attack on marrow and joints by the STAT 3-activated LGL.
leukemia is at the intersection of a clonal lymphoproliferative disease, The key molecular signaling components in LGL leukemia are depicted
chronic inflammation, and autoimmunity. We hypothesize that an in Figure 6. Key features of the model are further summarized below.
unknown antigen is the initial activating event, resulting in oligoclonal
LGL expansion. Such chronic and persistent antigen exposure leads to An initial viral antigenic stimulation
Stat3 activation and the emergence of a dominant clone. A shift from
oligoclonal to clonal dominance is supported by serial studies of T-cell LGL leukemic cells represent an expanded population of effector
repertoire utilization.36 Somewhat surprisingly, clonal drift was observed memory cytotoxic T cells, suggesting chronic antigen stimulation.25 A
with the emergence over time of a different Vbeta clone in 37% of role of human T-cell lymphotropic virus (HTLV) retroviral infection
patients.36 We speculate that clonal drift results from the emergence of has been suggested primarily by serologic studies demonstrating cross-
LGL clones recognizing different epitopes/peptides of the same chronic reactivity to HTLV epitopes. Such seroreactivity is directed toward the
antigen. This theory could also explain the observation of clonal T-cell envelope protein BA21 and is seen in 30% to 50% of the patients.
LGL populations seen in patients with chronic NK lymphocytosis, as However, there is no definite evidence for HTLV-1 infection in LGL
well as the emergence of a new NK clone in patients with established leukemia patients,74-78 whereas HTLV-2 has been described only
T-cell LGL leukemia.72 occasionally.79,80
LGL leukemia is characterized by profound dysregulation of the Two cases of LGL leukemia associated with B-indolent lymphoma
normal process of activation-induced cell death. The fundamental were reported in a patient infected with hepatitis C virus infection. Both
pathogenic feature of LGL leukemia is the activation of a survival were successfully treated by antiviral therapy. This underlies a potential
network, which keeps the leukemic LGL alive and functioning as killer link between hepatitis C virus chronic infection and LGL leukemia.81
cells.73 The central hub of this survival network is Stat3. We hypothesize Recently, Sandberg et al analyzed CDR3-b and -a chain in 26 T CD81
that activating mutations of Stat3 support clonal dominance by causing a abTCR LGL patients and found heterogeneity in the CDR3 region,
higher level of transcription of survival components. This theory is suggesting that a unique antigen-driving LGL leukemia may be
supported by the observation that STAT3 mutations are correlated with unlikely.82
1088 LAMY et al BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9

Table 2. Principal associated diseases with LGL leukemia leukemic LGL survival.73 IL-15 has also been implicated in LGL
Associated diseases with LGL leukemia* Frequency (%) leukemogenesis using a unique IL-15 transgenic mouse model,
Neoplasms 4-10 demonstrating an increase of global DNA methylation level in LGL
Autoimmune cytopenia 5 cells.86 Activation of survival pathways by PDGF occurs through an
PRCA autocrine loop in leukemic LGL.87
AIHA
ITP Constitutive activation of Jak-Stat3 signaling pathway
Evans syndrome
B-cell lymphoid neoplasms 5 Constitutive activation of Stat3 (pStat3), in our opinion, plays the
Low-grade NHL fundamental pathogenic role in LGL leukemia, because the
DLBCL transcriptome of LGL leukemia patients is that of Stat3-regulated
Mantle cell lymphoma genes.6,40 In vitro inhibition of Stat3 by STA-21 restores the
MM apoptosis of LGL cell independent of Stat3 mutational status. This
CLL
finding implies that Stat3 mutation is not itself mandatory to
Hairy cell leukemia
explain LGL clonal expansion. It raises the question of mechanism

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Waldenstrom macroglobulinemia
Hodgkin lymphoma
of Stat3 activation in unmutated patients. The proinflammatory
Lymphomatoid granulomatosis cytokine IL-6 is able to activate the Jak-Stat3 pathway and a high
Heavy chain disease amount of IL-6 is observed in LGL patients.62 Inhibition of this
Autoimmune diseases/connective tissue disorders 10-20 cytokine restores LGL apoptosis. Dendritic cells could trigger the
RA 10-18 clonal proliferation and maintain LGL expansion by IL-6
Systemic lupus erythematosus
production. Because SOCS3 transcription is induced by IL-6
Vasculitis
through pStat3, SOCS3 was postulated to be high in LGL
Systemic sclerosis
Endocrinopathy
leukemia. Surprisingly, Teramo et al showed that SOCS3 messenger
APECED RNA and protein level was significantly decreased in LGL leukemia.
MEN-1 Demethylation agent restored SOCS3 expression in leukemic
Hashimoto disease LGL, and consequently decreased Stat3 and Mcl-1 expression. No
Grave disease mutation or methylation of SOCS3 promoter has been found to
CIBD explain this downregulation.62 Although Stat3 activation plays the
Celiac disease most important pathogenenic role, multiple other cell survival
Gougerot-Sjogren syndrome pathways are dysregulated and these are briefly described in the
Glomurolenephritis
sections to follow.
Polymyositis
Inclusion body myositis
Resistance to Fas/Fas-L–mediated apoptosis
Poly/multinevritis
RPA
Leukemic LGL are resistant to Fas-mediated apoptosis.30 However,
Inflammatory arthritis (unclassified)
apoptosis is restored using IL-2 stimulation, suggesting an inhibition of
Lambert-Eaton myasthenic syndrome
Good syndrome
this pathway and not a complete defect. Moreover, sFas, detected in
Behcet disease LGL patient sera, acts as a decoy receptor able to inhibit Fas-dependent
MS apoptosis.60 Decreased level of an inhibitory protein named c-FLIP is
Acquired factor VIII inhibitor found in leukemic LGL contributing to DISC formation defect. This
MDS 3-10 protein blocks the initial event of Fas-mediated apoptosis through Fas-
AML ,1 associated protein with death domain and caspase 8 recruitment.25
Hemophagocytic syndrome ,1
Pulmonary hypertension ,1 Ras–Raf-1–MEK1-ERK pathway
Post-organ or hematopoietic SCT ,1
Post viral infection ,1 Overactive Ras plays a role in the survival signaling in LGL leukemia.
Constitutive activation of Ras and ERK was found in NK-LGL
AIHA, autoimmune hemolytic anemia; AML, acute myeloid leukemia; APECED,
polyendocrinopathy candidosis-ectodermal dystrophy; CIBD, chronic inflammatory bowel leukemia and G12 KRAS mutation was detected in the LGL leukemia
disease; CLL, chronic lymphocytic leukemia; DLBCL, diffuse large B-cell lymphoma; ITP, cell line.88 Blockade of either ERK or Ras activity may restore Fas
idiopathic thrombocytopenic purpura; MEN-type 1, multiple endocrine neoplasia type 1; sensitivity in leukemic LGLs.89
MM, multiple myeloma; MS, multiple sclerosis; NHL, non-Hodgkin lymphoma; RPA,
rhizomelic pseudopolyarthritis; SCT, stem cell transplantation.
*Some patients presented with more than one auto-immune–associated Dysregulation of PI3K/Akt pathway
disease.
Activated Akt is observed in leukemic LGL. Proinflammatory proteins
RANTES, IL-18, and MIP-1b, which activate the PI3K pathway, are
Initiating role of IL-15 and PDGF upregulated in LGL patients.61 Increased activity of the PI3K-AKT
signaling axis has been found in T-LGL cells and participated in
IL-15 proinflammatory cytokine and PDGF play a crucial role in LGL apoptosis inhibition.90
leukemia expansion by promoting NK-cell or leukemic-LGL
survival.73,83 IL-15 receptor-a2/2 mice display an NK-cell and CD81 Activation of NF-kB pathway
memory T-cell defect. LGL cell growth is dependent of IL-15, and
IL-15a chain messenger RNA was detectable in LGL-purified cells.84,85 Leukemic LGL exhibit a higher level of c-Rel (a member of NF-kB
In a network model of LGL leukemia survival signaling, IL-15 and family) and high NF-kB activity. NF-kB inhibition induces leukemic
PDGF were predicted to be the master activation switches necessary for LGL apoptosis. It has been shown that NF-kB acts downstream of the
BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9 LGL LEUKEMIA: OVERVIEW 1089

