Treatment of erythrodermic cutaneous T-cell lymphoma with extracorporeal photochemotherapy

Efficacy and tolerability of currently available therapies for the mycosis fungoides and Sezary syndrome variants of cutaneous T-cell lymphoma

Primary cutaneous T-cell lymphomas are a heterogenous group of non-Hodgkin lymphomas. The characteristic clinicopathologic and immunophenotypic features and prognoses of the various cutaneous lymphomas have been recently described by the World Health Organization and European Organization for Research and Treatment of Cancer. Cutaneous T-cell lymphoma variants include mycosis fungoides and Sezary syndrome, which are generally associated, respectively, with indolent and aggressive clinical courses and are the subject of this review. Currently utilized treatments for cutaneous T-cell lymphoma include skin-directed therapies (topical agents such as corticosteroids, mechlorethamine, carmustine, and retinoids, phototherapy, superficial radiotherapy, and total skin electron beam therapy), systemic therapies (photophoresis, retinoids, denileukin diftitox, interferons, and chemotherapy), and stem cell transplantation (autologous and allogeneic). This review will describe recent advances in our understanding of the biology (immunologic, cytogenetic, and genetic) of cutaneous T-cell lymphomas and discuss the efficacy and tolerability of the current therapeutic options for cutaneous T-cell lymphomas. Disease progression in over 20% of patients with early stages of disease and the current lack of a definitive treatment which produces durable responses in advanced stages of disease indicates a critical unmet need in CTCL. New insights into the molecular and immunologic changes associated with cutaneous T-cell lymphomas should ultimately lead to the identification of novel therapeutic targets and the development of improved therapeutic options for patients with these malignancies.

Mycosis fungoides ? a review of the management of 28 patients and of the recent literature

BACKGROUND

Mycosis fungoides is an uncommon cutaneous T-cell lymphoma characterized by malignant monoclonal proliferation of T-helper lymphocytes. Its course is variable with a potential for lymphatic and hematogenous involvement. We report the investigations, staging, treatment, follow-up, and outcome of 28 patients. This is the first such study reported from Ireland.

METHODS

Twenty-eight patients with mycosis fungoides (14 women, 14 men; average age, 52.5 years) were reviewed over 12 years in the dermatology clinic which assesses an average of 4500 patients per year. All mycosis fungoides patients were referred from their family physicians. The diagnosis was made in all cases from a combination of clinical findings, histology, and immunohistochemistry. TNM staging revealed 11 patients at diagnosis stage IA (T1), 12 at stage IB (T2), four at stage IIB (T3), and one at stage III (T4).

RESULTS

The usual male preponderance was not found. Eight patients needed multiple biopsies to establish the diagnosis. Detailed investigations were not useful in the early stages. Patients were followed up over a 12-year period. Thirteen patients died as a result of cutaneous lymphoma. Two patients with stage IA disease progressed rapidly and died, a feature reported in only 10% of patients at this stage. Five patients showed unusual features, including a long history prior to presentation, the development of the rarely reported bullous mycosis fungoides, and aggressive disease beginning at a young age.

CONCLUSIONS

Mycosis fungoides is rare; we reviewed 28 patients over 12 years. The prognosis is poor at the later stages; 13 patients died. Two patients who died were unusual in that they rapidly progressed from stage IA disease; however, in the majority of patients with this stage, the prognosis is excellent. Detailed investigations were unhelpful in early stage disease. Close clinical follow-up is essential to identify disease progression.

Receptor-mediated DNA-targeted photoimmunotherapy

We show the efficacy of a therapeutic strategy that combines the potency of a DNA-binding photosensitizer, UV(A)Sens, with the tumor-targeting potential of receptor-mediated endocytosis. The photosensitizer is an iodinated bibenzimidazole, which, when bound in the minor groove of DNA and excited by UV(A) irradiation, induces cytotoxic lesions attributed to a radical species resulting from photodehalogenation. Although reminiscent of photochemotherapy using psoralens and UV(A) irradiation, an established treatment modality in dermatology particularly for the treatment of psoriasis and cutaneous T-cell lymphoma, a critical difference is the extreme photopotency of the iodinated bibenzimidazole, approximately 1,000-fold that of psoralens. This feature prompted consideration of combination with the specificity of receptor-mediated targeting. Using two in vitro model systems, we show the UV(A) cytotoxicity of iodo ligand/protein conjugates, implying binding of the conjugate to cell receptors, internalization, and degradation of the conjugate-receptor complex, with release and translocation of the ligand to nuclear DNA. For ligand-transferrin conjugates, phototoxicity was inhibited by coincubation with excess native transferrin. Receptor-mediated UV(A)-induced cytotoxicity was also shown with the iodo ligand conjugate of an anti-human epidermal growth factor receptor monoclonal antibody, exemplifying the potential application of the strategy to other cancer-specific targets to thus improve the specificity of phototherapy of superficial lesions and for extracorporeal treatments.

Technology insight: ECP for the treatment of GvHD--can we offer selective immune control without generalized immunosuppression?

Hematopoietic stem-cell transplantation remains an important curative therapy for many conditions and its use is increasing annually. Graft-versus-host disease (GvHD) is the major cause of mortality and suffering following allogeneic hematopoietic stem-cell transplantation. Conventional treatments are associated with multiple side effects and are often ineffective. New therapeutic approaches for the control of GvHD are desperately required. Extracorporeal photochemotherapy (ECP) was developed in the 1970s for the treatment of cutaneous T-cell lymphoma and was approved by the FDA as the first selective immunotherapy for a cancer. ECP has also proved an effective therapy for immune-related conditions, particularly GvHD, even in patients refractory to conventional therapies. The treatment involves the mechanical separation of circulating white cells, which are exposed to psoralen and UVA light and then returned to the patient. ECP is extremely well tolerated with minimal side effects and is not associated with the increased rates of infection or relapse of malignant disease typical of conventional immunosuppressive agents. Thus, ECP appears to offer selective immune modulation without generalized immunosuppression, but its mechanism of action remains poorly understood. This review discusses the development of ECP, its use in the treatment of GvHD, as well as current theories of its mechanism of action.

Extracorporeal photopheresis: A focus on apoptosis and cytokines

Induction of apoptosis and changes to cytokine secretion patterns have been implicated in the mechanism of action of extracorporeal photopheresis (ECP). Lymphocyte apoptosis is initially detected in significant numbers prior to re-infusion and by 48 h post-ECP the majority of treated lymphocytes are apoptotic. The early apoptosis involves changes to mitochondrial function, reversal of the Bcl-2/Bax ratio and externalisation of phosphatidylserine. Apoptotic lymphocytes, observed from 20 h post-ECP, are associated with enhanced levels of CD95 and Fas-ligand. For cutaneous T cell lymphoma (CTCL), processing of the apoptotic lymphocytes, by suitable antigen presenting cells (APCs), is suggested to induce a clonal cytotoxic response which targets the malignant T cell population. Increased levels of TNFalpha and IFNgamma, observed post-ECP in monocytes and lymphocytes, respectively, are thought to further contribute to the proposed anti-tumour reaction seen in CTCL. However, down-regulation of pro-inflammatory cytokines and enhanced anti-inflammatory responses have been reported following ECP treatment. These immune responses may contribute to the tempering of the inflammatory conditions, such as graft versus host disease, which respond to ECP. Furthermore, untreated monocytes exposed to ECP-treated lymphocytes have also demonstrated a shift in monocyte cytokine-secretory pattern, toward one associated with immune tolerance. Recently, a mechanism of ECP-induced immune tolerance has been linked to the stimulation of the anti-inflammatory cytokines IL10 and TGFbeta by T regulatory cells, following the infusion of ECP-treated CD11c(+) APCs. Ultimately, the multifaceted responses, induced by ECP, may explain the diversity of clinical conditions that benefit.

