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Pathology International 2014; 64: 142–147 doi:10.1111/pin.12143

Case Report
De novo hairy cell leukemia with a major BCR/ABL1
rearrangement: A case report with a literature review

Young-Woong Won,1 Sung Jong Kim,1 Tae Sung Park,2 Seung Hwan Oh,3 Thomas S.K. Wan4 and
Eun Jung Baek5
Departments of 1Internal Medicine and 5Laboratory Medicine, Hanyang University College of Medicine, Seoul,
2
Department of Laboratory Medicine, School of Medicine, Kyung Hee University, Seoul, 3Department of Laboratory
Medicine, Inje University College of Medicine, Busan, South Korea and 4Department of Pathology, University of
Hong Kong, Hong Kong, China

Hairy cell leukemia (HCL) is a very rare mature B-cell neo- ment after HCL diagnosis has been reported in two cases.4,5
plasm and its simultaneous occurrence with chronic In addition, HCL as a secondary malignancy has been
myeloid leukemia has been reported in only three cases. reported in some cases including four cases of precedent
The pathogenesis and relationship of the two diseases are
myeloproliferative disease6 including one case of CML.7
not clear. Here we report a case of HCL expressing a BCR/
Coexistence of de novo HCL and CML at the time of diagno-
ABL1 clone, which showed molecular remission of the
fusion clones and achieved partial remission over nine sis is extremely rare only with three cases documented.8–10
months of cladribine therapy. After a thorough analysis of Due to the rarity of case reports of HCL with CML, the
previous studies and the results of this patient, we specu- possible relationship of the two diseases is not clear. In those
late that a subclone evolved to have an additional genetic cases, proving the existence of either two independent dis-
BCR/ABL1 rearrangement. We also review all published lit- eases or common clonal expression is difficult due to the
erature on HCL with BCR/ABL1 rearrangement and discuss
limitations of marrow samples and detection techniques.
the pathophysiology of these unusual cases.
Also, there is no proven therapeutic recommendation or sum-
marized data related to disease course.
Key words: hairy cell leukemia, BCR/ABL1, therapy, cladribine
Here, we report a case of HCL with a BCR/ABL1 fusion
gene and review the relationship between HCL and BCR/
Hairy cell leukemia (HCL) is a mature B-cell neoplasm char-
ABL1 translocation. As there was no consensus regarding
acterized by lymphocytes with hair-like cytoplasmic projec-
appropriate therapy in this case, we followed the patient’s
tions infiltrating the bone marrow (BM) and spleen, leading to
long-term progress and reviewed all the reported cases of
pancytopenia, BM fibrosis, and splenic enlargement.1 Even
HCL with BCR/ABL1 rearrangements to evaluate the char-
though it is a rare disease comprising only 2% of all leukemia
acteristics of the pathogenesis and to suggest therapy
cases, occurrence of a secondary malignancy in patients with
options.
HCL has been well recognized.2 For example, HCL showed
subsequent malignancies in 8.7% of cases, which typically
present as solid tumors.3 Also, Philadelphia chromosome-
positive chronic myelogenous leukemia (Ph+ CML) develop-
CLINICAL SUMMARY

A 36-year-old male was admitted with the chief complaint of

Correspondence: Eun Jung Baek, MD, PhD, Department of Labora-
tory Medicine, School of Medicine, Hanyang University, 153,
Gyeongchun-ro, Guri-si, Gyeonggi-do 471-701, Republic of Korea.
Email: doceunjung@hanyang.ac.kr
Disclosure: None declared.
Received 2 October 2013. Accepted for publication 27 January
2014.
© 2014 The Authors
Pathology International © 2014 Japanese Society of Pathology and
Wiley Publishing Asia Pty Ltd
weight loss and dizziness which began 3 months prior to
presentation. He had no relevant past medical or family
history. Physical examination revealed massive hepato-
megaly and splenomegaly, but no palpable enlarged lymph
nodes. Abdominopelvic computerized tomographic scan
revealed massive hepatosplenomegaly.
The complete blood count (CBC) revealed a hemoglobin
(Hb) concentration of 4.4 g/dL and a white blood cell (WBC)