Figure 5. Model of LGL leukemia pathogenesis.

Activation and expansion occur, resulting in an oligoclo-
Production of inflammatory cytokines
nal cytotoxic lymphocyte population (colored outline 1
represents a distinct clone, blue triangle represents an
unknown antigen). STAT3 is activated and may acquire Oligoclonal
a mutation. Chronic antigen stimulation leads to expan- Monoclonal
cytotoxic
sion of one dominant (monoclonal) cytotoxic lymphocyte cytotoxic
Iymphocyte
population (all are outlined in black signifying the Iymphocyte
population resulting population with Outcomes: symptoms (neutropenia,
monoclonal population). Three outcomes occur. In panel from an unknown STAT3 anemia, fatigue), autoimmune disease (RA)
1, the production of inflammatory cytokines (starburst antigen activation/mutation
shapes representing: IFN-g, IL-8, IL-10, IL-1b, IL-12p35,
leading to 3 2 Functional killer cells release cytotoxic
IL-18, IL-1Ra, RANTES, MIP1-a, and MIP1-b) causes STAT3 granules
symptoms such as neutropenia, anemia, and fatigue, activation/ outcomes.
and can also cause an autoimmune disease such as mutation
RA. In panel 2, the functional killer cells release cytotoxic
granules containing perforin and granzyme B (purple
unknown Outcomes: symptoms (neutropenia,
dots); this leads to the same outcomes as in panel 1. In
antigen anemia, fatigue), autoimmune disease (RA)
panel 3, the STAT3-mediated survival network results
in a persisting clone due to profound dysregulation of

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apoptosis, including resistance to Fas/FasL-mediated
3 STAT3-mediated survival network
death and upregulation of Mcl-1. IFN, interferon; MIP,
macrophage inflammatory protein. Chronic antigen STAT3
stimulation apoptosis
Outcome: persisting clone due to profound
dysregulation of apoptosis (resistance to
Fas/FasL-mediated death, Mcl-1 upregulation...)

PI3K-AKT pathway to prevent apoptosis through Mcl-1 independently primarily based on small retrospective series. The most clinical
of Stat3.73 Recently, a recurrent nonsynonymous mutation in the gene experience has been reported using low-dose MTX, cyclophospha-
encoding an NF-kB signaling inhibitor, TNFAIP3, was found in 3 out mide, and cyclosporine A (CyA) as single agents (see next section).
of 39 patients (8%), underlying the important role of NF-kB activity in
LGL leukemia.91 Supportive therapy

Supportive care could be considered for patients suffering from anemia

Dysregulation of sphingolipid rheostat in LGL leukemia
or neutropenia using erythropoietin or granulocyte colony-stimulating
Molecular expression profile analysis in LGL leukemia shows a factor (G-CSF), respectively. However, such treatment does not
predominant expression of prosurvival sphingolipids, such as S1P.92 address the underlying illness. G-CSF delivered as a single agent may
SphK1, which converts sphingosine into S1P is increased in LGL be effective in rapidly increasing ANC. This could be of some value in
leukemia and SphK1 inhibition leads to leukemic LGLs apoptosis. the setting of patients with episodes of severe febrile neutropenia in
SP1 binding to SP1R activates prosurvival signal through ERK1/2 which a rapid neutrophil response would be desirable. However,
signaling.93 Moreover, expression of the S1P receptor, mainly S1PR5, is G-CSF is not effective in all LGL leukemia patients. Of note, G-CSF may
increased in LGL leukemia.94,95 induce the exacerbation of splenomegaly and articular symptoms.97,98
Therapy with erythropoietin in LGL leukemia patients has been reported
only infrequently and with disappointing results.14

First-line therapy
Prognosis
Immunosuppressive therapy is the foundation of treatment of LGL
T and chronic NK-LGL leukemia are considered indolent diseases. The leukemia based on the rationale that leukemic LGL represent
vast majority of patients will eventually need treatment at some point constitutively activated cytotoxic lymphocytes.
during disease evolution. Disease-related deaths are mainly due to First-line therapy relies on the use of single immunosuppressive oral
severe infections that occur in ,10% of the patient population.10,14,96 agents such as MTX (10 mg/m2 per week), cyclophosphamide (100 mg
Overall survival at 10 years is ;70%. Conversely, the prognosis of per day), or CyA (3 mg/kg per day). A minimum of 4 months of therapy
aggressive NK-LGL leukemia is very poor because patients are is required before assessing response. Since the initial publication on
refractory to treatment.11,12 the efficacy of MTX and until now, this drug has been considered
as the best first-line option, mainly for neutropenic patients.99 Oral
cyclophosphamide has been preferentially used in patients with
predominant anemia and particularly, PRCA.59,100
Therapy Based on retrospective studies, the overall response rate (ORR)
appears quite broad ranging from 21% to 85% (median, ;50%), with
Treatment options are similar for T-LGL leukemia and chronic NK-cell similar responses to each of the 3 drugs, making comparison difficult.
lymphocytosis. Indications for treatment include severe neutropenia The complete response (CR) rate is relatively low: ;21% for MTX,
(absolute neutrophil count [ANC] ,0.5 3 109/L), moderate neutropenia 33% for cyclophosphamide, and ,5% for CyA.9 Duration of response
(ANC .0.5 3 109/L) associated with recurrent infections, symptomatic is ;21 months for MTX. However, the relapse rate may be high, with
or transfusion-dependent anemia, and associated autoimmune condi- the French series reporting rates of 67%, compared with 13% for
tions requiring therapy.9 Standard treatment of LGL leukemia is patients receiving cyclophosphamide.9,14 Cyclophosphamide as first-
immunosuppressive therapy, but such treatment recommendations are line therapy may induce high ORR with ;50% CR rate for either
1090 LAMY et al BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9

