Extracorporeal photopheresis: cellular therapy for the treatment of acute and chronic graft-versus-host disease

Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially curative option for many disease states. Despite significant improvements in strategies used to prevent and treat acute and chronic graft-versus-host disease (a/cGVHD), they continue to negatively affect outcomes of HSCT significantly. Standard, first-line treatment consists of corticosteroids; beyond this, there is little consistency in therapeutic regimens. Current options include the addition of various immunosuppressive agents, the use of which puts patients at even higher risks for infection and other morbidities. Extracorporeal photopheresis (ECP) is a widely used cellular therapy currently approved by the US Food and Drug Administration for use in patients with cutaneous T-cell lymphoma; it involves the removal of peripherally circulating white blood cells, addition of a light sensitizer, exposure to UV light, and return of the cells to the patient. This results in a series of events ultimately culminating in transition from an inflammatory state to that of tolerance, without global immunosuppression or known long-term adverse effects. Large-scale, prospective studies of the use of ECP in patients with a/cGVHD are necessary in order to develop the optimal treatment regimens.

Increased Levels of Plasma Epstein Barr Virus DNA Identify a Poor-Risk Subset of Patients With Advanced Stage Cutaneous T-Cell Lymphoma

INTRODUCTION

Outcomes in advanced stage (AS) cutaneous T-cell lymphomas (CTCL) are poor but with great variability. Epstein-Barr virus (EBV) is associated with a subset of non-Hodgkin lymphomas. Frequency of plasma EBV-DNA (pEBVd) detection, concordance with EBV RNA (EBER) in tumor tissue, codetection of plasma cytomegalovirus DNA (pCMVd), and prognostic effect in AS CTCL are unknown.

PATIENTS AND METHODS

Patients (n = 46; 2006-2013) with AS CTCL (≥IIB) were retrospectively studied. pEBVd and pCMVd were longitudinally measured using quantitative real-time polymerase chain reaction. EBER in situ hybridization (ISH) was performed on tumor samples. Survival from time of diagnosis (ToD) and time of progression to AS was assessed.

RESULTS

Plasma EBV-DNA and pCMVd were detected in 37% (17 of 46) and 17% (8 of 46) of AS CTCL patients, respectively. pCMVd detection was significantly more frequent in pEBVd-positive (pEBVd(+)) than pEBVd(-) patients (35% vs. 7%; P = .038). Tumor tissue for EBER-ISH was available in 14 of 17 pEBVd(+) and 22 of 29 pEBVd(-) patients; 12 of 14 (85.7%) pEBVd(+) patients were EBER(+) versus 0 of 22 pEBVd(-) patients. Frequency of large cell transformation (LCT) tended to be greater in pEBVd(+) patients, but was not significant (10 of 14 pEBVd(+) vs. 10 of 23 pEBVd(-); P = .17). No notable differences in rates of increased levels of serum lactate dehydrogenase (LDH) were observed (17 of 17 pEBVd(+) vs. 27 of 29 pEBVd(-)). pEBVd detection was associated with significantly worse survival from ToD (P = .021) and time of progression to AS (P = .0098).

CONCLUSION

Detection of cell-free plasma EBV-DNA was highly concordant with the presence of EBERs in tumor tissue, predicted survival independent of LDH and LCT, and should be further studied as a biomarker in AS CTCL.

Total Skin Electron Beam Therapy as Part of Multimodal Treatment Strategies for Primary Cutaneous T-Cell Lymphoma

Total-skin electron beam therapy (TSEBT) is one of most effective treatments that has been used for cutaneous T-cell lymphoma. Low-dose TSEBT regimens (10-12 Gy) appear to be an effective alternative to conventional-dose TSEBT (30-36 Gy), yielding short-term remission of cutaneous manifestations with minimal toxicity. TSEBT can be administered to patients any time after a diagnosis of mycosis fungoides (MF). Patients requiring rapid relief from cutaneous lesions or symptoms may particularly benefit from TSEBT as an initial therapy. Radiotherapy (RT) dose, boost radiation delivery, maintenance treatment, and radiation tolerability may enhance remission rates and improve relapse-free survival following TSEBT. In addition, salvage local RT or TSEBT may be safely applied with high effectiveness. In this review, we focus on the use of TSEBT in patients with several forms of primary cutaneous T-cell lymphoma, and highlight the potential of low-dose TSEBT as part of a promising therapeutic approach.