A randomized, double-blind, placebo-controlled trial of photopheresis in systemic sclerosis

BACKGROUND

Systemic sclerosis is a multisystemic connective tissue disease with marked involvement of the skin and joints for which few effective evidence based therapies are available. To further investigate the efficacy of extracorporeal photochemotherapy on early aggressive cutaneous disease, a randomized, double-blind, placebo-controlled trial was performed.

OBJECTIVE

Our aim was to evaluate the efficacy of photopheresis in the treatment of patients with systemic sclerosis (scleroderma).

METHODS

This randomized, double-blind, placebo-controlled clinical trial was conducted at 16 investigational sites in the United States, Canada, and Europe. Sixty-four patients with typical clinical and histologic findings of scleroderma, of less than 2 years' duration, were studied. Patients did not receive any other concomitant treatment for scleroderma. Patients were randomized to receive either active or sham photopheresis treatment on two consecutive days monthly for 12 months. Severity of skin (skin scores assessed in 22 body regions) and joint involvement (60 joints examined for contractures) were assessed on a monthly basis.

RESULTS

A statistically significant improvement in skin scores as compared with baseline was observed at 6 months (P = .0024) and 12 months (P = .008) among those who received active photopheresis, but not among those who received sham photopheresis. Comparison of skin scores between the two study arms did not achieve statistical significance because of the small sample size of the study arms. Joint involvement was also significantly improved after 6 months (P = .002) and 12 months (P = .001) of active photopheresis when compared with baseline.

LIMITATIONS

The study lacks sufficient statistical power to reveal a significant difference in skin and joint manifestations between the active and sham photopheresis arms.

CONCLUSION

Photopheresis induced significant improvement of skin and joint involvement in patients with scleroderma of recent onset; however, any effect when compared with sham treatment and a possible placebo effect may be modest.

Emerging drugs in cutaneous T-cell lymphomas

Cutaneous T-cell lymphomas are a heterogeneous group of rare lympho-proliferative disorders. In most cases, they are characterised by the accumulation of clonal CD4+ lymphocytes in the skin. Extracutaneous involvement is present in late stages only. Unfortunately, only few drugs are registered for these disfiguring diseases. Skin-directed therapies using topical formulations are the preferred first-line modalities for cutaneous lesions in early stages. In this field there are interesting developments using topical retinoids and gene therapy products, such as adeno-IFN-gamma. Systemic treatment uses biologicals, such as fusion molecules, monoclonal antibodies and immune response modifiers (IFNs, retinoids), and well-tolerated antiproliferative drugs, such as histone deacetylase inhibitors or liposomal doxorubicin.

EORTC consensus recommendations for the treatment of mycosis fungoides/Sézary syndrome

Several reviews and guidelines on the management of mycosis fungoides and Sézary syndrome (MF/SS) have been published; however, treatment strategies for patients with MF/SS vary from institution to institution and no European consensus has yet been established. There are few phase III trials to support treatment decisions for MF/SS and treatment is often determined by institutional experience. In order to summarise the available evidence and review 'best practices' from each national group, the European Organisation for Research and Treatment of Cancer (EORTC) Cutaneous Lymphoma Task Force met in September 2004 to establish European guidelines for the treatment of MF/SS. This article reviews the treatment regimens selected for inclusion in the guidelines and summarises the clinical data for treatments appropriate for each stage of MF/SS. Guideline recommendations are presented according to the quality of supporting data, as defined by the Oxford Centre for Evidence-Based Medicine. Skin-directed therapies are the most appropriate option for early-stage MF/SS and most patients can look forward to a normal life expectancy. Patients with advanced disease should be encouraged to participate in clinical trials and maintenance of quality of life should be paramount.

DNA targeted UVA photosensitization: characterization of an extremely photopotent iodinated minor groove binding DNA ligand

Previous studies have described UVA-induced DNA strand breakage at the binding sites of iodinated DNA minor groove binding bisbenzimidazoles. The DNA breakage, presumably mediated by the carbon-centred ligand radical produced by photodehalogenation, was also shown to be cytotoxic. The earlier studies included a comparison of three ligand isomers, designated ortho-, meta- and para-iodoHoechst, and the efficiency of photo-induction of strand breaks in plasmid DNA proved to be much higher for the ortho-isomer. We have now extended the comparison of the three isomers with respect to photo-induced cytotoxicity in K562 cells. Although the relationship between the extent of nuclear uptake and the concentration of the ligand in the medium was similar for the three isomers, assay of in situ dehalogenation in drug-treated cells indicated that the apparent cross-section for dehalogenation of the ortho-isomer was greater than 5-fold higher than that for the meta- and para-isomers. Also, analysis of clonogenic survival data showed that the dehalogenation event associated with ortho-iodoHoechst was a more efficient mediator of UVA-induced cytotoxicity in K562 cells than that for meta- or para-iodoHoechst. The number of dehalogenation events associated with 50% cell-kill for ortho-iodoHoechst (1.23+/-0.04 x 10(4)) was less than that for the para- (3.92+/-0.29 x 10(4)) and meta- (11.6+/-0.90 x 10(4)) isomers. Thus it is concluded that the photopotency of ortho-iodoHoechst, which is an important feature in the context of its potential use in clinical phototherapy, is due not only to more efficient UVA-mediated dehalogenation of the ligand, but also to greater cytotoxic potency per dehalogenation event.

Photopheresis in solid organ transplant rejection

Photopheresis has become a key component in the therapeutic armamentarium of cutaneous T-cell lymphoma, graft-versus-host disease following stem cell transplant, and allograft rejection of solid organs such as heart. Although it is considered a new treatment modality in its present form, the field of phototherapy dates back thousands of years. In this review, the reader will learn more about the history of photopheresis and how it became a therapeutic alternative for patients with solid organ transplants. An extensive literature search will highlight the evidence-based benefits of photopheresis (or lack thereof). A discussion of the mechanism of action of photopheresis and the technical aspects of the procedure will also be covered. Since photopheresis may be the best tolerated form of immunomodulation, current promising, albeit preliminary data on its efficacy warrant further investigation and understanding.

Evidence-based practice of photopheresis 1987-2001: a report of a workshop of the British Photodermatology Group and the U.K. Skin Lymphoma Group

Photopheresis or extracorporeal photochemotherapy (ECP) is a novel immunomodulatory therapy which involves separation of the patient's leucocyte-rich plasma, followed by ex vivo administration of a photosensitizer and ultraviolet A radiation, before reinfusion. ECP has been used successfully for the treatment of cutaneous T-cell lymphoma (CTCL: Sézary syndrome), graft-versus-host disease (GVHD) and cardiac transplant rejection. ECP has a dose-sparing effect on concurrent immunosuppressive therapy. The procedure induces apoptosis of the irradiated lymphocytes, but the exact mechanism by which ECP exerts its therapeutic effect in these different conditions is uncertain. The treatment has very few adverse effects and in particular is not associated with an increased incidence of opportunistic infections. The evidence for the efficacy of ECP has been appraised by a combined British Photodermatology Group and U.K. Skin Lymphoma Group workshop on the basis of evidence published up to the end of 2001 and on the consensus of best practice. There is fair evidence for the use of ECP in erythrodermic CTCL and steroid-refractory GVHD, but randomized controlled studies are needed. There is good evidence supporting the use of ECP in preventing cardiac rejection following transplantation. Randomized controlled trials have also shown a therapeutic benefit in type 1 diabetes mellitus, but the inconvenience associated with the procedure outweighed the clinical benefit. There is fair evidence not to use ECP for the treatment of systemic sclerosis and multiple sclerosis, and good evidence not to use ECP for other forms of CTCL.