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Figure 6. Key molecular abnormalities in LGL leukemia. Fas-mediated death-inducing signaling complex (DISC) inhibition: LGL leukemia cells are resistant to Fas-
mediated apoptosis. sFas acts as a decoy receptor able to inhibit Fas-dependent apoptosis. Increased level of an inhibitory protein named cellular FADD-like IL-1
converting enzyme inhibitory protein (c-FLIP) contributes to the DISC formation defect. Jak/Stat3 pathway: Stat3 is constitutively activated in LGL leukemia and is
responsible for the transcription of B-cell lymphoma 2 and myeloid cell leukemia 1 (Mcl-1) protein expression. Inhibition of Stat3 restores apoptosis of LGL cells whatever
the Stat3 mutation status, which implies that Stat3 mutation is not itself mandatory to explain LGL clonal expansion. SOCS3, which inhibits the Jak/Stat3 pathway is
significantly decreased in LGL leukemia. Survival signal: LGL leukemia shows a predominant expression of specificity protein 1 (SP1). Sphingosine kinase 1 (SphK1),
which converts sphingosine into SP1 is increased in LGL leukemia and SphK1 inhibition leads to leukemic LGLs apoptosis. SP1 binding to SP1R activates a prosurvival
signal through extracellular signal-regulated kinase 1/2 (ERK1/2) signaling. Moreover, the expression of SP1 receptor, mainly SP1R5, is increased in LGL leukemia.
Ras–Raf-1–MEK1-ERK, phosphatidylinositol 3-kinase (PI3K)/AKT pathway are upregulated in LGL leukemia and the inhibition leads to LGL apoptosis. Increased activity
of the PI3K-AKT signaling axis is found in T-LGL cells and participate in apoptotic inhibition. NF-kB activity is upregulated in LGL leukemia. NF-kB acts downstream of
the PI3K-AKT pathway to prevent apoptosis through Mcl-1 independently of Stat3. A recurrent nonsynonymous mutation in the gene encoding an NF-kB signaling
inhibitor, tumor necrosis factor alpha-induced protein 3 (TNFAIP3), was found in 8% of LGL leukemia patients. IL-15 and platelet-derived growth factor (PDGF): IL-15
promotes myc expression through the NF-kB pathway (model of IL-15 transgenic mouse). IL-15 is associated with an increase of global DNA methylation level in LGL
leukemia through DNA methyltransferase 3A (DNMT3A) upregulation. The downregulation of microRNA-29 (miR-29) is responsible for the upregulation of DNMT3A,
which induce methylation of the tumor suppressor gene Ibd4. GP130, glycoprotein 130; NF-kB, nuclear factor kB; pSTAT3, phosphoSTAT3; SFK, Src family kinase;
SP1R5, specificity protein 1 receptor 5.

neutropenic or anemic patients.101 CyA corrects cytopenia without chest radiographs. Our recommendation is to stop cyclophosphamide
elimination of the LGL clone.14,15,102 It has been suggested that HLA- after 8 to 12 months because of its mutagenic potential. Renal function
DR4 (observed in 32% of LGL leukemia) could be highly predictive of and blood pressure have to be carefully monitored during CyA
CyA responsiveness.103 treatment.9 The effects of prednisone as single agent in the treatment of
The results of the first large prospective study of immunosuppres- LGL leukemia are not convincing but may decrease some inflammatory
sive agents in LGL leukemia was recently reported.47 Fifty-five patients symptoms related to RA, and in rare cases, it may transiently improve
received MTX at first-line and nonresponders were switched to neutropenia.
cyclophosphamide. The ORR was 38% in step 1 (which is lower
compared with the results of the large retrospective studies) and 64% in Second-line therapy
step 2. These data indicate that a high proportion of patients may
respond to cyclophosphamide even after having failed to respond to It is difficult to make any treatment recommendations for patients
MTX.14,98 As discussed earlier, Stat3 Y640F mutation may be a refractory to the first-line agents because of the rarity of the disease and
predictive biomarker for response to MTX, but this observation needs the general absence of prospective data. To the authors’ knowledge,
validation in a larger cohort of patients. An important randomized trial there is only 1 ongoing clinical trial in the United States, which
(#NCT01976182) investigating first-line MTX vs cyclophosphamide investigates alemtuzumab.104 T.P.L.’s practice is to refer refractory
is ongoing in France and will hopefully determine the best choice of patients for consideration for participation in this study, which is
initial therapy in this disease. being conducted at the National Institutes of Health.
In case of failure of primary therapy, a switch between MTX and Clinical experience using a number of different options in a smaller
cyclophosphamide should be considered. In our practice, CyA is number of patients has been reported for LGL leukemia patients and
reserved for patients failing both drugs. Both MTX and CyA are these could be considered for refractory patients. These results are
maintained indefinitely, as long as these medications are reasonably summarized as follows:
tolerated and disease response is maintained. Long-term use and Purine analogs. Less than 50 patients have been reported to be
monitoring of low-dose MTX follows guideline recommendations of treated with either fludarabine, cladribine, deoxycoformycine, or
its use in RA. Hepatic (hepatitis) and lung dysfunction (hypersensitivity bendamustine.14,102,105-107 The ORR looks promising at ;79%.
pneumonitis) may occur requiring regular evaluation of liver tests and Remissions are usually obtained rapidly and the patients may be
BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9 LGL LEUKEMIA: OVERVIEW 1091

