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Hairy cell leukemia: A diagnosis by endoscopic ultrasound guided fine needle aspiration

Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA.
CytoJournal 02/2006; 3:1. DOI: 10.1186/1742-6413-3-1
Source: PubMed
ABSTRACT
Endosonography (EUS) guided FNA is a relatively new imaging modality which is increasingly used for sampling deep-seated lymph nodes in the diagnosis and staging of various malignancies, both primary as well as metastatic. It is also useful for staging of non-Hodgkin's lymphoma as well as diagnosing recurrence. The diagnosis of leukemia on FNA samples from deep-seated lymphadenopathy poses an even greater challenge. Hairy cell leukemia (HCL) is an uncommon, but distinct, lympho-proliferative disorder of B cell origin. It usually affects the spleen and bone marrow and uncommonly involves lymph nodes. There are only a few cases reported where HCL was diagnosed on FNA specimens.
We report the first case of HCL accurately rendered on EUS-FNA samples.
This report underscores the concept that the presence of a cytopathologist in the endoscopy suite plays an important role in providing accurate diagnoses of lymphoid lesions biopsied with EUS-FNA.

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Available from: Nirag Jhala
BioMed Central
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CytoJournal
Open Access
Research
Hairy cell leukemia: A diagnosis by endoscopic ultrasound guided
fine needle aspiration
Regina S Meara
1
, Vishnu Reddy
1
, Juan Pablo Arnoletti
2
, Darshana Jhala
1
,
Shyam Varadarajulu
3
and Nirag Jhala*
1
Address:
1
Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA,
2
Department of Surgery, University of Alabama
at Birmingham, Birmingham, AL, USA and
3
Department of Gastroenterology, University of Alabama at Birmingham, Birmingham, AL, USA
Email: Regina S Meara - rschmidt@path.uab.edu; Vishnu Reddy - vreddy@path.uab.edu; Juan Pablo Arnoletti - pablo.arnoletti@ccc.uab.edu;
Darshana Jhala - djhala@path.uab.edu; Shyam Varadarajulu - shyamvaradarajulu@uab.edu; Nirag Jhala* - njhala@path.uab.edu
* Corresponding author
Abstract
Background: Endosonography (EUS) guided FNA is a relatively new imaging modality which is
increasingly used for sampling deep-seated lymph nodes in the diagnosis and staging of various
malignancies, both primary as well as metastatic. It is also useful for staging of non-Hodgkin's
lymphoma as well as diagnosing recurrence. The diagnosis of leukemia on FNA samples from deep-
seated lymphadenopathy poses an even greater challenge. Hairy cell leukemia (HCL) is an
uncommon, but distinct, lympho-proliferative disorder of B cell origin. It usually affects the spleen
and bone marrow and uncommonly involves lymph nodes. There are only a few cases reported
where HCL was diagnosed on FNA specimens.
Case presentation: We report the first case of HCL accurately rendered on EUS-FNA samples.
Conclusion: This report underscores the concept that the presence of a cytopathologist in the
endoscopy suite plays an important role in providing accurate diagnoses of lymphoid lesions
biopsied with EUS-FNA.
Background
Image-guided fine needle aspiration (FNA) of lymph
nodes is commonly used for detecting and staging malig-
nancies and is also useful in demonstrating therapy-asso-
ciated change [1,2]. Despite concerns[3], there is an
overwhelming consensus amongst cytopathologists that
with correct utilization of the technique, cytology in con-
junction with immunophenotyping can serve as a power-
ful modality to diagnose as well as subtype lymphomas in
majority of cases [4-10]. EUS guided FNA may provide a
high cellular yield even from small (<25 mm) lymph
nodes [11]. This modality can also provide sufficient
material to make a morphologic diagnosis and in addi-
tion enough cells to perform ancillary studies [1,2,11,12].