count of 1000/mm3 with 60.2% lymphocytes, and a
decreased platelet count of 19 000/mm3 (Fig. 1). The periph-
eral blood (PB) smear demonstrated rare hairy cells.
PATHOLOGICAL FINDINGS
The first BM biopsy revealed a cellularity of more than 95%
and marrow cells are mostly replaced by oval- to spindle-
shaped malignant cells with fibrotic changes (Fig. 2). Reticulin
stain showed extensive diffuse increase in coarse fibers. In
aspirates, hairy cells were found (Fig. 2a). Tartrate resistant
acid phosphatase (TRAP) stain was positive for hairy cells
(Fig. 2b). Immunohistochemical CD20 stain on a biopsy
section revealed intensely positive hairy leukemic cells,
involving almost 100% of the marrow (Fig. 2c). CD5 stain on a
biopsy section was negative in hairy cells, excluding the
diagnosis of mantle cell lymphoma and chronic lymphocytic
leukemia.
Obtaining BM aspirates for conventional cytogenetic analy-
sis and flow cytometry failed due to dry tap, which is a common
finding in HCL. After a diagnosis of HCL was made, we found
that the sample was positive for the BCR/ABL1 major (b3a2)
rearrangement using multiplex nested reverse transcriptase-
© 2014 The Authors
Pathology International © 2014 Japanese Society of Pathology and Wiley Publishing Asia Pty Ltd
Hairy cell leukemia with BCR/ABL1 143
Figure 1 Hematologic response after
chemotherapy. A patient with HCL and a
BCR/ABL1 fusion gene showed pancyto-
penia at the time of diagnosis. Through two
cycles of cladribine therapy (Chemo), the
level of hemoglobin (Hb), platelets, and
the WBC returned to normal levels. In the
bone marrow (BM) biopsy specimen, the
proportion of hairy leukemic cells (HC)
continuously decreased for nine months.
The BCR/ABL1 rearrangement disap-
peared after the first round of chemo-
therapy. , Hb; , Platelet; , WBC.
polymerase chain reaction (RT-nested PCR). To confirm this,
we repeated the molecular experiments from the separately
aliquoted marrow aspirates in two independent laboratories
and it consistently revealed the presence of the BCR/ABL1
rearrangement. To rule out false positivity for the BCR/ABL1
rearrangement of RT-PCR, we performed HemaVision (DNA
Technology, Aarhus, Denmark) using separate BM aspirate
samples, followed by cloning and gene sequencing. Again, we
could confirm the presence of the BCR/ABL1 fusion gene
(Fig. 3). Therefore, we concluded that the patient had hairy
cell leukemia together with a BCR/ABL1 rearrangement.
Subsequently, we failed to demonstrate BCR/ABL1 fusion
in a BM biopsy specimen in five attempts by fluorescence in
situ hybridization (FISH) analysis, since the BM biopsy speci-
men was fixed in the Bouin’s fixation solution. It is well known
that Bouin’s fixative will destroy DNA and RNA and is sub-
optimal for FISH experiments. Therefore, we performed FISH
on unstained BM aspirate slides.2 Two orange signals (ABL1)
and two green signals (BCR) could be observed among the
45 cells analyzed, demonstrating that the BCR/ABL1 fusion
was negative in hairy cells.
As the patient had no symptoms of CML at the time
of diagnosis, the patient was started on 2-chlorodeoxya-
denosine (cladribine), which is a nucleoside analog
144 S. J. Kim et al.

a b

c d

e f

© 2014 The Authors

Pathology International © 2014 Japanese Society of Pathology and Wiley Publishing Asia Pty Ltd
 Hairy cell leukemia with BCR/ABL1 145

Figure 2 Hairy cells in peripheral blood and bone marrow. (a) At the time of diagnosis, hairy cells with cytoplasmic projections were found in
peripheral blood and bone marrow (BM) aspirates (Wright-Giemsa stain, ×1000). (b) Hairy cells were positively stained by tartrate-resistant acid
phosphatase (TRAP) stain (×1000). (c) Initial BM biopsy showed effacement of marrow by atypical lymphoid cells with fibrosis (Hematoxylin
and Eosin stain, ×40) and was strongly immunostained by CD20 (×40). (d) After the first cycle of cladribine chemotherapy, cellularity decreased
in focal areas and normal hematopoiesis was found in 25% of the area (×40). (e) A third BM biopsy at day 149 post-diagnosis showed that
normal hematopoiesis occurred in 40% of marrow (×40). (f) After the second cycle of cladribine, the marrow showed hematopoiesis in 80% of
the marrow area.
◀