treated with a maximum of 1 to 3 courses in order to limit toxicity. However, in complete responders, STAT3-mutated subclones are still
Fludarabine has been used in combination with mitoxantrone with detected.46 There are recent exciting data concerning Jak3 pathway
long-lasting complete remission. Whether or not purine analogs inhibition. Jak3 is now considered a target for immunosuppression.
should be integrated into first-line therapy is an open question. Tofacitinib citrate (CP690550), a Jak3-specific inhibitor has demon-
Combined chemotherapy. Polychemotherapy based on cyclo- strated impressive activity in refractory RA.118,119 Recently, 9 patients
phosphamide, doxorubicin, vincristine, and prednisone-like or cytosine- with refractory LGL leukemia and RA were treated with tofacitinib
arabinoside–containing regimen has not demonstrated efficacy in chronic citrate. Hematologic response was observed in 6 of 9 cases, with
refractory form of disease and should be reserved for rare cases of improvement in neutropenia observed in 5 of 7 patients.120 Because
aggressive LGL leukemia. In some cases of multirefractory patients, SCT NF-kB is constitutively active in T-LGL, bortezomib could be
could be considered. We recently reported the European Society for considered a promising agent for investigation in LGL leukemia, as
Blood and Marrow Transplantation series of 15 patients receiving auto or supported by demonstrated efficacy in the LGL leukemia model of
allogeneic SCT.108 Six patients remained disease-free posttransplantation. IL-15 transgenic mice.86 In LGL leukemia, proapoptotic signals
Immunotherapy. Alemtuzumab (Campath), which is a humanized (ceramide) are downregulated and prosurvival signals (S1PR5) are
monoclonal antibody (mAb) (anti-CD52) has been proposed for upregulated.93,94 We showed that FTY720, a S1PR agonist, induced
refractory patients in very limited series. The ORR is ;60%.9,14,15,104

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apoptosis of LGL cells and that C6-ceramide encapsulated in
However, the general availability of this drug is now limited and nanoliposomes and led to apoptosis in an NK-LGL rat leukemia
infectious risks limit the use of this agent. Efficacy of extracorporeal model by targeting survivin. A trial of ceramide nanoliposomes is
photopheresis has been reported recently with documented CR.109 ongoing in patients with advanced solid tumors (#NCT02834611)
Rituximab, the specific anti-CD20 mAb, has been paradoxically and this could be a potential therapeutic candidate for LGL leukemia.
used in patients with both RA and LGL leukemia. It was suggested that
eradication of B-cell expansion and autoimmune antigens could have
led to the eradication of reactive LGL clones. In our opinion, this is not a
reasonable option for LGL leukemia.110,111 Conclusion
Splenectomy. Splenectomy may be considered in patients with
symptomatic splenomegaly associated or not with cyopenias. An It appears that immunosuppressive agents, such as MTX, cyclophos-
overall review of the literature shows an ORR of 56% but sustained phamide, and CyA are limited in their capacity to eradicate the LGL
responses are infrequent.14,15,112,113 clone and induce long-lasting remission. Due to a lack of prospective
Targeted therapy. Considering the pathogenesis of LGL leuke- comparative clinical trials, a decision as to which one of these 3 agents is
mia, different specific pathways conceivably could be targeted using best proposed as first-line therapy cannot be made. There is an urgent
either cytokine antagonistic agents, mAbs directed against membrane unmet need to develop better therapeutics for LGL leukemia, because
receptors, Jak/Stat inhibitors, NF-kB, or farnesyl transferase/Ras inhibitors. this disease remains incurable. Significant progress has been made in
Regarding IL-15 targeting, a clinical trial (#NCT 00076180) has our understanding of LGL clonal expansion, primarily based on the
tested the effects of Hu-Mikb1, which blocks IL-15 trans presentation importance of Stat3 activation/mutation in pathogenesis of illness. This
to T cells that express IL-2/IL-15Rb (CD122). Administration of Hu- knowledge suggests the possibility of using targeted therapy such as
Mikb1 to patients was safe but clinical responses were not observed.114 Jak/Stat inhibitors, which are currently under development, have
A phase 1 study with an anti-CD2 mAb (siplizumab) was conducted in entered clinical trials, or are already US Food and Drug Administration-
2005 in patients with relapsed/refractory CD21 T-cell lymphoma/ approved for other medical conditions.
leukemia, including T-LGL leukemia (#NCT00123942). To our
knowledge, the results of this trial have not been published.
Based on constitutive Ras activation in leukemic LGL, a phase 2
study investigating the use of farnesyltransferase inhibitor (tipifarnib) Authorship
enrolled a total of 8 patients. No clinical responses were observed
despite a significant improvement in marrow hematopoiesis and Contribution: T.L., A.M., and T.P.L. participated in the writing of
increased hematopoietic colony growth in vitro.115 this manuscript.
A Stat inhibitor, OPB-31121, had a significant antitumor effect on Conflict-of-interest disclosure: The authors declare no competing
leukemia cells with Stat-addictive oncokinases.116 Stat3 inhibition financial interests.
could be a good therapeutic option in LGL leukemia. Of interest, low- Correspondence: Thierry Lamy, Department of Hematology,
dose MTX was recently identified as a very active inhibitor of the Jak/ Pontchaillou University Hospital, 2 Rue Henri le Guilloux, 35000
Stat pathway, perhaps now explaining its efficacy in LGL leukemia.117 Rennes, France; e-mail: [email protected].

References
1. Loughran TP Jr, Kadin ME, Starkebaum G, et al. H, Vardiman JW (eds). Ann Oncol. 2002;13(3): lymphocytic leukemia. N Engl J Med. 2012;
Leukemia of large granular lymphocytes: 490-491. 366(20):1905-1913.
association with clonal chromosomal 7. Lamy T, Loughran TP Jr. Clinical features of
4. Swerdlow SH, Campo E, Harris NL, et al. WHO
abnormalities and autoimmune neutropenia, large granular lymphocyte leukemia. Semin
Classification of Tumours of Haematopoietic and
thrombocytopenia, and hemolytic anemia. Ann Hematol. 2003;40(3):185-195.
Lymphoid Tissues. 4th ed. Lyon, France: IARC
Intern Med. 1985;102(2):169-175.
Publications; 2008. 8. Sokol L, Loughran TP Jr. Large
2. Loughran TP Jr. Clonal diseases of large 5. Swerdlow SH, Campo E, Pileri SA, et al. The granular lymphocyte leukemia. Oncologist.
granular lymphocytes. Blood. 1993;82(1):1-14. 2016 revision of the World Health Organization 2006;11(3):263-273.
classification of lymphoid neoplasms. Blood. 9. Lamy T, Loughran TP Jr. How I treat LGL
3. Hossfeld DK. World Health Organization
2016;127(20):2375-2390. leukemia. Blood. 2011;117(10):2764-2774.
Classification of Tumours: Pathology and
Genetics of Tumours of Haematopoietic and 6. Koskela HLM, Eldfors S, Ellonen P, et al. 10. Dinmohamed AG, Brink M, Visser O, Jongen-
Lymphoid Tissues. In: Jaffe ES, Harris NL, Stein Somatic STAT3 mutations in large granular Lavrencic M. Population-based analyses
1092 LAMY et al BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9