Leukemic infiltrates in solid organs and lymph nodes are
rare and pose an even greater challenge than diagnosing
lymphoma on cytology samples. Hairy cell leukemia
(HCL) is an uncommon, but distinct, lympho-prolifera-
tive disorder of B cell origin. It usually affects the spleen
and bone marrow and uncommonly affects lymph nodes
[13,14]. There are only a few cases reported in which HCL
was diagnosed on FNA samples [15-17]. The use of EUS-
FNA in the diagnosis of leukemia has not been reported.
Published: 23 January 2006
CytoJournal 2006, 3:1 doi:10.1186/1742-6413-3-1
Received: 31 May 2005
Accepted: 23 January 2006
This article is available from: http://www.cytojournal.com/content/3/1/1
© 2006 Meara et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Here we report an unusual case of HCL diagnosed from
samples obtained by EUS-FNA.
Case presentation
A 79-year-old white male with a history of HCL for which
he underwent splenectomy 19 years ago, presented with
acute onset of abdominal pain, nausea and vomiting.
These symptoms resolved spontaneously after a day or
two. The patient denied fever, night sweats, weight loss,
dysphasia, skin rashes, hemetemesis or altered bowel hab-
its. Physical examination revealed a soft, nontender abdo-
men and no palpable peripheral lymphadenopathy. The
patient had been treated with 2-chlorodeoxyadenosine
(2-Cda) therapy for the past four years.
Laboratory values
The patient's white blood cell count remained within the
reference range for the past 4 years, ranging from 4.8–6.5
× 10
3
/µl (reference range: 3.5 – 10.0 × 10
3
µl). Lym-
phocytes ranged from 47–53% (reference range: 15–
52%). No atypical lymphoid cells were noted in the
peripheral smears.
Imaging Studies
A CT scan of the chest, abdomen and pelvis demonstrated
multiple enlarged mediastinal lymph nodes as well as
bulky retroperitoneal and gastro-hepatic lymphadenopa-
thy suggestive of lymphoma.
EUS- FNA
After informed consent, EUS was performed which dem-
onstrated multiple enlarged lymph nodes around the gas-
tro-hepatic region, the largest of which measured 14 × 8
mm. The lymph node appeared hypoechoic with round
borders.
Cytology
Air-dried smears from samples obtained by EUS-FNA
were stained with Romanowsky stain (Diff Quik) in the
endoscopy suite to determine whether the target lesion
was indeed aspirated as has been described previously [2].
Aspirates revealed small to intermediate sized mononu-
clear cells with moderate cytoplasm, round to oval nuclei
with smooth nuclear borders, a stippled chromatin pat-
tern and occasional single nucleoli. The cytoplasm was
pale grey and granular with hair-like and short, blunt,
cytoplasmic projections (cytoplasmic blebs) (figures 1, 2).
Occasional groups of glandular cells with a honey-comb
appearance, preserved nuclear to cytoplasmic ratio, regu-
lar nuclear membrane and lack of marked pleomorphism
and mitoses helped distinguish them from the gastroin-
testinal tract mucosa as benign epithelial cell groups.
Additional samples were collected in RPMI medium for
flow cytometry examination to perform immunopheno-
A higher magnification of the aspirate from same area as shown in Figure 1 shows small to intermediate sized mono-nuclear cells with moderate cytoplasm, round to oval nuclei with smooth nuclear borders, a stippled chromatin pattern and occasional single nucleoliFigure 2
A higher magnification of the aspirate from same area as
shown in Figure 1 shows small to intermediate sized mono-
nuclear cells with moderate cytoplasm, round to oval nuclei
with smooth nuclear borders, a stippled chromatin pattern
and occasional single nucleoli. The cytoplasm is pale grey and
granular with hair-like and short, blunt, cytoplasmic projec-
tions. (Stain: Diff Quik, Magnification: × 60).
Aspirate from the EUS-FNA of lymph node revealed small to intermediate sized mononuclear cells with moderate cyto-plasm, round to oval nuclei with smooth nuclear borders, a stippled chromatin pattern and occasional single nucleoliFigure 1
Aspirate from the EUS-FNA of lymph node revealed small to
intermediate sized mononuclear cells with moderate cyto-
plasm, round to oval nuclei with smooth nuclear borders, a
stippled chromatin pattern and occasional single nucleoli.
