Clinicopathological definition, management and prognostic value of mogamulizumab-associated rash and other cutaneous events: A systematic review

Mogamulizumab is a first-in-class IgG1k monoclonal antibody that selectively targets the chemokine receptor type 4. The drug has received Food and Drug administration authorisation for mycosis fungoides and Sézary syndrome following failure of at least one previous course of systemic therapy and now is available in Europe. One of the most common treatment-related side effects observed has been the mogamulizumab-associated rash (MAR), which affects up to a quarter of patients and is the most frequent adverse event leading to drug discontinuation. The aim of this study is to perform a systematic review of the literature on patients diagnosed with MAR and other mogamulizumab-related cutaneous events to describe the clinical and histological characteristics, the management in clinical practice and to assess whether these events have prognostic implications. In total, 2073 records were initially identified through a literature search, 843 of which were duplicates. After screening for eligibility and inclusion criteria, 49 articles reporting mogamulizumab-associated cutaneous events were included. Totally, 1516 patients were retrieved, with a slight male prevalence as for the available data (639 males and 570 females, i.e. 52.9% vs. 47.1%). Regarding the reported clinicopathological findings of the cutaneous reactions, the five most common patterns were spongiotic/psoriasiform dermatitis (22%), eruptions characterized by the presence of papules and/or plaques (16.1%), cutaneous granulomatosis (11.4%), morbilliform or erythrodermic dermatitis (9.4%) and photodermatitis (7.1%). Our results highlight how the majority of the reported cutaneous adverse events on mogamulizumab are of mild-to-moderate entity and generally manageable in clinical practice, though prompt recognition is essential and case-by-case assessment should be recommended. Future research will need to focus on the MAR prognostic implications and to identify genomic and molecular markers for a more rapid and accurate diagnosis.

Dissection of DLBCL microenvironment provides a gene expression-based predictor of survival applicable to formalin-fixed paraffin-embedded tissue

Background

Gene expression profiling (GEP) studies recognized a prognostic role for tumor microenvironment (TME) in diffuse large B-cell lymphoma (DLBCL), but the routinely adoption of prognostic stromal signatures remains limited.

Patients and methods

Here, we applied the computational method CIBERSORT to generate a 1028-gene matrix incorporating signatures of 17 immune and stromal cytotypes. Then, we carried out a deconvolution on publicly available GEP data of 482 untreated DLBCLs to reveal associations between clinical outcomes and proportions of putative tumor-infiltrating cell types. Forty-five genes related to peculiar prognostic cytotypes were selected and their expression digitally quantified by NanoString technology on a validation set of 175 formalin-fixed, paraffin-embedded DLBCLs from two randomized trials. Data from an unsupervised clustering analysis were used to build a model of clustering assignment, whose prognostic value was also assessed on an independent cohort of 40 cases. All tissue samples consisted of pretreatment biopsies of advanced-stage DLBCLs treated by comparable R-CHOP/R-CHOP-like regimens.

Results

In silico analysis demonstrated that higher proportion of myofibroblasts (MFs), dendritic cells, and CD4⁺ T cells correlated with better outcomes and the expression of genes in our panel is associated with a risk of overall and progression-free survival. In a multivariate Cox model, the microenvironment genes retained high prognostic performance independently of the cell-of-origin (COO), and integration of the two prognosticators (COO + TME) improved survival prediction in both validation set and independent cohort. Moreover, the major contribution of MF-related genes to the panel and Gene Set Enrichment Analysis suggested a strong influence of extracellular matrix determinants in DLBCL biology.

Conclusions

Our study identified new prognostic categories of DLBCL, providing an easy-to-apply gene panel that powerfully predicts patients’ survival. Moreover, owing to its relationship with specific stromal and immune components, the panel may acquire a predictive relevance in clinical trials exploring new drugs with known impact on TME.