among 184 patients diagnosed with large 27. Oshimi K, Shinkai Y, Okumura K, Oshimi Y, highly specific for large granular lymphocytic
granular lymphocyte leukemia in the Netherlands Mizoguchi H. Perforin gene expression in leukemia. Leukemia. 2013;27(7):1598-1600.
between 2001 and 2013. Leukemia. 2016;30(6): granular lymphocyte proliferative disorders.
43. Ohgami RS, Ma L, Merker JD, Martinez B,
1449-1451. Blood. 1990;75(3):704-708.
Zehnder JL, Arber DA. STAT3 mutations are
11. Imamura N, Kuramoto A. Effect of splenectomy 28. Bourgault-Rouxel AS, Loughran TP Jr, Zambello frequent in CD301 T-cell lymphomas and T-cell
in aggressive large granular lymphocyte R, et al. Clinical spectrum of gammadelta1 T cell large granular lymphocytic leukemia. Leukemia.
leukaemia. Br J Haematol. 1988;69(4):577-578. LGL leukemia: analysis of 20 cases. Leuk Res. 2013;27(11):2244-2247.
2008;32(1):45-48.
12. Suzuki R, Suzumiya J, Nakamura S, et al; NK- 44. Jerez A, Clemente MJ, Makishima H, et al.
cell Tumor Study Group. Aggressive natural 29. Sandberg Y, Almeida J, Gonzalez M, et al. STAT3 mutations unify the pathogenesis of
killer-cell leukemia revisited: large TCRgammadelta1 large granular lymphocyte chronic lymphoproliferative disorders of NK cells
granular lymphocyte leukemia of cytotoxic NK leukemias reflect the spectrum of normal and T-cell large granular lymphocyte leukemia.
cells. Leukemia. 2004;18(4):763-770. antigen-selected TCRgammadelta1 T-cells. Blood. 2012;120(15):3048-3057.
Leukemia. 2006;20(3):505-513.
13. Semenzato G, Zambello R, Starkebaum G, 45. Andersson E, Kuusanmäki H, Bortoluzzi S, et al.
Oshimi K, Loughran TP Jr. The 30. Lamy T, Liu JH, Landowski TH, Dalton WS, Activating somatic mutations outside the SH2-
lymphoproliferative disease of Loughran TP Jr. Dysregulation of CD95/CD95 domain of STAT3 in LGL leukemia. Leukemia.
granular lymphocytes: updated criteria for ligand-apoptotic pathway in CD3(1) large 2016;30(5):1204-1208.
diagnosis. Blood. 1997;89(1):256-260. granular lymphocyte leukemia. Blood. 1998;
92(12):4771-4777. 46. Rajala HLM, Olson T, Clemente MJ, et al.
14. Bareau B, Rey J, Hamidou M, et al. Analysis The analysis of clonal diversity and therapy

Downloaded from https://ashpublications.org/blood/article-pdf/129/9/1082/1026878/blood692590.pdf by guest on 15 October 2019

