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. 2012 Jan;87(1):67-76.
doi: 10.1016/j.mayocp.2011.09.001.

My treatment approach to hairy cell leukemia

Rahul R Naik  1 , Alan Saven
Affiliations

My treatment approach to hairy cell leukemia

Rahul R Naik et al. Mayo Clin Proc. 2012 Jan.

Abstract

Hairy cell leukemia (HCL) is a rare chronic lymphoproliferative disorder characterized by circulating B cells with cytoplasmic projections, pancytopenia, splenomegaly, and a typical flow cytometry pattern. Recently, the BRAF V600E mutation was uniformly identified in one HCL series, which may provide insights into the pathogenic mechanisms. The disease course is usually indolent but inexorably progressive. Patients require treatment when they have significant cytopenia or occasionally recurrent infections from immunocompromise. In the mid-1980s, interferon replaced splenectomy as the initial treatment. A few years later, 2 purine nucleoside analogs, cladribine and pentostatin, showed promising activity in HCL. Complete response rates approached 95% with cladribine given as a single 7-day intravenous infusion. Newer methods of cladribine administration and modified dosing schedules have since been studied. Pentostatin response rates are comparable. We generally prefer cladribine because of its ease of administration, single infusion schema, and favorable toxicity profile. Since the introduction of these drugs, which have never been randomly compared, long-term follow-up studies have confirmed impressive and durable response durations. However, roughly 40% of patients with HCL eventually relapse. In this setting, patients can be re-treated with purine analogs. Rituximab also has a reasonable response rate in relapsed HCL; it can be given as a single agent sequentially after purine nucleosides or concurrently. Immunotoxins have robust responses but remain in development. Targeting the BRAF pathway will be an exciting future area of research. Many patients have minimal residual disease after initial treatment, but the clinical significance of this remains unknown.

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Figures

FIGURE 1
FIGURE 1
Peripheral blood smear specimen showing circumferential cytoplasmic projections characteristic of hairy cell leukemia (Wright-Giemsa, original magnification ×1000).
FIGURE 2
FIGURE 2
Bone marrow biopsy specimen from patient with hairy cell leukemia showing hypercellularity with hairy cells having nuclei widely separated by abundant cytoplasm, giving characteristic “fried egg” appearance (hematoxylin-eosin, original magnification ×600).
FIGURE 3
FIGURE 3
Treatment algorithm. aCladribine preferred because of its ease of administration, favorable toxicity profile, and higher complete response rates. bIndicates consider switching to other purine analog given lack of cross-resistance. HCL = hairy cell leukemia.
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