Here’s how readers responded to a You Make the Call question about management of a patient with T-cell large granular lymphocytic leukemia.
Disclaimer: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk.
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
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