Maintenance phase in psoralen-ultraviolet A phototherapy of early-stage mycosis fungoides. A critically appraised topic

A 65-year-old patient affected by mycosis fungoides (MF) stage IB achieved complete remission (CR) after a cycle of PUVA phototherapy. The U.S. Cutaneous Lymphoma Consortium (USCLC) guidelines suggest that the patient should be kept in the maintenance phase, defined as a 'period of gradual decrease of frequency of UVL [ultraviolet light] while in clinical remission before discontinuation of phototherapy' by slowly tapering the number of psoralen-ultraviolet A (PUVA) applications over time up to clinical relapse. The USCLC guidelines also suggest a standardized schedule for the maintenance phase. Alternatively, the patient could end PUVA therapy and go straight to follow-up. The aim of this critically appraised topic (CAT) was to determine if a maintenance phase gives a significant benefit in terms of relapse rate (RR) and RFI in patients affected by early-stage MF who had achieved CR under PUVA phototherapy. Embase, PubMed and TRIP databases were searched for 'mycosis fungoides' AND [('photochemotherapy' OR 'puva') OR 'psoralen'] in June 2016. Three articles matched our inclusion criteria and are discussed in this CAT. In this field of research the literature is poor and the reported level of evidence is low. Only one of the studies was conducted prospectively, and none were randomized. No significant difference in terms of reduction in relapse rate or increase in RFI in patients who underwent a PUVA maintenance phase emerged when compared with those who went for simple follow-up. Further randomized clinical trials (RCTs) are required in order to evaluate maintenance phase vs. no treatment before it can be favoured as the standard protocol of treatment in early-stage MF. At the time of writing this paper, we report an ongoing Austrian multicentre RCT (Clinical Trial.gov identifier: NCT01686594) that will hopefully give useful results in this topic.

Multiple Myeloma Plasma Cell Kinetics: Rapid and Reliable Evaluation using 5-Bromo-2-Deoxyuridine (BrdUrd) DNA Incorporation Detected by an Anti-BrdUrd Monoclonal Antibody

In 19 patients with monoclonal gammopathy, plasma cell proliferative activity was evaluated using 5-bromo-2-deoxyuridine (BrdUrd) incorporation, as revealed by an anti-BrdUrd monoclonal antibody. A simultaneous standard labelled thymidine incorporation was carried out in all patients as reference test. The BrdUrd method was confirmed as a reliable test and is recommended for routine clinical application in monoclonal gammopathies.

Monoclonal Immunoglobulin Gene Rearrangement in Peripheral Lymphocytes of a Patient with Multiple Myeloma

We analyzed the immunoglobulin (Ig) heavy chain gene rearrangement in the peripheral blood lymphocytes of a patient with multiple myeloma (MM). Although the morphological and immunological examination did not reveal the presence of circulating plasma cells, a monoclonal Ig gene rearrangement was detected. This observation indicates that a monoclonal expansion of circulating B cells was present in the peripheral lympocytes of this patient.

Characteristics of Cell Proliferation in Children's Lymphoblastic Leukemia

The proliferative activity of the bone marrow and peripheral cells of acute infant lymphoblastic leukemia was evaluated by « in vitro » incorporation of thymidine-H3. The proliferative activity of leukemic lymphoblasts proved roughly similar to that already observed in hemocito-myeloblastic acute leukemias of adults. Within the lymphoblastic population, incorporation of tritiated thymidine was distributed very heterogeneously and there was no labelling of the smaller blasts. In the larger blasts, the labelling index increased progressively with the increase in cell diameter. The acute leukemia population can thus be divided into two classes: proliferating and non-proliferating. A study of the proliferative activity of lymphoblasts, contemporaneously in bone marrow and peripheral cells, suggested a division of cases into two groups. In one proliferative activity in the marrow was greater than in the peripheral blood; in the other it was equal to or less than in the peripheral blood. The second group was made up of cases whose clinical features presented a much more marked hepato-splenomegaly and high peripheral leucocytosis. A more detailed study of proliferative activity considering various classes of blasts within the same population showed that, in the first group of patients, the highest percentage of large blast cells is found at bone marrow level, while in the second the percentage of large blasts in the marrow is equal to or less than that observed in the peripheral blood. It was also shown that total proliferative activity is correlated to the percentage of large blasts. On the basis of these findings, one may admit that in first group forms the leukemia cells are generated prevalently in the bone marrow, while in second group forms most leukemic cells are formed elsewhere.