Innovative Treatment Concepts for Cutaneous T-Cell Lymphoma Based on Microenvironment Modulation

Cutaneous T-cell lymphomas (CTCL) are a rare and biologically heterogeneous malignant entity comprising mycosis fungoides and Sézary syndrome as the most common subtypes. The current treatment outcome is characterized by high rates of relapse, but survival is usually not significantly shortened in low-stage disease. This is different in tumor-stage disease or aggressive CTCL subtypes where survival is significantly reduced. Recent advances have been made on several levels of tumor biology: Whole genome sequencing has resulted in novel strategies of NF-κB or JAK inhibition, ongoing translational research has revealed new targets like CD30 or CCR4, and, finally, research focusing on impaired immunosurveillance has gained more importance. Based on the growing knowledge about the functional roles of the tumor microenvironment and non-malignant infiltrating cells, current research aims to develop novel CTCL treatment strategies. This review focuses on the mounting evidence for efficiently targeting tumor-infiltrating immune cells and thereby modulating the tumor microenvironment and restoring immunosurveillance.

Renaissance of Low-Dose Radiotherapy Concepts for Cutaneous Lymphomas

Primary cutaneous B- and T-cell lymphomas are rare types of non-Hodgkin's lymphoma with a unique presentation. This can make it challenging for clinicians to manage these cases, and quite often the management mirrors that of other commonly seen lymphomas. This document summarizes how to manage primary cutaneous lymphoma with specific focus on the role of ultralow-dose radiation.

Proteomic Approaches to Biomarker Discovery in Cutaneous T-Cell Lymphoma

Cutaneous T-cell lymphoma (CTCL) is the most frequently encountered type of skin lymphoma in humans. CTCL encompasses multiple variants, but the most common types are mycosis fungoides (MF) and Sezary syndrome (SS). While most cases of MF run a mild course over a period of many years, other subtypes of CTCL are very aggressive. The rapidly expanding fields of proteomics and genomics have not only helped increase knowledge concerning the carcinogenesis and tumor biology of CTCL but also led to the discovery of novel markers for targeted therapy. Although multiple biomarkers linked to CTCL have been known for a relatively long time (e.g., CD25, CD45, CD45RA, and CD45R0), compared to other cancers (lymphoma, melanoma, colon carcinoma, head and neck cancer, renal cancer, and cutaneous B-cell lymphoma), information about the antigenicity of CTCL remains relatively limited and no dependable protein marker for CTCL has been discovered. Considering the aggressive nature of some types of CTCL, it is necessary to identify circulating molecules that can help in the early diagnosis, differentiation from inflammatory skin diseases (psoriasis, nummular eczema), and aid in predicting the prognosis and evolution of this pathology. This review aims to bring together some of the information concerning protein markers linked to CTCL, in an effort to further the understanding of the convolute processes involved in this complex pathology.

75% Complete Response and 15% Partial Response to Extracorporeal Photopheresis Combined With Other Therapies in Resistant Early Stage Cutaneous T-Cell Lymphoma

INTRODUCTION

Extracorporeal photopheresis (ECP) has been used for the treatment of advanced stage or treatment refractory cutaneous T-cell lymphoma (CTCL) since 1987, and more recently has also been shown to be of benefit for earlier stage resistant CTCL. Complete response rates in prior studies of ECP in early CTCL have ranged from 0% to 40%.

METHODS

We reviewed electronic medical records of all CTCL patients seen in the University of Kansas Cancer Center between June 2007 and May 2011. International review board approval was obtained. Inclusion criteria were (1) early stage CTCL and (2) ECP treatment. Data included demographics, type of intravenous access employed, CTCL subtype, cytogenetic features, adverse events, adjuvant treatments, and survival time in years. Treatment response was assessed via a modified severity weighted assessment tool (mSWAT). Primary outcome measures were response rates to ECP at 6 months and 12 months after beginning treatment.

RESULTS

Of 20 patients (13 female; 7 male), 7 were Stage 1A, 11 were 1B, and 2 were 2A. Seven patients with stable disease and 2 patients with progression at 6 months received adjuvant therapy (PUVA/systemic retinoids/metotrexate/interferon) in addition to ECP. Twelve-month response to ECP was 90%: 15 patients (75%) had complete responses, 3 (15%) had partial responses, 1 had stable disease, and 1 progressed.