of a French cohort of patients with large 31. Perzova R, Loughran TP Jr. Constitutive responses using STAT3 mutations as a
granular lymphocyte leukemia: a report on 229 expression of Fas ligand in large molecular marker in large granular lymphocytic
cases. Haematologica. 2010;95(9):1534-1541. granular lymphocyte leukaemia. Br J leukemia. Haematologica. 2015;100(1):91-99.
Haematol. 1997;97(1):123-126.
15. Mohan SR, Maciejewski JP. Diagnosis 47. Loughran TP Jr, Zickl L, Olson TL, et al.
and therapy of neutropenia in large 32. Zambello R, Falco M, Della Chiesa M, Immunosuppressive therapy of LGL leukemia:
granular lymphocyte leukemia. Curr Opin et al. Expression and function of KIR and prospective multicenter phase II study by the
Hematol. 2009;16(1):27-34. natural cytotoxicity receptors in NK-type Eastern Cooperative Oncology Group (E5998).
lymphoproliferative diseases of Leukemia. 2015;29(4):886-894.
16. Lundell R, Hartung L, Hill S, Perkins SL, Bahler granular lymphocytes. Blood. 2003;102(5):
DW. T-cell large granular lymphocyte leukemias 1797-1805. 48. Rajala HLM, Porkka K, Maciejewski JP,
have multiple phenotypic abnormalities involving Loughran TP Jr, Mustjoki S. Uncovering the
pan-T-cell antigens and receptors for MHC 33. Clemente MJ, Przychodzen B, Jerez A, et al.
pathogenesis of large granular lymphocytic
molecules. Am J Clin Pathol. 2005;124(6): Deep sequencing of the T-cell receptor
leukemia-novel STAT3 and STAT5b mutations.
937-946. repertoire in CD81 T-large granular lymphocyte
Ann Med. 2014;46(3):114-122.
leukemia identifies signature landscapes. Blood.
17. O’Malley DP. T-cell large granular leukemia and 2013;122(25):4077-4085. 49. Burks EJ, Loughran TP Jr. Pathogenesis of
related proliferations. Am J Clin Pathol. 2007; neutropenia in large granular lymphocyte
127(6):850-859. 34. Langerak AW, van Den Beemd R, Wolvers-
leukemia and Felty syndrome. Blood Rev. 2006;
Tettero ILM, et al. Molecular and flow cytometric
18. Bigouret V, Hoffmann T, Arlettaz L, et al. 20(5):245-266.
analysis of the Vbeta repertoire for clonality
Monoclonal T-cell expansions in asymptomatic assessment in mature TCRalphabeta T-cell 50. Morice WG, Kurtin PJ, Tefferi A, Hanson CA.
individuals and in patients with large granular proliferations. Blood. 2001;98(1):165-173. Distinct bone marrow findings in T-cell granular
leukemia consist of cytotoxic effector T cells lymphocytic leukemia revealed by paraffin
expressing the activating CD94:NKG2C/E and 35. Lima M, Almeida J, Santos AH, et al.
section immunoperoxidase stains for CD8, TIA-1,
NKD2D killer cell receptors. Blood. 2003;101(8): Immunophenotypic analysis of the TCR-Vbeta
and granzyme B. Blood. 2002;99(1):268-274.
3198-3204. repertoire in 98 persistent expansions
of CD3(1)/TCR-alphabeta(1) large 51. Osuji N, Beiske K, Randen U, et al.
19. Rajala HLM, Eldfors S, Kuusanmäki H, et al. granular lymphocytes: utility in assessing Characteristic appearances of the bone marrow
Discovery of somatic STAT5b mutations in large clonality and insights into the pathogenesis in T-cell large granular lymphocyte leukaemia.
granular lymphocytic leukemia. Blood. 2013; of the disease. Am J Pathol. 2001;159(5): Histopathology. 2007;50(5):547-554.
121(22):4541-4550. 1861-1868.
52. Evans HL, Burks E, Viswanatha D, Larson RS.
20. Gentile TC, Uner AH, Hutchison RE, et al. CD31, 36. Clemente MJ, Wlodarski MW, Makishima H, Utility of immunohistochemistry in bone
CD561 aggressive variant of large granular et al. Clonal drift demonstrates unexpected marrow evaluation of T-lineage large
lymphocyte leukemia. Blood. 1994;84(7): dynamics of the T-cell repertoire in T-large granular lymphocyte leukemia. Hum Pathol.
2315-2321. granular lymphocyte leukemia [published 2000;31(10):1266-1273.
21. Garrido P, Ruiz-Cabello F, Bárcena P, et al. correction appears in Blood. 2012;120(9):1963].
53. Zambello R, Berno T, Cannas G, et al.
Monoclonal TCR-Vbeta13.11/CD41/NKa1/ Blood. 2011;118(16):4384-4393.
Phenotypic and functional analyses of dendritic
CD8-/1dim T-LGL lymphocytosis: evidence for 37. Fischer L, Hummel M, Burmeister T, Schwartz S, cells in patients with lymphoproliferative disease
an antigen-driven chronic T-cell stimulation origin. Thiel E. Skewed expression of natural-killer of granular lymphocytes (LDGL). Blood. 2005;
Blood. 2007;109(11):4890-4898. (NK)-associated antigens on lymphoproliferations 106(12):3926-3931.
22. Lima M, Almeida J, Dos Anjos Teixeira M, of large granular lymphocytes (LGL). Hematol
Oncol. 2006;24(2):78-85. 54. Mailloux AW, Zhang L, Moscinski L, et al.
et al. TCRalphabeta1/CD41 large granular
Fibrosis and subsequent cytopenias are
lymphocytosis: a new clonal T-cell 38. Epling-Burnette PK, Painter JS, Chaurasia P, associated with basic fibroblast growth factor-
lymphoproliferative disorder. Am J Pathol. et al. Dysregulated NK receptor expression in deficient pluripotent mesenchymal stromal cells
2003;163(2):763-771. patients with lymphoproliferative disease of in large granular lymphocyte leukemia.
23. Rodrı́guez-Caballero A, Garcı́a-Montero AC, granular lymphocytes. Blood. 2004;103(9): J Immunol. 2013;191(7):3578-3593.
Bárcena P, et al. Expanded cells in monoclonal 3431-3439.
55. Lamy T, Loughran TP Jr. Current concepts: large
TCR-alphabeta1/CD41/NKa1/CD8-/1dim 39. Scquizzato E, Teramo A, Miorin M, et al. granular lymphocyte leukemia. Blood Rev. 1999;
T-LGL lymphocytosis recognize hCMV Genotypic evaluation of killer immunoglobulin- 13(4):230-240.
antigens. Blood. 2008;112(12):4609-4616. like receptors in NK-type lymphoproliferative
disease of granular lymphocytes. Leukemia. 56. Poullot E, Zambello R, Leblanc F, et al. Chronic
24. Andersson EI, Tanahashi T, Sekiguchi N, et al.
2007;21(5):1060-1069. natural killer lymphoproliferative disorders:
High incidence of activating STAT5B mutations
characteristics of an international cohort of 70
in CD4-positive T-cell large granular lymphocyte 40. Epling-Burnette PK, Liu JH, Catlett-Falcone R, patients. Ann Oncol. 2014;25(10):2030-2035.
leukemia. Blood. 2016;128(20):2465-2468. et al. Inhibition of STAT3 signaling leads
to apoptosis of leukemic large 57. Watters RJ, Liu X, Loughran TP Jr. T-cell and
25. Yang J, Epling-Burnette PK, Painter JS, et al.
granular lymphocytes and decreased Mcl-1 natural killer-cell large granular lymphocyte
Antigen activation and impaired Fas-induced
expression. J Clin Invest. 2001;107(3):351-362. leukemia neoplasias. Leuk Lymphoma. 2011;
death-inducing signaling complex formation in
52(12):2217-2225.
T-large-granular lymphocyte leukemia. Blood. 41. Jerez A, Clemente MJ, Makishima H, et al.
2008;111(3):1610-1616. STAT3 mutations indicate the presence of 58. Steinway SN, LeBlanc F, Loughran TP Jr.
subclinical T-cell clones in a subset of aplastic The pathogenesis and treatment of large
26. Zambello R, Trentin L, Pizzolo G, et al. Cell
anemia and myelodysplastic syndrome patients. granular lymphocyte leukemia. Blood Rev. 2014;
membrane expression and functional role of the
Blood. 2013;122(14):2453-2459. 28(3):87-94.
p75 subunit of interleukin-2 receptor in
lymphoproliferative disease of granular 42. Fasan A, Kern W, Grossmann V, Haferlach C, 59. Go RS, Li CY, Tefferi A, Phyliky RL. Acquired
lymphocytes. Blood. 1990;76(10):2080-2085. Haferlach T, Schnittger S. STAT3 mutations are pure red cell aplasia associated with
BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9 LGL LEUKEMIA: OVERVIEW 1093

lymphoproliferative disease of granular seroreactivity in large granular lymphocyte cytotoxic lymphocytes. Blood. 2008;112(3):
T lymphocytes. Blood. 2001;98(2):483-485. leukemia. Leuk Res. 2005;29(4):381-387. 770-781.
60. Liu JH, Wei S, Lamy T, et al. Blockade of Fas- 77. Loughran TP Jr, Sherman MP, Ruscetti FW, 93. LeBlanc FR, Liu X, Hengst J, et al.
dependent apoptosis by soluble Fas in LGL et al. Prototypical HTLV-I/II infection is rare in Sphingosine kinase inhibitors decrease viability
leukemia. Blood. 2002;100(4):1449-1453. LGL leukemia. Leuk Res. 1994;18(6):423-429. and induce cell death in natural killer-large
78. Pawson R, Schulz TF, Matutes E, Catovsky D. granular lymphocyte leukemia. Cancer Biol
61. Kothapalli R, Nyland SB, Kusmartseva I, Bailey
The human T-cell lymphotropic viruses types I/II Ther. 2015;16(12):1830-1840.
RD, McKeown TM, Loughran TP Jr. Constitutive
production of proinflammatory cytokines are not involved in T prolymphocytic leukemia 94. Liu X, Ryland L, Yang J, et al. Targeting of
RANTES, MIP-1beta and IL-18 characterizes and large granular lymphocytic leukemia. survivin by nanoliposomal ceramide induces
LGL leukemia. Int J Oncol. 2005;26(2):529-535. Leukemia. 1997;11(8):1305-1311. complete remission in a rat model of NK-LGL
79. Loughran TP Jr, Coyle T, Sherman MP, et al. leukemia. Blood. 2010;116(20):4192-4201.
62. Teramo A, Gattazzo C, Passeri F, et al. Intrinsic
and extrinsic mechanisms contribute to maintain Detection of human T-cell leukemia/lymphoma 95. Kothapalli R, Kusmartseva I, Loughran TP.
the JAK/STAT pathway aberrantly activated in virus, type II, in a patient with large Characterization of a human sphingosine-1-
T-type large granular lymphocyte leukemia. granular lymphocyte leukemia. Blood. phosphate receptor gene (S1P5) and its
Blood. 2013;121(19):3843-3854, S1. 1992;80(5):1116-1119. differential expression in LGL leukemia. Biochim
80. Heneine W, Chan WC, Lust JA, et al. Biophys Acta. 2002;1579(2-3):117-123.
63. Viny AD, Lichtin A, Pohlman B, Loughran T,
Maciejewski J. Chronic B-cell dyscrasias are an HTLV-II infection is rare in patients with large 96. Pandolfi F, Loughran TP Jr, Starkebaum G, et al.
important clinical feature of T-LGL leukemia. granular lymphocyte leukemia. J Acquir Immune Clinical course and prognosis of the