Monitoring of a Long Survival Myeloma Patient

Monitoring with anti-idiotypic sera has been applied to identify tumoral cells in a myeloma patient still alive in complete remission 9 years after diagnosis. Monoclonal plasma cells displayed a labeling index that decreased in complete remission below 1 %. The great majority of B lymphocytes belonged to the tumoral clone even in complete remission and were therefore not affected by conventional chemothrapy. Some aspects of this myeloma patient are discussed in the light of these immunologic and kinetic findings. In addition, it is suggested that the therapeutic management of the complete remission should be re-examined, by considering a lymphocytolytic therapy.

Presence of Three Philadelphia Chromosomes (Ph1) in the Blastic Crisis of a Case of Chronic Myeloid Leukemia

Three Philadelphia chromosomes in addition to other extra-chromosomes in most of the bone marrow cells (70%) were observed in the terminal course of a case of chronic myeloid leukemia with blastic crisis. The percentage distribution of extra-chromosomes in the single groups of the Denver system was evaluated and compared with the theoretical expectation. This analysis showed a distribution of extra-chromosomes widely different from the random expectation, several chromosome groups being highly underrepresented (namely A, B, D and E) and others (C, F and G) overrepresented. From the karyotype analysis the commonest feature (27,4%) appeared to be the presence of three extra-chromosomes in group C, one extra in group F, and two extra Ph1 in group G. The leukocyte alkaline phosphatase performed on smears of peripheral blood gave a total value higher than normal. Various workers have connected the low values usually observed in chronic myeloid leukemia with the loss in chromosome 21 genetic material. In the present case, the increase in leukocyte alkaline phosphatase alongside an increase in chromatin 21 material might suggest a correlation between these two parameters.

Global patterns of care in advanced stage mycosis fungoides/Sezary syndrome: a multicenter retrospective follow-up study from the Cutaneous Lymphoma International Consortium

BACKGROUND

Advanced-stage mycosis fungoides (MF)/Sézary syndrome (SS) patients are weighted by an unfavorable prognosis and share an unmet clinical need of effective treatments. International guidelines are available detailing treatment options for the different stages but without recommending treatments in any particular order due to lack of comparative trials. The aims of this second CLIC study were to retrospectively analyze the pattern of care worldwide for advanced-stage MF/SS patients, the distribution of treatments according to geographical areas (USA versus non-USA), and whether the heterogeneity of approaches has potential impact on survival.

PATIENTS AND METHODS

This study included 853 patients from 21 specialist centers (14 European, 4 USA, 1 each Australian, Brazilian, and Japanese).

RESULTS

Heterogeneity of treatment approaches was found, with up to 24 different modalities or combinations used as first-line and 36% of patients receiving four or more treatments. Stage IIB disease was most frequently treated by total-skin-electron-beam radiotherapy, bexarotene and gemcitabine; erythrodermic and SS patients by extracorporeal photochemotherapy, and stage IVA2 by polychemotherapy. Significant differences were found between USA and non-USA centers, with bexarotene, photopheresis and histone deacetylase inhibitors most frequently prescribed for first-line treatment in USA while phototherapy, interferon, chlorambucil and gemcitabine in non-USA centers. These differences did not significantly impact on survival. However, when considering death and therapy change as competing risk events and the impact of first treatment line on both events, both monochemotherapy (SHR = 2.07) and polychemotherapy (SHR = 1.69) showed elevated relative risks.

CONCLUSION

This large multicenter retrospective study shows that there exist a large treatment heterogeneity in advanced MF/SS and differences between USA and non-USA centers but these were not related to survival, while our data reveal that chemotherapy as first treatment is associated with a higher risk of death and/or change of therapy and thus other therapeutic options should be preferable as first treatment approach.