CONCLUSION

Used alone or in combination with adjuvant treatments, ECP can be an effective treatment method in early stage CTCL. <br /><br /> <em>J Drugs Dermatol.</em> 2016;15(10):1212-1216.

Small-molecule inhibitors of Ataxia Telangiectasia and Rad3 related kinase (ATR) sensitize lymphoma cells to UVA radiation

BACKGROUND

Psoralen plus ultraviolet A (PUVA) photochemotherapy is a combination treatment used for inflammatory and neoplastic skin diseases such as mycosis fungoides (MF), the most common type of cutaneous T-cell lymphoma (CTCL). However, 30% of MF patients do not respond sufficiently to PUVA and require more aggressive therapies.

OBJECTIVE

The aim of this project was to investigate whether inhibition of Ataxia Telangiectasia and Rad3 related kinase (ATR) may enhance efficacy of phototherapy.

METHODS

CTCL cell lines (MyLa2000, SeAx and Mac2a) served as in vitro cell models. ATR and Chk1 were inhibited by small molecule antagonists VE-821, VE-822 or Chir-124, or by small interfering RNAs (siRNAs). Cell cycle and viability were assessed by flow cytometry.

RESULTS

Small molecule inhibitors of ATR and Chk1 potently sensitized all cell lines to PUVA and, importantly, also to UVA, which by itself did not cause apoptotic response. VE-821/2 blocked ATR pathway activation and released the cells from the G2/M block caused by UVA and PUVA, but did not affect apoptosis caused by other chemotherapeutics (etoposide, gemcitabine, doxorubicine) or by hydrogen peroxide. Knockdown of ATR and Chk1 with siRNA also blocked the ATR pathway and released the cells from G2/M block but did not sensitize the cells to UVA as observed with the small molecule inhibitors. The latter suggested that the synergism between VE-821/2 or Chir-124 and UVA was not solely caused by specific blocking of ATR kinase but also ATR-independent photosensitization. This hypothesis was further verified by administrating VE-821/2 or Chir-124 before and after UVA irradiation, as well as comparing their activity with other ATR and Chk1 inhibitors (AZD6738 and MK8776). We found that only VE-821/2 and Chir-124 kinase inhibitors had synergistic effect with UVA, and only if applied before treatment with UVA.

CONCLUSION

Small molecule ATR and Chk1 inhibitors potently sensitize lymphoma cells to UVA radiation and induce a prominent apoptotic response. Interestingly, this effect is due to the dual (kinase inhibiting and photosensitizing) mode of action of these compounds.

Induction of anti-tumor CD8 T cell responses by experimental ECP-induced human dendritic antigen presenting cells

Extracorporeal photochemotherapy (ECP), or photopheresis, is distinguished by the specificity of the clinically potent immunologic reactions it initiates or regulates. The selectivity of ECP-induced immunoprotection for the malignant clone in cutaneous T cell lymphoma (CTCL), and for the pathogenic clones in allograft rejection and graft-versus-host disease (GVHD), has suggested a central mechanistic role for dendritic antigen presenting cells (DC). Discovery of ECP's induction of monocyte-derived DC, via monocyte signaling by ECP-plate activated platelets, and the absolute dependency of experimental ECP on such induced DC, supports that premise. Herein, we show that ECP-induced DC are capable of stimulating CD8 T cell responses to tumor antigens with which they are loaded. They internalize an antigen-specific melanoma-associated protein then present it onto a class I major histocompatibility, which then stimulates expansion of anti-tumor CD8 T cell populations. We conclude that ECP-induced DC prominently contribute to its initiation of anti-tumor immunity and raise the possibility that the therapy may be applicable to the immunotherapeutic management of a broader spectrum of cancers.

Cutaneous Lymphoma in Korea: A Nationwide Retrospective Study

The epidemiological and clinicopathological features of cutaneous lymphoma may vary by geographical area. However, only a few large-scale epidemiological studies of cutaneous lymphoma have been performed, mainly in the USA and Europe. This aim of this study was to determine the recent characteristics of cutaneous lymphoma in Korea according to the WHO/EORTC classification. A total of 422 patients with newly diagnosed cutaneous lymphoma from January 2009 to December 2013 comprising 293 cases of mature T-cell and natural killer (NK)-cell lymphoma and 39 cases of mature B-cell lymphoma were retrospectively reviewed. The incidence of mature B-cell lymphoma was lower in Korea than in Europe and the USA. Diffuse large B-cell lymphoma was more prevalent in Korea than in Western countries. The incidence of extranodal NK/T-cell lymphoma, nasal-type was higher in Korea than in Western countries and Japan.