Downloaded from https://ashpublications.org/blood/article-pdf/129/9/1082/1026878/blood692590.pdf by guest on 15 October 2019

Leuk Lymphoma. 2008;49(5):932-938. Defic Syndr. 1994;7(7):736-737. lymphoproliferative disease of
81. Poullot E, Bouscary D, Guyader D, et al. Large granular lymphocytes. A multicenter study.
64. Zhang R, Shah MV, Loughran TP Jr. The root of
granular lymphocyte leukemia associated with Cancer. 1990;65(2):341-348.
many evils: indolent large granular lymphocyte
leukaemia and associated disorders. Hematol hepatitis C virus infection and B cell lymphoma: 97. Litam PP, Friedman HD, Loughran TP Jr.
Oncol. 2010;28(3):105-117. improvement after antiviral therapy. Leuk Splenic extramedullary hematopoiesis in a
Lymphoma. 2013;54(8):1797-1799. patient receiving intermittently administered
65. Audemard A, Lamy T, Bareau B, et al. Vasculitis granulocyte colony-stimulating factor. Ann Intern
associated with large granular lymphocyte (LGL) 82. Sandberg Y, Kallemeijn MJ, Dik WA, et al. Lack
of common TCRA and TCRB clonotypes in CD8 Med. 1993;118(12):954-955.
leukemia: presentation and treatment outcomes
of 11 cases. Semin Arthritis Rheum. 2013;43(3): (1)/TCRab(1) T-cell large granular lymphocyte 98. Lamy T, LePrise PY, Amiot L, et al. Response
362-366. leukemia: a review on the role of antigenic to granulocyte-macrophage colony-stimulating
selection in the immunopathogenesis of CD8(1) factor (GM-CSF) but not to G-CSF in a case
66. Murphy PW, Brett LK, Verla-Tebit E, Macik BG, T-LGL. Blood Cancer J. 2014;4:e172. of agranulocytosis associated with large
Loughran TP Jr. Acquired inhibitors to factor VIII granular lymphocyte (LGL) leukemia. Blood.
and fibrinogen in the setting of T-cell large 83. Hodge DL, Yang J, Buschman MD, et al.
Interleukin-15 enhances proteasomal 1995;85(11):3352-3353.
granular lymphocyte leukemia: a case report and
review of the literature. Blood Coagul degradation of bid in normal lymphocytes: 99. Loughran TPJ Jr, Kidd PG, Starkebaum G.
Fibrinolysis. 2015;26(2):211-213. implications for large granular lymphocyte Treatment of large granular lymphocyte
leukemias. Cancer Res. 2009;69(9):3986-3994. leukemia with oral low-dose methotrexate.
67. Greenberg SA, Pinkus JL, Amato AA, Kristensen Blood. 1994;84(7):2164-2170.
T, Dorfman DM. Association of inclusion body 84. Zambello R, Facco M, Trentin L, et al.
myositis with T cell large granular lymphocytic Interleukin-15 triggers the proliferation and 100. Fujishima N, Sawada K, Hirokawa M, et al;
leukaemia. Brain. 2016;139(pt 5):1348-1360. cytotoxicity of granular lymphocytes in patients PRCA Collaborative Study Group. Long-term
with lymphoproliferative disease of responses and outcomes following
68. Rossoff LJ, Genovese J, Coleman M, Dantzker granular lymphocytes. Blood. 1997;89(1): immunosuppressive therapy in large
DR. Primary pulmonary hypertension in a patient 201-211. granular lymphocyte leukemia-associated pure
with CD8/T-cell large granulocyte leukemia: red cell aplasia: a Nationwide Cohort Study in
amelioration by cladribine therapy. Chest. 1997; 85. Chen J, Petrus M, Bamford R, et al. Increased
serum soluble IL-15Ra levels in T-cell large Japan for the PRCA Collaborative Study Group.
112(2):551-553. Haematologica. 2008;93(10):1555-1559.
granular lymphocyte leukemia. Blood. 2012;
69. Go RS, Tefferi A, Li CY, Lust JA, Phyliky RL. 119(1):137-143. 101. Moignet A, Hasanali Z, Zambello R, et al.
Lymphoproliferative disease of granular Cyclophosphamide as a first-line therapy in LGL
T lymphocytes presenting as aplastic anemia. 86. Mishra A, Liu S, Sams GH, et al. Aberrant
overexpression of IL-15 initiates large leukemia. Leukemia. 2014;28(5):1134-1136.
Blood. 2000;96(10):3644-3646.
granular lymphocyte leukemia through 102. Osuji N, Matutes E, Tjonnfjord G, et al. T-cell
70. Risitano AM, Maciejewski JP, Muranski P, et al. chromosomal instability and DNA large granular lymphocyte leukemia: A report on
Large granular lymphocyte (LGL)-like clonal hypermethylation. Cancer Cell. 2012;22(5): the treatment of 29 patients and a review of the
expansions in paroxysmal nocturnal 645-655. literature. Cancer. 2006;107(3):570-578.
hemoglobinuria (PNH) patients. Leukemia.
2005;19(2):217-222. 87. Yang J, Liu X, Nyland SB, et al. Platelet-derived 103. Battiwalla M, Melenhorst J, Saunthararajah Y,
growth factor mediates survival of leukemic large et al. HLA-DR4 predicts haematological
71. Maciejewski JP, O’Keefe C, Gondek L, Tiu R. granular lymphocytes via an autocrine regulatory response to cyclosporine in T-large
Immune-mediated bone marrow failure pathway. Blood. 2010;115(1):51-60. granular lymphocyte lymphoproliferative
syndromes of progenitor and stem cells: disorders. Br J Haematol. 2003;123(3):449-453.
88. Mizutani N, Ito H, Hagiwara K, et al. Involvement
molecular analysis of cytotoxic T cell clones.
of KRAS G12A mutation in the IL-2-independent 104. Dumitriu B, Ito S, Feng X, et al. Alemtuzumab
Folia Histochem Cytobiol. 2007;45(1):5-14.
growth of a human T-LGL leukemia cell line, in T-cell large granular lymphocytic leukaemia:
72. Gattazzo C, Teramo A, Passeri F, et al. PLT-2. Nagoya J Med Sci. 2012;74(3-4): interim results from a single-arm, open-label,
Detection of monoclonal T populations in 261-271. phase 2 study. Lancet Haematol. 2016;3(1):
patients with KIR-restricted chronic e22-e29.
89. Epling-Burnette PK, Bai F, Wei S, et al. ERK
lymphoproliferative disorder of NK cells.
couples chronic survival of NK cells to 105. Zaja F, Baldini L, Ferreri AJM, et al.
Haematologica. 2014;99(12):1826-1833.
constitutively activated Ras in lymphoproliferative Bendamustine salvage therapy for T cell
73. Zhang R, Shah MV, Yang J, et al. Network model disease of granular lymphocytes (LDGL). neoplasms. Ann Hematol. 2013;92(9):
of survival signaling in large granular lymphocyte Oncogene. 2004;23(57):9220-9229. 1249-1254.
leukemia. Proc Natl Acad Sci USA. 2008;
90. Schade AE, Wlodarski MW, Maciejewski JP. 106. Ma SY, Au WY, Chim CS, et al. Fludarabine,
105(42):16308-16313.
Pathophysiology defined by altered signal mitoxantrone and dexamethasone in the
74. Starkebaum G, Loughran TP Jr, Kalyanaraman transduction pathways: the role of JAK-STAT treatment of indolent B- and T-cell lymphoid
VS, et al. Serum reactivity to human T-cell and PI3K signaling in leukemic large malignancies in Chinese patients. Br J
leukaemia/lymphoma virus type I proteins in granular lymphocytes. Cell Cycle. 2006;5(22): Haematol. 2004;124(6):754-761.
patients with large granular lymphocytic 2571-2574. 107. Fortune AF, Kelly K, Sargent J, et al. Large
leukaemia. Lancet. 1987;1(8533):596-599.
91. Johansson P, Bergmann A, Rahmann S, et al. granular lymphocyte leukemia: natural history
75. Loughran TP Jr, Hadlock KG, Perzova R, Recurrent alterations of TNFAIP3 (A20) in T-cell and response to treatment. Leuk Lymphoma.
et al. Epitope mapping of HTLV envelope large granular lymphocytic leukemia. Int J 2010;51(5):839-845.
seroreactivity in LGL leukaemia. Br J Cancer. 2016;138(1):121-124. 108. Marchand T, Lamy T, Finel H, et al.
Haematol. 1998;101(2):318-324.
92. Shah MV, Zhang R, Irby R, et al. Molecular Hematopoietic stem cell transplantation for T-cell
76. Sokol L, Agrawal D, Loughran TP Jr. profiling of LGL leukemia reveals role of large granular lymphocyte leukemia: a
Characterization of HTLV envelope sphingolipid signaling in survival of retrospective study of the European Society for
1094 LAMY et al BLOOD, 2 MARCH 2017 x VOLUME 129, NUMBER 9