The cytoplasm is pale grey with hair-like and short, blunt,
cytoplasmic projections. (Stain: Diff Quik, Magnification: ×
40).
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typing and to determine clonality. Additional samples
were collected in Hank's balanced salt solution for paraf-
fin embedded cell block preparation. Several smears pre-
pared in the endoscopy suite were fixed in 95% alcohol
and were later stained with Papanicolaou stain.
Flow cytometry results
The EUS-FNA sample was analyzed by 4 color flow cytom-
etry (Facscan, BD
®
Instrument, Becton Dickinson Inc., San
Jose, CA). A total of 2.2 million mononuclear cells with
viability of 89% are obtained. These cells are stained by
panel of various fluorochrome conjugated antibodies
(mouse anti-human monoclonal antibodies, dilutions
ranging from 1:2 to 1:10, Caltag
®
Laboratories, Burlin-
game, CA.,). After standard washing steps and fixation
these are analyzed on BD
®
instrument. Selective gating on
lymphoid population (large cell gate) was positive for
clonal B-cells (>98%) expressing CD19, CD20, CD11c
bright, CD25 bright, CD103 and were lambda light chain
restricted. CD10, CD5 and CD3 were negative (figure 3).
This immuno-phenotype along with observed morphol-
ogy on the flow Wright stained cytospin smear was also
diagnostic of HCL. This immuno phenotype also ruled
out other non -Hodgkin's lymphomas. A final diagnosis
of recurrent HCL with involvement of the lymph node
was made.
Discussion
HCL is an uncommon, but distinct, lympho-proliferative
disorder of B cell origin with an indolent clinical course.
Less common sites of involvement by HCL include deep-
seated lymph nodes, liver, bone, retroperitoneum, thy-
roid, etc. An accurate diagnosis of HCL depends on clini-
cal features, as well as morphologic examination of
peripheral blood smears, bone marrow and other tissues
[14,18]. These patients generally present with anemia,
neutropenia, monocytopenia, and splenomegaly [14,18].
Abdominal lymph adenopathy is unlikely to occur at the
time of initial presentation; however, up to 15% of
patients may develop abdominal lymphadenopathy dur-
ing the course of their disease [14,19].
The presence of lymphadenopathy noted on the recent CT
scan raised the suspicion of a non-Hodgkin's lymphoma.
In a study by Goodman et al, second malignancies were
noted in 22% (47 patients) of HCL patients who were fol-
lowed for at least 7 years [20]. Only 3/47 (6%) patients
who developed second malignancies developed non-
Hodgkin's lymphoma [20]. Most cases of lymphoma
developing in patients with HCL are diffuse large B cell
lymphoma [18]. Occasional reports have also suggested
transformation of HCL to other low grade B cell lympho-
mas [18].
EUS-FNA samples on rapid assessment in the present case
revealed a small to intermediate-sized monotonous pop-
ulation of lymphoid cells; therefore, additional samples
were collected for ancillary studies to rule out possible
non-Hodgkin's lymphoma. The past medical history of
HCL was not available to the cytopathologist at the time
of aspiration. Morphology as well as a characteristic
immunophenotype on flow cytometry confirmed the
diagnosis of HCL and ruled out the possibility of other B
cell lymphomas which could arise in a setting of HCL.
This case is an example of how multi parameter (four
color) flow cytometer could provide a characteristic
immunophenotype of HCL even from a small quantity of
cells (total of just over 2 million cells). The new genera-
tion of flow cytometers, for example BD Facscanto (Bec-
Table 1: FNA studies performed for Hairy Cell Leukemia in the literature
Study Year FNA site Percutaneous
Vs. EUS
Flow cytometry Primary Vs.