Rapid construction of a dendritic cell vaccine through physical perturbation and apoptotic malignant T cell loading

We have demonstrated that adherence and release of monocytes from a plastic surface drives their differentiation into immature dendritic cells (DC,) that can mature further during overnight incubation in the presence of apoptotic malignant T cells. Based on these results, we sought to develop a clinically, practical, rapid means for producing DC loaded with malignant cells. A leukapheresis harvest containing the clonal, leukemic expansion of malignant CD4+ T cells was obtained from the blood of patients with cutaneous T cell lymphoma (CTCL). CTCL cells were purified with a CD3-magnetic bead column where CD3 engagement rendered the malignant T cells apoptotic. The monocyte fraction was simultaneously activated by column passage, re-added to the apoptotic CTCL cells and co-cultured overnight. CTCL cell apoptosis, DC differentiation and apoptotic malignant T cell ingestion were measured by immunostaining. The results demonstrate that as monocytes passed through the column matrix, they became activated and differentiated into semi-mature DC expressing significantly increased levels of class II, CD83 and CD86 (markers associated with maturing DC) and reduced expression of the monocyte markers CD14 and CD36. Apoptotic malignant T cells were avidly engulfed by the phagocytic transitioning DC. The addition of supportive cytokines further enhanced the number of DC that contained apoptotic malignant T cells. Functional studies confirmed that column passaged DC increased class II expression as shown by significantly enhanced stimulation in mixed leukocyte culture compared to control monocytes. In addition, DC loaded with apoptotic CTCL cells stimulated an increase in the percentage and absolute number of CD8 T cells compared to co-cultivation with non-loaded DC. After CD8 T cells were stimulated by DC loaded with malignant cells, they mediated increased apoptosis of residual CTCL cells and TNF-alpha secretion indicating development of enhanced cytolytic function. We report a simple one-step procedure where maturing DC containing apoptotic malignant T cells can be prepared rapidly for potential use in vaccine immunotherapy. Ready access to both the DC and apoptotic cells provided by this system will allow extension to other malignancies through the addition of a variety of apoptotic tumor cells and maturation stimuli.

Intravenous Infusion of Syngeneic Apoptotic Cells by Photopheresis Induces Antigen-Specific Regulatory T Cells

The basis of extracorporeal photopheresis is the reinfusion of leukocytes previously exposed to 8-methoxypsoralen (8-MOP) and UVA radiation. It has been approved for the palliative treatment of cutaneous T cell lymphoma and has reported benefits in autoimmune diseases, transplant rejection, and graft-vs-host disease. However, the underlying mechanism of photopheresis remains unresolved. Because UVB radiation can cause immune tolerance via induction of regulatory T cells, we studied whether photopheresis exerts a similar effect extracorporeally. Therefore, we established a model of photopheresis using a murine model of contact hypersensitivity. Splenocytes and lymph node cells of mice that were sensitized with dinitrofluorobenzene were exposed to 8-MOP plus UVA in vitro. Intravenous injection of these cells into naive mice caused inhibition of a hapten immune response, which was lost upon depletion of CD11c(+) cells but not T cells. Mice that received untreated cells or cells exposed to UVA or 8-MOP alone were not affected. Inhibition was cell-mediated and Ag-specific as demonstrated by transfer of tolerance from the primary recipients into naive animals, which could, however, properly respond to the unrelated hapten oxazolone. Transfer activity was lost when cells were depleted of CD4(+) or CD25(+) subpopulations. These data suggest that photopheresis exerts its immunomodulatory effects via the induction of Ag-specific regulatory T cells.

What's new in the management of cutaneous T-cell lymphoma?

The aetiology and clinical management of primary cutaneous T-cell lymphoma (CTCL) and specifically of mycosis fungoides and Sezary syndrome are poorly defined. Interesting new insights into CTCL disease biology as well as a number of emerging of novel therapeutic interventions make this an increasingly interesting area for dermatologists and oncologists involved in the treatment of CTCL. This review article covers much of this new information including new drugs, such as denileukin diftitox (Ontak) a targeted cytotoxic biological agent, Bexarotene an RXR selective retinoid, anti-CD4 monoclonal antibodies (mAb), new cytotoxics agents and vaccines.

Resistance to Activation-Induced Cell Death and Bystander Cytotoxicity Via the Fas/Fas Ligand Pathway Are Implicated in the Pathogenesis of Cutaneous T Cell Lymphomas

By engaging Fas, Fas ligand (FasL) on activated T lymphocytes induces activation-induced cell death (AICD), and also triggers apoptosis of target cells during immune downregulation. We previously showed that within cutaneous T cell lymphoma (CTCL) lesions, malignant CD4(+) T cells expressing FasL accumulated, and were inversely distributed with CD8(+) T cells. We thus determined the responses of human CTCL cells to AICD and their cytotoxic to Fas(+) target T cells in vitro. CTCL cells expressing Fas were resistant to AICD following activation by CD3 monoclonal antibody (mAb) whereas still undergoing apoptosis if Fas was ligated to Fas mAb. CTCL cell lines, as well as Sezary Syndrome patients' peripheral blood lymphocytes, exhibited ratio-dependent cytotoxicity to Fas(+) Jurkat cells. The kinetic study showed that FasL surface expression was absent before activation, and its expression was low and/or delayed after activation. We therefore hypothesize that CTCL cells express functional FasL possibly contributing to bystander cytotoxicity within tumor infiltrates. In addition, decreased and/or delayed FasL surface expression following activation may in part contribute to their resistance to AICD. Both bystander cytotoxicity and resistance to AICD are likely to contribute to the loss of cytotoxic anti-tumor CD8(+) T cells as well as the accumulation of malignant T cells in CTCL.

Cutaneous T-cell lymphoma: malignant proliferation of T-regulatory cells

Studies in an in vitro model of cutaneous T-cell lymphoma (CTCL) demonstrated that CTCL cell proliferation is stimulated by direct contact with autologous, immature dendritic cells (DCs), suggesting that CD4(+) CTCL cell division is driven by antigens presented by DC major histocompatibility complex (MHC) class 2. We now report that the T-cell receptor (TCR) of the CD4(+) CTCL cells is triggered after interaction with DCs loaded with apoptotic CTCL cells, as shown by reduced membrane expression of CD3 and the TCR, up-regulation of cytotoxic T lymphocyte antigen-4 (CTLA-4), and calcium mobilization. CTCL cells adopt a T-regulatory (Treg) phenotype expressing CD25/CTLA-4 and FoxP3 and secreting interleukin-10 (IL-10) and transforming growth factor-beta (TGF-beta). Treg CTCL cells suppress normal T-cell antigen-driven secretion of IL-2 and interferon-gamma (IFN-gamma). Blocking DC MHC class 2 expression or transport inhibited CTCL cell adoption of a Treg phenotype. Allogeneic CTCL cells or normal CD4 T cells served as sources of apoptotic material for CTCL cell conversion to a Treg phenotype. Conversion of CTCL cells to Treg cells may explain the anergic, immunosuppressive nature of the malignancy.