Blood and Marrow Transplantation. Leukemia. leukemia with splenomegaly and cytopenia. Exp 116. Hayakawa F, Sugimoto K, Harada Y, et al. A
2016;30(5):1201-1204. Hematol. 2008;36(9):1078-1083. novel STAT inhibitor, OPB-31121, has a
significant antitumor effect on leukemia with
109. Garban F, Carras S, Drillat P, et al. 113. Dhodapkar MV, Li CY, Lust JA, Tefferi A, STAT-addictive oncokinases. Blood Cancer J.
Extracorporeal photopheresis as a curative Phyliky RL. Clinical spectrum of clonal 2013;3:e166.
treatment strategy in non epidermotropic T-cell proliferations of T-large granular
lymphoma and large granular lymphocyte lymphocytes: a T-cell clonopathy of 117. Thomas S, Fisher KH, Snowden JA, Danson SJ,
leukemia. Ann Oncol. 2012;23(9):2386-2390. undetermined significance? Blood. 1994; Brown S, Zeidler MP. Methotrexate is a JAK/
84(5):1620-1627. STAT pathway inhibitor. PLoS One. 2015;10(7):
110. Raposo A, Cerqueira M, Costa J, Sousa Neves
e0130078.
J, Teixeira F, Afonso C. Rheumatoid arthritis and 114. Waldmann TA, Conlon KC, Stewart DM, et al.
associated large granular lymphocytic Phase 1 trial of IL-15 trans presentation 118. Fleischmann R, Kremer J, Cush J, et al; ORAL
leukemia—successful treatment with rituximab. blockade using humanized Mikb1 mAb in Solo Investigators. Placebo-controlled trial of
Acta Reumatol Port. 2015;40(4):384-387. patients with T-cell large granular tofacitinib monotherapy in rheumatoid arthritis.
lymphocytic leukemia. Blood. 2013;121(3): N Engl J Med. 2012;367(6):495-507.
111. Cornec D, Devauchelle-Pensec V, Jousse-Joulin
S, et al. Long-term remission of T-cell large 476-484. 119. Traynor K. FDA approves tofacitinib for
granular lymphocyte leukemia associated with rheumatoid arthritis. Am J Health Syst Pharm.
115. Epling-Burnette PK, Sokol L, Chen X, et al.
rheumatoid arthritis after rituximab therapy. 2012;69(24):2120.
Clinical improvement by farnesyltransferase
Blood. 2013;122(9):1583-1586.
inhibition in NK large granular lymphocyte 120. Bilori B, Thota S, Clemente MJ, et al. Tofacitinib
112. Subbiah V, Viny AD, Rosenblatt S, Pohlman B, leukemia associated with imbalanced NK as a novel salvage therapy for refractory T-cell

Downloaded from https://ashpublications.org/blood/article-pdf/129/9/1082/1026878/blood692590.pdf by guest on 15 October 2019

Lichtin A, Maciejewski JP.Outcomes of receptor signaling. Blood. 2008;112(12): large granular lymphocytic leukemia. Leukemia.
splenectomy in T-cell large granular lymphocyte 4694-4698. 2015;29(12):2427-2429.