Recurrent
Clinically
suspected
Moriarty A et al
1
1993 Spleen Percutaneous Y Primary Y
Kaw Y et al
2
1994 Mesentery Percutaneous Y Recurrent Y
Pinto G et al
3
1995 Spleen Percutaneous N Primary Y
Lam et al
4
1999 Thyroid Percutaneous N Disseminated N
Present Study 2005 Lymph node EUS Y Recurrent N
Immunophenotyping performed using selective gating on lymphoid cell population shows that neoplastic cells are posi-tive for clonal B-cells (>98%) expressing CD19, CD20, CD11c bright, CD25 bright, CD103Figure 3
Immunophenotyping performed using selective gating on
lymphoid cell population shows that neoplastic cells are posi-
tive for clonal B-cells (>98%) expressing CD19, CD20,
CD11c bright, CD25 bright, CD103. surface immunoglobulin
and are lambda light chain restricted.
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ton Dickinson, San Jose Ca) which has a capacity for
eight-parameter detection, will offer an opportunity to
provide immunophenotyping on even smaller quantities
of neoplastic cells.
To the best of our knowledge, there have been only four
previous reports where FNA was performed in patients
with HCL (see table 1). In three of the four cases, a diag-
nosis of HCL was clinically suspected which helped estab-
lish the diagnosis of HCL on FNA samples [21]. In one
unsuspected case of HCL, FNA did not prove to be as use-
ful in making a diagnosis of HCL [21].
Unlike percutaneous FNA, EUS-FNA obtains samples by
piercing the gastrointestinal tract mucosa. Rare fragments
of glandular epithelium were noted in the aspirates in the
present case; however, these did not pose any concern for
metastatic carcinoma. Glandular epithelium can often be
seen in the EUS-FNA samples, but their characteristic
honey-comb appearance and benign appearing cytologic
features are helpful in avoiding possible over-interpreta-
tions[2,22].
The patient in the present study was in complete remis-
sion with peripheral blood and differential counts
remaining within the reference range. The patient had
undergone splenectomy 19 years ago, and no parameters
suggestive of recurrent HCL were noted in this patient. A
recent review by Goodman, et al suggests that a complete
remission has been noted in 50–95% of patients follow-
ing 2-chlorodeoxyadenosine (2-Cda) therapy [20]. In a
more recent study, 95% of 209 patients with HCL demon-
strated complete remission after 2-Cda treatment; the
median time of recurrence was 42 months [20]. In the
present study, the patient was in remission for at least 4
years (48 months) following 2-Cda therapy and demon-
strated abdominal pain and intra-abdominal lymphaden-
opathy as the first manifestation of recurrent disease.
Conclusion
This case shows that a diagnosis of HCL can be accurately
rendered on small EUS-FNA samples. This study also
underscores the concept that the presence of a cytopathol-
ogist in the endoscopy suite is not only important to
assess the specimen adequacy, but also plays an important
role in obtaining additional samples for appropriate
ancillary studies to arrive at an accurate diagnosis.
Authors' contributions
All authors made substantial contributions to the intellec-
tual content and/or presentation of the manuscript. RM
(cytopathology fellow) is the first author, and she wrote
the manuscript under the guidance of NJ (cytopatholo-
gist) senior author who coordinated the writing of this
manuscript. VB (hematopathologist) and DJ (cytopathol-
ogist with expertise in hematopathology), helped with
immunophenotyping as well as developing the manu-
script. SV (endosonographer) performed EUS-FNA and
provided necessary clinical information for writing and
revising the manuscript. JPA (surgical oncologist) pro-
vided the necessary clinical information as well as follow
up and revised the manuscript.
Acknowledgements
Co-editors of CytoJournal Vinod B. Shidham, MD, FRCPath, FIAC and Bar-
bara F. Atkinson, MD thank: the academic editor Dr. Ruth Katz, MD, Pro-
fessor, Pathology, University of Texas MD Anderson Center Houston, TX,
United States rkatz@mdanderson.org for organizing and completing the
peer-review process for this manuscript.
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