A randomized cross-over study to compare PUVA and extracorporeal photopheresis in the treatment of plaque stage (T2) mycosis fungoides

PUVA is a well-established and effective treatment for plaque stage mycosis fungoides (MF) but its use is limited on a long-term basis because of the risk of cutaneous carcinogenesis. A further disadvantage is that nonexposed areas (sanctuary sites) often develop persistent disease. Therefore it is important to find alternative methods of treatment. Extracorporeal photopheresis (ECP) is a form of photochemotherapy that involves exposure of white blood cells to UVA with psoralens and can be effective in Sézary syndrome and erythrodermic cutaneous T-cell lymphoma. The aim of this study was to compare the efficacy of PUVA and ECP in the treatment of patients with T2 plaque stage (Stage 1B) MF who had a detectable peripheral blood T-cell clone. The study was of a cross-over design. Sixteen patients were randomized to receive either PUVA twice weekly for 3 months followed by ECP once monthly for 6 months at relapse, or vice-versa. Response was assessed by monthly skin scores and peripheral blood T-cell clonality. Ten patients received PUVA initially and six ECP initially. Eight patients completed the study. Skin scores taken at the completion of each treatment arm in patients who completed the study were 113 units better (confidence interval, 42-184 units) following 3 months PUVA than 6 months ECP (P = 0.002). Peripheral blood T-cell clones were detectable in all patients post-treatment. This study indicates that ECP is not effective in the treatment of plaque stage (1B/T2) MF even in patients with molecular evidence of a peripheral blood T-cell clone. Although PUVA was more effective than ECP, neither treatment modality cleared malignant T-cells from the peripheral blood.

Treatment of advanced mycosis fungoides/Sézary syndrome with fludarabine and potential adjunctive benefit to subsequent extracorporeal photochemotherapy

BACKGROUND

Purine analogues [fludarabine monophosphate (FAMP); deoxycoformycin and 2-chlorodeoxyadenosine) and extracorporeal photochemotherapy (ECP) have been suggested to be active agents in advanced cutaneous T-cell lymphoma (CTCL) patients.

OBJECTIVES

To explore further the clinical efficacy and safety of FAMP monochemotherapy in advanced CTCL and to evaluate if the sequential association of ECP to FAMP in selected patients may improve the response rate (RR) and/or lengthen the remission duration.

PATIENTS AND METHODS

Forty-four CTCL patients [17 Sézary syndrome (SS); 26 mycosis fungoides (MF), stage IIB-IV or with peripheral blood involvement; one MF associated with lymphomatoid papulosis (LyP)] were enrolled in this pilot cohort study. All the patients received FAMP 25 mg m(-2) 5 days monthly; 19 patients (43.2%) underwent ECP after FAMP was discontinued. The majority of patients with erythrodermic CTCL or peripheral blood involvement underwent the combined FAMP-ECP schedule.

RESULTS

After a median follow-up of 4.2 years, the overall FAMP RR was 29.5% (13/44); a higher RR was obtained in SS (35.3%) than in MF patients (25.9%). According to the treatment group, the RR of the FAMP-ECP group (63.2%) was significantly higher than that of the FAMP monotherapy group (24%; P=0.021). No statistically significant difference was found in time-to-progression (TTP) or survival by therapy group, even if the TTP of the patients treated with the FAMP-ECP combination therapy was higher (median 13 vs. 7 months). A decrease or a normalization in the CD4+CD26- circulating subset was observed in responding patients, paralleling the reduction in the circulating Sézary cells.

CONCLUSIONS

FAMP confirms its clinical activity as a single agent in SS; conversely, FAMP results do not compare favourably with other therapeutic approaches for advanced stage MF patients. The sequential association of ECP after FAMP seems to increase the RR, even if future randomized studies are needed to confirm these results.

Management of the primary cutaneous lymphomas

Cutaneous lymphomas are rare and, although some are a manifestation of systemic lymphoma, the majority arise primarily from the skin. These primary cutaneous lymphomas comprise both T- and B-cell subtypes and represent a wide spectrum of disorders, which at times can be difficult to diagnose and classify. Classical therapeutic strategies include topical corticosteroids, phototherapy, radiotherapy, retinoids, extracorporeal photopheresis, topical chemotherapy, systemic chemotherapy and biological response modifiers. Newer therapies include the synthetic retinoid bexarotene, the immunotoxin conjugate denileukin diftitox, interleukin-12 and monoclonal antibodies such as alemtuzumab and rituximab.

The treatment of cutaneous T-cell lymphoma with photopheresis

Photopheresis or extracorporeal photochemotherapy (ECP) is an immunomodulating procedure that has been available for the treatment of cutaneous T-cell lymphoma (CTCL) since 1987. A concentrated white blood cell (WBC) sample spiked with 8-methoxypsoralen (methoxsalen) is exposed to an ultraviolet A light source, then all blood components are returned to the patient. Treatment of mycosis fungoides (MF) and Sézary syndrome (SS) with ECP has been reported in over 400 patients. The combined overall response rate for all stages of CTCL is 55.7% (244 out of 438) with 17.6% (77 out of 438) achieving a complete response. Efficacy in treating certain clinical stages (IB, IIA, III and IVA) and skin stages (T2 and T4) of MF and SS is favorable, although randomized trials comparing ECP to other standard therapies are needed. The use of ECP to treat early stage patients remains controversial. Efforts to establish the effectiveness of combining ECP with other newer immunoadjuvant therapies and modifications of the procedure to enhance immunomodulation are exciting prospects for patients with CTCL.

Bexarotene - an alternative therapy for progressive cutaneous T-cell lymphoma? First experiences

BACKGROUND

A standard therapy for advanced cutaneous T-cell lymphomas has not yet been defined. Bexarotene is a new retinoid x receptor-specific retinoid that has been approved for systemic second-line therapy for cutaneous T-cell lymphomas in the USA and Europe. In order to evaluate the efficacy of bexarotene in cutaneous T-cell lymphomas, a pilot trial was initiated.

PATIENTS AND METHODS

In a pilot project 10 patients with advanced cutaneous T-cell lymphomas, who had received a variety of previous treatments, were treated with bexarotene at the departments of dermatology in Münster, Minden and Charité Berlin, Germany. The patients received bexarotene at a dose of 300 mg/m2 body surface daily. According to the percentage of tumour reduction and affected body surface, the response rates were divided in complete and partial remission, stable disease and progressive disease. Laboratory parameters i.e. cholesterol, triglycerides transaminases, T3, T4, and TSH were screened regularly.

RESULTS

In 2 patients a short partial remission was achieved; however, after a few weeks progression followed. In 4 patients a lasting stabilisation was obtained. The other 4 patients showed a progressive disease during therapy. 6 patients developed hypertriglyceridemia with levels up to 2000 mg/dl; therapy had to be suspended in 3 patients because of these adverse drug events.

CONCLUSION

Weighing benefits and risks, bexarotene can at present not be recommended as standard therapy in the treatment of patients with progressive cutaneous lymphomas.

Lymphoma of the skin

This chapter describes the various ways in which the non-Hodgkin's lymphomas can involve the skin, how these diseases should be assessed, standard treatments available in 2002, and new directions in research. The goal of the session is to succinctly review recent developments in lymphoma classification and treatment as they apply to the unique aspects of lymphoma when manifest in the skin. In Section I, Dr. Eric Hsi reviews the special characteristics of the lymphomas seen when they proliferate in the skin and the application of the new World Health Organization classification system to the cutaneous lymphomas, emphasizing the unique challenges of recognizing and correctly classifying these diseases. He summarizes the evidence in favor of including the skin lymphomas in the overall lymphoma classification scheme and concludes with a practical description of the specific skin lymphoma entities. In Section II, Dr. Joseph Connors describes the current optimal treatment of the B-cell lymphomas when they present in or metastasize to the skin. Building on the classification scheme described by Dr. Hsi, Dr. Connors outlines a treatment approach based on current understanding of pathophysiology of these diseases and application of each of the effective modalities available for cutaneous lymphoma including radiation, chemotherapy, and immunotherapy. In Section III, Dr. Francine Foss concludes the session with a discussion of the different T-cell lymphomas that start in or spread to the skin concentrating on mycosis fungoides, cutaneous anaplastic large cell lymphoma and peripheral T-cell lymphoma. She includes comments on the newer anti-T-cell chemo- and immuno-therapeutics focusing on agents and techniques specific for cutaneous T-cell lymphomas.