Figure 3 Cloning and sequencing of

BCR/ABL1 transcripts from marrow aspi-
rates. The PCR product of the patient’s BM
aspirate was cloned and BCR/ABL1 fusion
(b3a2 type) breakpoint was confirmed by
direct sequencing.

(0.1 mg/kg/day for 7 days). Three months later, the patient
still showed pancytopenia. Three months after the cladribine
treatment, the second BM biopsy revealed normal hemato-
poiesis in the hypocellular areas (Fig. 2d). However, in the
hypercellular areas, BM was still replaced by hairy leukemia
cells. RT-PCR for the BCR/ABL1 rearrangement from BM
aspirate was negative. At that time, hepatomegaly and sple-
nomegaly were resolved. Two months later, a third BM biopsy
revealed residual hairy cells in 60% of the marrow area
(Fig. 2e). Because complete remission was still not achieved,
we proceeded with the second cycle of cladribine treatment
with the same dose schedule.
Three months after the second cycle of chemotherapy,
CBC showed only mild thrombocytopenia with normal Hb and
WBC values. The fourth BM examination showed normal
hematopoiesis in more than 80% of the area (Fig. 2f). Also,
RT-PCR for the BCR/ABL1 rearrangement from the BM
aspirate was negative. Conventional cytogenetic analysis
from the BM specimen showed no chromosomal abnormali-
ties. Finally, over 9 to 17 months post-diagnosis, CBC values
were normal. Imaging studies showed no new evidence of
organomegaly.
DISCUSSION
Hairy cell leukemia with CML, regardless of the order of
onset, has been reported in six cases (Table 1). CML and
© 2014 The Authors
Pathology International © 2014 Japanese Society of Pathology and Wiley Publishing Asia Pty Ltd
HCL share the clinical phenotype of splenomegaly, anemia,
and thrombocytopenia, however, other clinical features vary
widely. In this case, the characteristic features corresponding
to CML were hepatosplenomegaly, anemia, thrombocytope-
nia, and BCR/ABL1 clone. Four hypotheses for the patient
diagnosis could be as follows: CML in the chronic phase
existed first and HCL subsequently occurred; HCL was pro-
gressing and CML would appear later; two independent dis-
eases of HCL and CML developed concurrently; a subclone
of HCL expressed BCR/ABL1.
First, it is possible that CML existed in the chronic phase and
HCL occurred later. HCL and CML have some similar symp-
toms including anemia, thrombocytopenia and splenomegaly.
However, there is definite discrimination between the two
diseases according to the other laboratory findings and BM
biopsy results. The patient in our study had no relevant
medical history before this illness developed. After diagnosis
of HCL, our patient was treated with cladribine only, without
imatinib. In the three months after treatment, the BCR/ABL1
clone disappeared in contrast to the still prevalent HCL fea-
tures. Cladribine is known to induce hematologic responses in
CML, but does not suppress the Ph-chromosome.5,11 There-
fore, it is highly unlikely that one cycle of chemotherapy would
have contributed to the elimination of CML, if it existed inde-
pendently. In addition, it is extremely uncommon for HCL to
occur as a second malignancy in a patient with underlying
myeloproliferative neoplasm.10 Moreover, a previous report
analyzed a patient with CML who was diagnosed with HCL
146 S. J. Kim et al.