Illness Perception in Primary Cutaneous T-cell Lymphomas: What Patients Believe About Their Disease

There is currently no information available on illness perception in primary cutaneous T-cell lymphomas (CTCL). The aim of this study was therefore to gather initial information on disease understanding and interpretation in patients with CTCL. Consecutive patients from a hospital-based primary cutaneous lymphoma ward completed the Revised Illness Perception Questionnaire (IPQ-R) on 2 consecutive visits. A total of 24 patients with different variants of CTCL were included in the study. Patients experienced their condition as being long-lasting, but not fundamentally affecting their lives. Patients had poor belief in personal control, but strong belief in treatment control. They did not show a good understanding of their disease, and had a moderately negative emotional response to their illness. In conclusion, the IPQ-R provides a feasible and reproducible tool for measurement and better understanding of illness perception in patients with CTCL. Knowledge of patients' attitudes towards their disease should enable optimization of the patient-physician relationship and patient care.

[Subcutaneous panniculitis-like T-cell lymphoma : Two case reports]

Histopathology, immunohistochemical, and molecular genetic findings revealed the diagnosis of subcutaneous panniculitis-like T-cell-lymphoma in two patients, aged 44 and 70 years. The clinical morphology of the lymphoma manifestations showed varied significantly. One patient presented with a singular erythematous nodule in the chin region. The other patient suffered from extended plate-like resistances and atrophy of the face, upper arms and left breast. Hemophagocytic syndrome was not present in either patient. Prognosis of subcutaneous panniculitis-like T-cell lymphoma without associated hemophagocytic syndrome is reported to be favorable. Radiotherapy of the singular lesion on the chin and systemic corticosteroids of the extended plaques induced complete remission in both patients.

Clinical Practice Guidelines for Cutaneous Lymphomas

Primary cutaneous lymphomas are non-Hodgkin lymphomas, which are broadly divided into cutaneous T-cell lymphomas and cutaneous B-cell lymphomas. These classifications include numerous distinct entities, all with varying clinical presentations and disease courses. Herein, we will review the cutaneous T-cell lymphomas, including Mycosis Fungoides, Sézary syndrome, CD30+ lymphoproliferative disorders, as well as other less common entities. Cutaneous B-cell lymphomas will also be discussed, including primary cutaneous marginal zoned lymphoma, cutaneous follicle-center lymphoma, diffuse large B-cell lymphoma, leg type, as well as other less common entities. Accurate and early diagnosis is key, as the treatment and prognosis varies significantly between conditions.

[THE DYNAMICS OF IMMUNOLOGICAL RESULTS OF PATIENTS WITH T-CELL SKIN LYMPHOMAS AND PSORIASIS BY THE THERAPY OF ACTIVATION MECHANISMS SANOGENESIS METHODS]

The therapy T-cell skin lymphoma and psoriasis by the application of activation mechanisms sanogenesis methods, such as: original--a treatment plasmapheresis, a standard heparin infusion; used for the first time--wobenzym; solutions of acid acetic food and sodium bicarbonate; known--the basic sanitations of concomitant diseases, photopheresis caused remissions in 79.6% patients with different stages T-cell skin lymphoma (observed over an 8-year span), and in 67% of patients with psoriasis (observed over an 6-year span). Depuration reactions (phagocytosis, pinocytosis, toxin neutralization) has been activated by detoxication of treatment plasmapheresis and heparin infusions. The topical therapy with wobenzym, solutions of acid acetic food and sodium bicarbonate renewed natural immune barrier of skin. Basic therapy of concomitant diseases enhanced of patient state of health and mobilized compensatory resources. Photopheresis initiated autoimmunization processes by malignant CD4+ lymphocytes. When remission was achieved, the parameters of cellular and humoral immunity returned to normal levels, or the parameters made worse in the absence of remission.