Extracorporeal photopheresis therapy in the management of steroid-refractory or steroid-dependent cutaneous chronic graft-versus-host disease after allogeneic stem cell transplantation: feasibility and results

We conducted a retrospective analysis of all allogeneic stem cell transplantation (ASCT) patients started on extracorporeal photopheresis (ECP) for the management of steroid-dependent (SD) or steroid-refractory (SR) cutaneous chronic graft-versus-host disease (cGVHD) following ASCT during a 36-month period (9/98-8/01). Only SD or SR patients who were treated by ECP after day 100 and who received at least 4 weeks of ECP were considered evaluable for this analysis. Out of 64 ASCT patients reviewed, 32 patients met the inclusion criteria. All 32 patients had been previously treated with systemic corticosteroids with 11 (34%) being SR and 21 (66%) SD. Cutaneous cGVHD was extensive in 28 patients (88%) and was accompanied by visceral (hepatic, gastrointestinal) cGVHD in 23 patients (72%). The 32 evaluated patients had received a median of three prior therapies before ECP, most commonly systemic corticosteroids, tacrolimus, and mycophenolate mofetil. Patients received a median of 36 ECP sessions (range 12-98) over a median of 5.3 months (range 1-28), with a median of six sessions per month. The complete response (CR) rate was 22% (n=7) and the partial response rate was 34% (n=11). In all, 28 patients were on systemic corticosteroid therapy at ECP initiation and 18 patients achieved 50% dose reduction while on ECP, yielding a 64% steroid-sparing response rate. Of seven CRs, five are ongoing. A total of 11 (34%) patients have died after ECP, with all cases due to visceral cGVHD or cGVHD-related infectious complications. All 21 surviving patients remain on at least some immunosuppressive cGVHD therapy (including ECP in eight). Overall, ECP displays a substantial response rate and, in particular, steroid-sparing activity in SR/SD extensive cutaneous cGVHD. However, most patients continue to require at least some chronic therapy and cGVHD-related morbidity and mortality remain high.

Sézary syndrome and seronegative polyarthritis: treatment with extracorporeal photochemotherapy

We describe a patient with therapy-resistant cutaneous T-cell lymphoma, Sézary syndrome variant, in association with concurrent polyarthritis and vitiligo, who was successfully treated with extracorporeal photochemotherapy (ECP). The combination of Sézary syndrome with seronegative rheumatoid arthritis is rare. In our patient the T-cell lymphoma was refractory to standard treatments that included psoralen-UVA, lymph node irradiation, and polychemotherapy. ECP has been shown to be effective in the treatment of selected cases of Sézary syndrome. There is a strong suggestion that ECP as a monotherapy can provide a significant benefit for other T-cell-mediated diseases including rheumatoid arthritis. In spite of a disease duration of 10 years, a very low CD8 cell count (2% of lymphocytes), a very high CD4 cell count (94%), and multiple unsuccessful chemotherapeutic trials before initiation of ECP, our patient achieved a long-lasting complete remission of both diseases with normalization of the CD4+ and CD8+ T-lymphocyte subsets. Concurrent developing vitiligo was unaffected by ECP.

Identification of amplified clonal T cell populations in the blood of patients with chronic graft-versus-host disease: positive correlation with response to photopheresis

Chronic graft-versus-host disease (cGVHD) is a multiorgan disorder with skin manifestations resembling scleroderma. Since photopheresis, a treatment that induces an anticlonotypic immune response, has proven to be effective in both cutaneous T cell lymphomas with circulating clonal T cells and in cGVHD, we have searched for circulating clonal T cell populations in patients with cGVHD, and determined whether T cell clonality in the blood is associated with therapeutic response. We screened blood samples from 27 patients after HLA-matched allogeneic bone marrow transplantation (allo-BMT), 10 without cGVHD and 17 with extensive cGVHD, for clonal T cell receptor gamma (TCR gamma) gene rearrangements using fluorescent-based polymerase chain reaction (PCR) and automated high-resolution capillary electrophoresis. Amplified populations of clonal T cells with unique TCR gamma gene rearrangements were found in six of 10 (60%) allo-BMT patients without cGVHD and 13 of 17 (76.5%) allo-BMT patients with cGVHD (P = 0.41), as compared to none of 10 (0%) healthy controls. Twelve patients with cGVHD were treated by photopheresis, and the presence of amplified populations of clonal T cells was found to be associated with a cutaneous response to photopheresis, as eight of eight (100%) clone-positive vs none of four (0%) clone-negative patients experienced a clinically significant cutaneous response to treatment (P = 0.001). Our findings suggest that patients with cGVHD that have detectable expanded clonal T cell populations in their peripheral blood, may be more likely to respond to treatment by photopheresis.

Extracorporeal photochemotherapy--the Columbia Presbyterian experience

BACKGROUND

Cutaneous T Cell Lymphoma (CTCL) is a lymphoma of skin homing usually CD4 + lymphocytes. There are numerous treatments available both for the early as well as the more advanced stages of the disease. Extracorporeal photochemotherapy is a well-accepted form of treating CTCL. The purpose of our study was to review the experience of treating 20 CTCL patients with extracorporeal photochemotherapy (ECP) at Columbia Presbyterian Medical Center over a seven-year period.

METHODS

The study was conducted as a retrospective chart review of these 20 patients. Summarized demographic characteristics included age at diagnosis, gender, and race. We analyzed the overall response by categorizing patients as having complete response, partial response, stable disease, and progressive disease. We also analysed the predictive value for three factors: peripheral blood CD4 : CD8 (< 10, > 10), LDH level (normal, elevated), and erythrodermic status (erythrodermic or nonerythrodermic). The potential prognostic variables were evaluated for linear association with response using Mantel-Haenszel chi-square tests. All statistical tests were two-sided with alpha = 0.05. The tests were considered to be exploratory and no adjustments for multiple testing were made.

RESULTS

There was a significant linear association between response and CD4 : CD8. Patients with a ratio < 10 were more likely to respond than patients with a ratio > 10. There was a marginally significant linear association between response and LDH level. Patients whose LDH was not elevated at the start of treatment, tended to have a better response to ECP compared to patients with an elevated LDH. There was a suggestion of an association between erythroderma and response although this was not statistically significant. The majority of patients with erythroderma were responders compared to the majority of non-erythrodermic patients who were non-responders. The treatment was well tolerated with minimal side-effects.

CONCLUSION

Apparent predictors of good response to ECP include erythroderma, a relatively low (closer to normal) peripheral CD4 : CD8, and a normal LDH. This report confirms reports from other institutions indicating that CTCL patients who are erythrodermic with a relatively intact immune system are optimal candidates for ECP.

Effect of insulin-dependent diabetes mellitus on response to extracorporeal photopheresis in patients with Sézary syndrome

BACKGROUND

Extracorporeal photopheresis (ECP) has become a primary therapy for selected forms of cutaneous T-cell lymphoma, especially Sézary syndrome. Variability in response of patients with Sézary syndrome to ECP has been reported.

OBJECTIVE

Our purpose was to determine whether underlying medical conditions influence the efficacy of ECP in patients with Sézary syndrome.