Table 1 Clinical and genetic features of hairy cell leukemia with BCR/ABL1 translocation from the Literature
Order of Time Treatment & Clonal
occurrence Case interval clinical outcome relationship References
CML HCL 1 4 years after HCL after CML tx with three Clonally different Setoodeh et al. J Med cases
CML tx types of TKI (2012)7
HCL CML 1 48 months after – Unidentified Wandroo et al. J clin pathol
onset of HCL (2000)4
2 17 months after Cladribine Ph chromosome Unidentified Reeves et al. Cancer (1995)5
the onset of remained after therapy
HCL (12
months within
one year of
cladribine tx)
HCL & CML at 1 Coexisting Interferon, Imatinib, Rituximab Likely two different clones Orciuolo et al. Leukemia res
diagnosis CML cured but HCL (2006)9
remained
2 HCL dx 2 Hydroxyurea TKI 25 d Likely a common stem cell clone Gopaluni et al. J clin oncol
months after after HCL dx, cladribine with a bi-lineage manifestation (2012)10
CML tx TKI planned
3 Clinical features Hydroxyurea BMT expire Common clonal origin Pajor et al. Cancer genetics
of CML, BM from infections cytogenetics (2002)8
features of
both CML and
HCL
4 Clinical features Cladribine complete Likely a subclone with aberrant The present study
of HCL with remission of a BCR/ABL1 genetic alteration
BCR/ABL1 clone partial remission in 1
translocation year
BMT, bone marrow transplantation; dx, diagnosis; TKI, tyrosine kinase inhibitors; tx, treatment.

after chemotherapy for CML, which might act as a causative
stimulator.10
The second malignancy in HCL patients is usually skin
tumors with one case of Hodgkin’s disease and one case of
myelodysplastic syndrome reported.3 HCL with consequen-
tial CML has been reported in only two cases.4,5 However,
contrary to our case, these second malignancies were
related to HCL therapy.5
Also, CML and HCL could exist at the same time indepen-
dently. A previous report described a patient with CML and
HCL who received CML therapy. Despite molecular remis-
sion of CML, minimal residual disease remained for HCL,9
which is contrary to the response outcome of our case.
The most possible hypothesis for our case is that a small
population of HCL clones acquired additional genetic aber-
ration of BCR/ABL1. This assumption is supported by one
case report that HCL cells occasionally showed deletions at
22q11.2.12 For evidence of the lymphoid cells with BCR/ABL1
translocation, a high incidence (30%) of BCR/ABL1 translo-
cation was also observed in biphenotypic acute leukemia.13
In addition, it has been documented that various fractions of
mature B cells belong to the leukemic compartment and are
Ph+ CML. Also, some B-cell neoplasms may exhibit lineage
heterogeneity, or even more rarely, lineage plasticity.1,14
In our case, even though the BCR/ABL1 disappeared at
the second BM intervention, hairy cells persisted, meaning
Pathology International © 2014 Japanese Society of Pathology and Wiley Publishing Asia Pty Ltd
the BCR/ABL1-positive clone was not the only type, but was
a clonally evolved subclone. The negative FISH result for
BCR/ABL1 rearrangement on BM aspirates would prefer this
theory. Therefore, we concluded that the final diagnosis of
our patient was HCL with a subclone of an additional genetic
BCR/ABL1 rearrangement.
The course of HCL is usually chronic, but can often be
progressive. If there are underlying CML clones, a CML flare
up is possible after treatment of HCL. Tyrosine kinase inhibi-
tors (TKIs) are the first-line treatment for CML and the rec-
ommended treatment regimens for Ph+ ALL. Ph+ ALL is
known to have poor outcome, with at least a 10% lower
chance of remission than standard-risk ALL, but achieves
higher remission rates when treated with TKI.5 However, in
our case, Ph+ HCL has been treated successfully only with
cladribine, without the help of TKI, showing that the prognosis
is different from that of Ph+ ALL. In summary, we present a
case of de novo HCL combined with a BCR/ABL1 positive
subclone which developed without any preceding chemo-
therapy. After one cycle of chemotherapy, the BCR/ABL1
fusion gene disappeared and another cycle of cladribine
produced a relatively good BM response and normal CBC
levels over nine months. Although the relationship between
HCL and BCR/ABL1 remains unclear, this case provides new
insight into clonal abnormalities of HCL and BCR/ABL1 rear-
rangement.
© 2014 The Authors

ACKNOWLEDGMENTS
This work was supported by the research fund of Hanyang
University (HY-2011-0224).
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