Reader Responses: How would you manage this patient with T-cell large granular lymphocytic leukemia?

Here’s how readers responded to a You Make the Call question about management of a patient with T-cell large granular lymphocytic leukemia.

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If the assay is available, studying erythroid blast forming units (BFU-E) in the presence/absence of patient T cells can be very useful to ensure that the hypoproliferative anemia is due to the T-cell subset. If this remains the case, a trial of cyclosporine is OK, but if the patient is robust, one could consider rabbit antithymocyte globulin and cyclosporine.

If the T-cell depletion does not lead to robust BFU-E, next-generation sequencing should be performed to look for evidence of a myelodysplastic syndromes (MDS)–related clonal abnormality (this should have already been done). If they one is present, then an MDS-oriented therapeutic strategy may be warranted.

Steven Gore, MD
Rockville, MD

As the patient is asymptomatic, I would not treat until she has had at least one admission with febrile neutropenia. I have not had success with methotrexate in this setting. If she requires intervention, I would give her two to four cycles of bendamustine plus rituximab, as tolerated and depending on response.

Leanne Berkahn, MD
Auckland, New Zealand