METHODS

We retrospectively reviewed the medical records of 55 patients with Sézary syndrome who received ECP between 1987 and 2000. Efficacy criteria included decrease in Sézary cell count, erythroderma, lymphadenopathy, organomegaly, and pruritus.

RESULTS

Thirty-four patients responded well and 10 patients responded partially to ECP; 11 patients had no response. Nine patients with no response to ECP had insulin-dependent diabetes mellitus (IDDM). IDDM was documented in only 2 patients with a good response and in no patients with a partial response to ECP.

CONCLUSION

Patients with Sézary syndrome and IDDM typically respond poorly to the standard ECP treatment regimen.

T cell clonality and the effect of photopheresis in systemic sclerosis and graft versus host disease

Photopheresis, a leukapheresis-based therapy that combines 8-methoxypsoralen (8-MOP) and ultraviolet-A irradiation, has been shown to be an effective treatment for advanced cutaneous T cell lymphoma (CTCL), but also appears to be effective in certain patients with systemic sclerosis (SSc) and chronic graft versus host disease (cGVHD). In CTCL, clinical responsiveness to photopheresis has been shown to be dependent on the presence of detectable circulating clonal T cells in peripheral blood. Herein we review recent work from our group demonstrating that circulating clonal populations of T cells are detectable in a subgroup of patients with SSc and cGVHD. Furthermore, we provide initial evidence that the presence of a T cell clone in such patients may be associated with responsiveness to photopheresis.

Transimmunization and the evolution of extracorporeal photochemotherapy

We are now aware that extracorporeal photopheresis (ECP) - in which a patient's leukocytes are isolated, passed through an ultrathin clear plastic plate, and exposed to 8-methoxypsoralen (8-MOP) and ultraviolet A light prior to reinfusion - is a simple and efficient dendritic cell (DC) therapy and the first FDA approved selective immunotherapy for cancer. DCs, as the most effective antigen presenting cells (APCs), are central to many ongoing efforts to stimulate immune responses to cancer cells. Moreover, ECP has not only demonstrated efficacy in the treatment of a T cell malignancy--namely cutaneous T-cell lymphoma (CTCL)--but also in treatment of oligoclonal T-cell-mediated diseases such as graft-versus-host-disease (GVHD) and organ transplant rejection. Recent advances in the understanding of DC/T-cell interactions provide insight into how ECP-induced DCs (EI-DCs) can be utilized to stimulate specific T-cell (i.e. anti-tumor) responses, or down-regulate a pre-existing potent T-cell response. The mechanism of this apparent paradox of EI-DC functionality is likely dependent on several fundamental principles: (1) the status of existing in vivo T-cell reactions, (2) the temporal stage of EI-DC differentiation, and (3) the affinity of the available repertoire of T-cell receptors (TCRs) for the antigen(s) in question. Further investigation into DC/T-cell interactions will help to shape the future of ECP and the ability to optimize this therapy for the desired immune effect. To this end, we are developing and testing Transimmunization to replace conventional ECP.

Transimmunization, a novel approach for tumor immunotherapy

This review describes our experience with the development of a novel form of immunotherapy that may represent the first practical and effective means of performing tumor-loaded dendritic cell (DC) immunotherapy. We have modified the highly successful extracorporeal photopheresis (ECP) treatment that has been used in the therapy of cutaneous T cell lymphoma (CTCL). autoimmune disease, transplantation rejection episodes and graft-versus-host disease to enhance its efficacy by the addition of an overnight incubation period. This adaption of ECP is termed "transimmunization (TI)" since the new therapy permits transfer of tumor antigens that have been previously poorly recognized to potent antigen presenting cells where the tumor epitopes can be displayed in the full context of major histocompatibility, co-stimulatory and adhesion molecules. The TI modification of ECP is a practical and safe means of rapidly inducing DC differentiation from peripheral blood monocytes in the presence of apoptotic tumor cells. Uptake of the apoptotic CTCL cells by the immature DC, in the presence of inflammatory cytokines, further drives their maturation into potent antigen presenting cells. Reinfusion of these tumor-loaded DC, that have access to the full spectrum of tumor antigens, has the potential to invoke an anti-tumor immune response in the recipient. Standard ECP has been a very useful form of immunotherapy and a modification of this approach that can enhance its ellicacy and utility should broaden its application to a larger variety of disorders including potentially the treatment of solid tumors and the modulation of the immune response in graft-versus-leukemia and graft-versus-host transplantation regimens. An understanding of the mechanism of ECP and TI will provide the physician with the ability to more finely tune the desired immune response and thereby, provide an enhanced immunotherapy for malignancy and other disorders of immunocompetence.

Current treatment options in systemic Sclerosis (Scleroderma)

Systemic Sclerosis (SSc) or Scleroderma is a generalized autoimmune disease with variable involvement of the skin and major organs. Etiology and pathogenesis are still largely unknown, but a variety of humoral and cellular autoimmune phenomena can be observed, and a pivotal role of T lymphocytes in SSc pathogenesis is postulated. The rarity of the disease, the wide spectrum of clinical manifestations and severity as well as a variable course render therapy in SSc a major challenge. In view of the immunopathogenesis of SSc, many (presumed) immunomodulatory agents have been used, but no single agent has been proven to be convincingly effective. Trials with extracorporeal therapies (such as photopheresis, plasmapheresis) or even stem cell transplantation are in progress. In contrast to the hitherto unsuccessful therapeutic approaches for the overall disease course, some life-threatening organ manifestations can often be treated successfully, e.g. interstitial pneumonitis with i.v. cyclophosphamide and scleroderma renal crisis with ACE inhibitors and haemodialysis, respectively. Furthermore, pharmacological and supportive treatment of Raynaud's phenomenon and gastrointestinal involvement can alleviate the burden of the disease. Current therapeutic options as well as hitherto investigated immunomodulators are reviewed in this article.

Extracorporeal photopheresis and adjuvant aerosolized granulocyte-macrophage colony-stimulating factor for Sézary syndrome

Encouraged by preliminary phase 1 studies of aerosolized granulocyte-macrophage colony-stimulating factor (GM-CSF, sargramostim) in the treatment of patients with melanoma and other malignancies, we treated a 72-year-old patient with Sézary syndrome, using alternate-week cycles of aerosolized GM-CSF in combination with monthly cycles of extracorporeal photopheresis (ECP). Sézary syndrome, one of the more aggressive forms of cutaneous T-cell lymphoma, is a devastating and highly symptomatic form of non-Hodgkin lymphoma in which malignant clones of mature helper CD4 T cells, containing large, convoluted nuclei known as Sézary cells, circulate in the blood and infiltrate skin. Extracorporeal photopheresis, an immunomodulatory therapy, has become a primary treatment for patients with Sézary syndrome. This pheresis-based therapy combines psoralen and ultraviolet A radiation as systemic photochemotherapy to induce immune responses. However, the activity and efficacy of ECP vary considerably. To our knowledge this is the first patient with Sézary syndrome treated with adjuvant aerosolized GM-CSF combined with ECP. It produced clinical improvement and decreased the number of circulating Sézary cells in a previously ECP-refractory patient.