Primary cutaneous follicular helper T-cell lymphoma treated with allogeneic bone marrow transplantation: immunohistochemical comparison with angioimmunoblastic T-cell lymphoma

Primary cutaneous follicular helper T (TFH)-cell lymphoma has recently been proposed, and is characterized by proliferation of malignant T cells expressing TFH-cell markers, such as CXCL13, accompanied by numerous reactive B cells. We report here a patient whose skin histology showed massive infiltration of both T and B cells, with a proliferation of arborizing high endothelial venules and follicular dendritic cells. Infiltrating T cells were positive for CXCL13, programmed death (PD)-1, inducible T-cell co-stimulator, and BCL-6. Southern blot analyses using DNA from the skin revealed monoclonality of both T and B cells. The patient had marked resistance to treatments, and complete remission was achieved only after allogeneic stem cell transplantation. The present case showed overlapping features with angio-immunoblastic T-cell lymphoma (AITL), although systemic symptoms were not observed. Further study is needed to define the criteria of this provisional entity, representing the cutaneous counterpart of the nodal follicular peripheral T-cell lymphoma or AITL.

Allogeneic stem cell transplantation versus conventional therapy for advanced primary cutaneous T-cell lymphoma

BACKGROUND

Primary cutaneous T-cell lymphomas (CTCL) belong to the group of non-Hodgkin lymphomas and usually run an indolent course. However, some patients progress to advanced tumour or leukaemic stages. To date, there is no cure for those cases. In the last few years, several publications reported durable responses in some patients following allogeneic stem cell transplantation (alloSCT). This is an update of a Cochrane review first published in 2011 and updated in 2013.

OBJECTIVES

To compare the efficacy and safety of conventional therapies with allogeneic stem cell transplantation in patients with advanced primary cutaneous T-cell lymphomas.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1), MEDLINE (1950 to January 2013), Internet-databases of ongoing trials, conference proceedings of the American Society of Clinical Oncology (ASCO, 2009 to July 2013) and the American Society of Hematology (ASH, 2009 to July 2013). We also contacted members of the European Organisation for Research and Treatment of Cancer (EORTC) Cutaneous Lymphoma Task Force to check for ongoing study activities. We handsearched citations from identified trials and relevant review articles. In addition, we handsearched randomised controlled trials from the European Group for Blood and Marrow Transplantation (EBMT) and International Conference on Cutaneous T-cell Lymphoma, ASCO and ASH up to July 2013.

SELECTION CRITERIA

Trials eligible for inclusion were genetically randomised controlled trials (RCTs) comparing alloSCT plus conditioning therapy (regardless of agents) with conventional therapy as treatment for advanced CTCL.

DATA COLLECTION AND ANALYSIS

Two review authors would have extracted data from eligible studies and assessed their quality. The primary outcome measure was overall survival; secondary outcomes were time to progression, response rate, treatment-related mortality, adverse events and quality of life.

MAIN RESULTS

We did not identify any randomised controlled trials from the updated search in January 2013. In 2011, we found 2077 citations but none were relevant genetically or non-genetically randomised controlled trials. All 41 studies that were thought to be potentially suitable were excluded after full text screening for being non-randomised, not including CTCL or being review articles.

AUTHORS' CONCLUSIONS

We planned to report evidence from genetically or non-genetically randomised controlled trials comparing conventional therapy and allogeneic stem cell transplantation. However, we did not identify any randomised controlled trials addressing this question. Nevertheless, prospective genetically randomised controlled trials need to be initiated to evaluate the precise role of alloSCT in advanced CTCL.

Panniculitis in children

This paper will give a comprehensive view of the most frequent panniculitides seen in childhood, with emphasis on the types exclusively found in infancy, and for all other types of panniculitides also found in adults. Aim of this paper is also to analyze the clinical differences between panniculitis in childhood and in adulthood, and to give reliable histopathologic criteria for a specific diagnosis. A review of the literature is here integrated by authors' personal contribution. Panniculitides in children is a heterogeneous group of diseases, as well as in adult life, characterized by inflammation of the subcutaneous fat. Only very few types of panniculitis are exclusively found in childhood, such as Sclerema neonatorum and subcutaneous fat necrosis of the newborn, while the vast majority of the other types may be found both in paediatric age and in adults. Furthermore, this paper will consider in detail panniculitis according to their frequency, such as Erythema nodosum, Lupus panniculitis, Cold panniculitis, panniculitis in Behçet disease, and poststeroid panniculitis. It will also describe rare forms of panniculitis, such as Eosinophilic panniculitis (a pathological entity debated by many authors), Subcutaneous panniculitis T-cell lymphoma, and the different forms of the so call "Lipophagic panniculitis", encompassing respectively the febrile relapsing panniculitis of Weber-Christian disease and the non-relapsing form of Rothmann-Makai disease. For each type of panniculitis considered concise information will be given about epidemiology, etiology, clinical findings, laboratory data, prognosis and therapy, while histopathologic findings will be described in detail.