Efficient tumor antigen loading of dendritic antigen presenting cells by transimmunization

Extracorporeal photochemotherapy (ECP), or photopheresis, was originally introduced for the management of patients with cutaneous T cell lymphoma (CTCL). Today, ECP remains the only FDA approved tumor-targeting selective immunotherapy for the treatment of any cancer. The key cellular events permitting ECP-induced anti-tumor immunity against CTCL are the induction of apoptotis in the malignant T cells, and the induction of monocyte-to-dendritic cell (DC) differentiation. In standard ECP, leukocytes extracorporeally exposed to psoralen and ultraviolet A light (UVA) are circulated back to the patient. However, recent findings suggest that co-incubation of these cells prior to re-infusion allows for more efficient phagocytosis and processing of the apoptotic malignant T cells by the newly formed DCs. Moreover, such a co-incubation step permits the direct external manipulation of this system and the design of strategies to augment the production of tumor-loaded DCs. These considerations have led to the development of Transimmunization, so named because it causes transfer of tumor antigens to newly formed dendritic cells capable of initiating immunization against the tumor cells, as the replacement technology for ECP. We will review the scientific understanding of ECP and explain how this can lead a more efficient, potentially broadly applicable, immunotherapy for cancer.

Therapy options in cutaneous T-cell lymphoma

The treatment of cutaneous T-cell lymphoma (CTCL) is continually evolving, as new and emerging drugs are added to the growing arsenal of CTCL therapy. The availability of newly approved investigational therapies, such as bexarotene, denileukin diftitox (DAB389- IL2), monoclonal antibodies and novel chemotherapeutic agents, adds complexity to decisions on the management and treatment of CTCL patients. In formulating a treatment plan, therapeutic options are best approached through consideration of overall clinical staging (stage IA-IVB) and skin staging (T1-T4), which affect prognosis and the characteristics of each individual patient's disease. This article will present and discuss the optimal therapeutic agents for all clinical stages of CTCL patients, based on currently available and investigational agents.

Extracorporeal photochemoimmunotherapy in cutaneous T cell lymphomas

Extracorporeal photochemotherapy (ECP), or photopheresis, is a widely used treatment for cutaneous T cell lymphoma (CTCL) and other T cell-mediated disorders, having been administered in more than 150 centers worldwide more than 200,000 times. Consistent with the theme of this conference--that is, highlighting the potentially most productive investigative avenues for unraveling the mysteries of CTCL in the next decade--ECP has been futuristic since its inception in the early 1980s. In 1988, the treatment was the first FDA-approved selective immunotherapy for any type of cancer. Yet, the mechanism by which it could suppress a clone of CTCL cells or inactivate multiple autoreactive T cell clones in graft-versus-host disease (GVHD) or allograft rejection remained obscure until quite recently. In fact, the scientific principles necessary to begin to comprehend the basis of ECP's efficacy were not available when the treatment was first introduced in 1982. In the intervening years, necessary detailed knowledge of the structure and function of the clonotypic T cell receptors, of class I major histocompatibility complex (MHC) presentation of tumor antigens, of CTCL tumor-specific antigens, of dendritic antigen presenting cell (DC) biology, and of 8-methoxypsoralen immunopharmacology has been attained. Although much remains to be learned, we now appreciate that ECP simultaneously and efficiently induces both apoptosis of disease-causing T cells and conversion of monocytes to functional DCs. By processing and presenting the unique antigenic determinants of pathogenic T cell clones, the DCs can either initiate a clinically relevant anti-CTCL cytotoxic response or suppress the activity of autoreactive T cell clones. This paper will review clinical trials of ECP in CTCL and evolving scientific understanding of ECP's mechanism in the context of exciting future directions.

Oral bexarotene in the treatment of cutaneous T-cell lymphoma

OBJECTIVE

To review the preclinical and clinical information related to oral bexarotene approved by the Food and Drug Administration for the treatment of cutaneous manifestations of cutaneous T-cell lymphoma (CTCL) in patients who are refractory to at least one prior systemic therapy.

DATA SOURCES

Literature accessed through MEDLINE (from 1990 to July 2000) and provided by the manufacturer. Key search terms included bexarotene, Targretin, LGD1069, and cutaneous T-cell lymphoma.

DATA SYNTHESIS

The management of CTCL remains controversial due to its rarity in the US and its heterogeneity. An evaluation focusing on the pharmacology of bexarotene and its role in the management of the different stages of CTCL was conducted.

CONCLUSIONS

Bexarotene has demonstrated activity in the treatment of CTCL. The oral route of administration and the adverse effect profile of bexarotene appear to make this drug a favorable option for the treatment of CTCL. Compared with other systemic therapies. Phase III randomized studies are needed to determine the clinical benefits of bexarotene as monotherapy or combination therapy in the treatment of CTCL.

Extracorporeal photopheresis in Sézary syndrome: hematologic parameters as predictors of response

Data were analyzed from 23 patients with Sézary syndrome (defined by erythroderma, more than 10% circulating atypical mononuclear cells, and peripheral blood T-cell clone) undergoing monthly extracorporeal photopheresis as the sole therapy for up to 1 year. The cohort showed a significant reduction of skin scores during treatment (P =.001). Thirteen patients (57%) achieved a reduction in skin score greater than 25% from baseline at 3, 6, 9, or 12 months (responders). Reduction in skin score correlated with reduction in the Sézary cell count as a percentage of total white cell count (P =.03). Responders and nonresponders were compared. None of the measured parameters was significantly different between the 2 groups. It was assessed whether any of the baseline parameters predicted outcome. A higher baseline lymphocyte count was significantly associated with a decrease in skin score at 6 months (P <.05). A higher baseline Sézary cell count as a percentage of total white cell count predicted a subject was more likely to be a responder after 6 months of treatment (P =.021). No other parameters predicted responder status. These data show that the modest falls in CD4, CD8, and Sézary cell counts were seen in all patients and might have resulted from lymphocyte apoptosis. This mechanism could explain the more favorable response seen in patients with higher percentages of Sézary cells in the peripheral blood. Alternatively, minimum tumor burden might be required for the induction of a cytotoxic response. Analysis of tumor-specific cytotoxic T cells is needed to investigate these possibilities further.

Complete molecular remission during biologic response modifier therapy for Sézary syndrome is associated with enhanced helper T type 1 cytokine production and natural killer cell activity

BACKGROUND

Cutaneous T-cell lymphoma (CTCL) is a clonally derived, skin-invasive malignancy of CD4(+) T lymphocytes with the phenotype of mature helper T cells. Advancing stages of CTCL are associated with depressed cell-mediated immunity, increased production of T helper type 2 cytokines and decreased levels of T helper type 1 cytokines.

OBJECTIVE

Our purpose was to evaluate the cytokine secretion pattern and cell-mediated cytotoxicity in peripheral blood mononuclear cells of patients with Sézary syndrome in relation to the presence of the malignant clone.

METHODS

Serial polymerase chain reaction for the T-cell receptor-beta or T-cell receptor-gamma gene rearrangement was used to determine the presence of the malignant clone. Enzyme-linked immunosorbent assays were used to determine the levels of interleukin 4 and interferon gamma produced by the peripheral blood mononuclear cells from the patients with Sézary syndrome.

RESULTS

We demonstrate 3 cases of Sézary syndrome with typically suppressed cell-mediated cytotoxicity, elevated production of interleukin 4, and depressed production of interferon gamma by their peripheral blood mononuclear cells before institution of therapy with biologic response modifier therapy. In all 3 cases after clinical and molecular remission, we observed striking immunologic changes, including an increase in levels of natural killer cell activity and interferon gamma production and decreased production of interleukin 4.

CONCLUSIONS

The observation that the cytokine secretion pattern by peripheral blood mononuclear cells from 3 patients with Sézary syndrome normalized with the disappearance of the malignant clone from the peripheral blood suggests that the malignant T cells account for the aberrant cytokine production. Moreover, the aberrant cytokine production may be the cause for suppression of cell-mediated immunity seen in advancing stages of CTCL.

Induction of human tumor-loaded dendritic cells

A preferred anti-cancer vaccine would be tumor-specific, simple to rapidly construct and safe to administer. It would permit immunization against a spectrum of the tumor's distinctive antigens, without requiring their prior identification. Toward these goals, we describe a modification of standard extracorporeal photopheresis (ECP) which initiates, within a single day, both monocyte-to-dendritic cell (DC) differentiation and malignant cell apoptosis. The transition of monocytes to immature DCs was identified by the expression of cytoplasmic CD83 and membrane CD36 in the absence of membrane CD14 staining, as well as induction of membrane CD83 expression. Differentiating DCs were avidly phagocytic and engulfed apoptotic malignant T cells. Differentiating DCs were capable of stimulating significant proliferation of normal alloreactive lymphocyte responders, indicting increased expression of membrane MHC class II molecules. This approach provides a clinically practical means of developing tumor-loaded cells that have initiated the transition to DCs without the requirement of exogenous cytokines, excessive cellular manipulation or isolation. Construction of DC vaccines using this methodology can be generalized to other diseases and may offer a novel approach for improved cancer immunotherapy.

Expression of apoptosis markers on peripheral blood lymphocytes from patients with cutaneous T-cell lymphoma during extracorporeal photochemotherapy

The mechanisms of extracorporeal photochemotherapy (ExP) therapeutic activity in cutaneous T-cell lymphomas (CTCLs) are not yet well understood, even though it has been suggested that a major mechanism may be induction of apoptosis. In vitro studies demonstrate that UVA-induced apoptosis is mediated by CD95-Fas expression and inhibited by Bcl-2 up-regulation and that UVA irradiation is able to down-regulate Bcl-2 expression. High-resolution multiparameter flow-cytometric analyses were used to evaluate Bcl-2/CD95-Fas expression on phenotypically identifiable circulating clonal T cells from 7 patients with CTCL (4 with Sézary syndrome and 3 with mycosis fungoides with peripheral involvement) before and during ExP, in an attempt to ascertain whether Bcl-2/CD95-Fas status can be related to the hematologic response. A Bcl-2 normal phenotype before ExP or a normalization in Bcl-2 expression during ExP were related to a better clinical response, whereas a persistent Bcl-2 high expression was a negative prognostic factor. On the other hand, no response was found in patients with a CD95-Fas-negative phenotype, whereas the expression of CD95-Fas was associated with hematologic remission. Although further studies are needed to confirm these preliminary results, this study suggests that Bcl-2 and CD95-Fas expression could be evaluated, together with the other known clinical and immunologic factors, as additional parameters related to clinical response in patients with CTCL undergoing ExP.

The treatment of cutaneous T-cell lymphoma with a novel retinoid

The clinical experience with bexarotene for cutaneous T-cell lymphoma (CTCL) at our center is reviewed here. Disease activity assessment was monitored every 4 weeks in all patients. Five target lesions were monitored, an area score was performed, and a CTCL-specific health assessment questionnaire was administered. Four patients with refractory plaque CTCL were treated with bexarotene gel. All target lesions disappeared after 8 weeks of therapy, with recurrences observed in untreated areas. In the follow-up period, no recurrences of the original target lesions were observed. One patient withdrew from the study. Patients with refractory patch/plaque disease were randomized to a high-dose (300 mg/m(2)) or low-dose (6.5 mg/m(2)) daily oral regimen of bexarotene. After showing disease progression, the two patients on the low-dose arm were entered into the high-dose arm after 8 weeks. Marked clinical responses were seen in all patients treated. The target lesions showed either complete disappearance or a reduction in lesion size, duration, and scale. No new lesions were noted in patients on high-dose bexarotene. Self-assessments also confirmed the palliative properties of the observed responses. All patients had hypertriglyceridemia despite the concomitant administration of atorvastatin at 60 mg/day. Dose reductions were required to maintain safe lipid levels. Four patients with erythrodermic CTCL were treated with high-dose oral therapy, and all patients showed rapid (within 2 weeks) improvement of erythroderma and symptoms.

Bexarotene and DAB(389)IL-2 (denileukin diftitox, ONTAK) in treatment of cutaneous T-cell lymphomas: algorithms

Mycosis fungoides (MF), CD4(+) epidermotropic cutaneous T-cell lymphoma (CTCL), often arises as indolent, inflammatory, chronic, persistent patches and plaques. Conservative and sequential topical therapy patients have the same survival as patients treated with aggressive chemotherapy. Hence, until curative therapy is found, therapies that keep MF in check and prevent progression to more advanced lymphoma may be desirable alternatives and may preserve quality of life. Stage IA patients with stable disease have a very favorable prognosis and often initially receive psoriasis-type therapy. Bexarotene gel, a new topical retinoid X receptor retinoid will resolve MF lesions, reducing dermal T-cell infiltrates when used as a single agent. However, it may be even more effective when combined with topical steroids, with phototherapy (ultraviolet B and psoralen-ultraviolet A), or even with oral bexarotene. The gel may also provide a safe adjunctive therapy for individual lesions that are refractory to other agents, including keratodermas. When more than 10% of the body is involved with CTCL or when adenopathy is present (> stage IB), systemic therapy is indicated. Bexarotene capsules have the advantage of easy oral administration and are extremely effective both for early-stage patients with long-standing extensive plaques and for late-stage patients with Sézary syndrome or large-cell transformation. Monitoring of white blood cell count, lipids, and thyroid function is required. Bexarotene should be tested in combination with interferon-alfa or other therapies such as photopheresis, psoralen-ultraviolet A, and methotrexate and for maintenance after total body skin electron beam. DAB(389)IL-2 is targeted to CD25(+), the interleukin-2 receptor on activated T cells as measured by the expression of CD25. DAB(389)IL-2 has given complete or partial remission in 30% of highly refractory patients with extensive plaques and disfiguring tumors. Because it is effective in killing T cells that surround dermal vessels, cytokine release may occur and result in capillary leak syndrome. Hence, it will be reserved for more advanced and refractory patients and will require intravenous administration and monitoring. The use of oral bexarotene first to reduce dermal infiltrates prior to DAB(389)IL-2 administration might reduce subsequent side effects imparted by this therapy. With three new highly effective agents in the armamentarium for the treatment of CTCL, new combination treatment algorithms can be tested to achieve maximal benefit and quality of life for these patients.

Extracorporeal photochemotherapy alone or with adjuvant therapy in the treatment of cutaneous T-cell lymphoma: a 9-year retrospective study at a single institution

BACKGROUND

Extracorporeal photochemotherapy (ECP; photopheresis) is a treatment option for cutaneous T-cell lymphoma (CTCL).

OBJECTIVE

This study describes the outcomes obtained with ECP alone or with adjuvant therapy in treating CTCL.

METHODS

A 9-year retrospective study was performed at a single institution.

RESULTS

Among 69 patients, 37 were treated with 6 months or more of ECP alone over an average of 36.9 months. Of these patients, 68% (25/37) had stage T2, 5% (2/37) had stage T3, and 27% (10/37) had stage T4 CTCL. Complete response (no skin or systemic disease for 1 month or more) and partial response (50%-99% skin improvement for 1 month or more) were achieved by 14% (5/37) and 41% (15/37) of patients, respectively, giving an overall response rate of 54% (20/37). In recalcitrant patients, adjuvant therapy significantly increased the response rate from 31% (4/13) to 69% (9/13) (P = 0.004). ECP was well tolerated in the entire patient population.

CONCLUSION

Response rates in this study compared favorably with those in previous studies, underscoring the potential value of ECP in treating CTCL. To our knowledge, this investigation included the largest group of CTCL patients ever treated with ECP at a single institution.