Erythrodermic CTCL: updated clues to diagnosis and treatment

Erythroderma is a rare but severe cutaneous condition characterized from a clinical point of view by a complete involvement (as per definition more than 80% body surface) of the skin surface. Pre-existing dermatoses account for about 70% of erythroderma cases, drug reactions are responsible for erythroderma in about 20%, whilst primary cutaneous T-cell lymphoma (CTCL) constitute less than 10% of and are represented by erythrodermic mycosis fungoides and Sézary syndrome. The challenge in these patients is represented by the identification of the etiological agents or conditions, which is clearly of overwhelming relevance in the clinical management and treatment strategies. In recent years, the development of multiparameter flow-cytometry, which allows to identify specific antigens expressed or not expressed on the surface of atypical lymphoid T-cells, and T-cell molecular biology techniques, which are aimed to identify the presence of a clonal T-cell population in the skin and blood on the basis of the finding of rearrangement of the T-cell receptor, have represented relevant useful tool in the differential diagnosis between benign and lymphomatous erythroderma. Moreover, a better understanding of the immunological and molecular pathways in CTCL disease evolution provided the identification of specific therapeutical targets, as well as the constant improvement in the laboratory techniques lead to the development of new and promising agents in CTCL.

Human anti-CCR4 minibody gene transfer for the treatment of cutaneous T-cell lymphoma

Background

Although several therapeutic options have become available for patients with Cutaneous T-cell Lymphoma (CTCL), no therapy has been curative. Recent studies have demonstrated that CTCL cells overexpress the CC chemokine receptor 4 (CCR4).

Methodology/Principal Findings

In this study, a xenograft model of CTCL was established and a recombinant adeno-associated viral serotype 8 (AAV8) vector expressing a humanized single-chain variable fragment (scFv)-Fc fusion (scFvFc or “minibody”) of anti-CCR4 monoclonal antibody (mAb) h1567 was evaluated for curative treatment. Human CCR4⁺ tumor-bearing mice treated once with intravenous infusion of AAV8 virions encoding the h1567 (AAV8-h1567) minibody showed anti-tumor activity in vivo and increased survival. The AAV8-h1567 minibody notably increased the number of tumor-infiltrating Ly-6G⁺ FcγRIIIa(CD16A)⁺ murine neutrophils in the tumor xenografts over that of AAV8-control minibody treated mice. Furthermore, in CCR4⁺ tumor-bearing mice co-treated with AAV8-h1567 minibody and infused with human peripheral blood mononuclear cells (PBMCs), marked tumor infiltration of human CD16A⁺ CD56⁺ NK cells was observed. The h1567 minibody also induced in vitro ADCC activity through both mouse neutrophils and human NK cells.

Conclusions/Significance

Overall, our data demonstrate that the in vivo anti-tumor activity of h1567 minibody is mediated, at least in part, through CD16A⁺ immune effector cell ADCC mechanisms. These data further demonstrate the utility of the AAV-minibody gene transfer system in the rapid evaluation of candidate anti-tumor mAbs and the potency of h1567 as a potential novel therapy for CTCL.

Annular plaques: An unusual manifestation of graft-versus-host disease

Chronic cutaneous graft-versus-host disease (GVHD) classically presents with lichenoid papules or sclerotic plaques. This case highlights an unusual clinical manifestation of chronic GVHD and demonstrates that the skin morphology of chronic GVHD and cutaneous lymphoma may be similar. We report for the first time a case of annular scleroderma-like graft-versus-host disease in a patient following allogeneic stem cell transplant for CD30+ anaplastic large cell lymphoma. Treatment of these skin lesions with ultraviolet A1 (UVA1) phototherapy resulted in significant improvement.

Allogeneic stem cell transplantation versus conventional therapy for advanced primary cutaneous T-cell lymphoma

BACKGROUND

Primary cutaneous T-cell lymphomas (CTCL) belong to the group of non-Hodgkin lymphomas and usually run an indolent course. However, some patients progress to advanced tumour or leukaemic stages. Up to now, no curative treatment has been established for those cases. In the last few years, several publications have reported durable responses in some patients following allogeneic stem cell transplantation (alloSCT).

OBJECTIVES

To compare the efficacy and safety of conventional therapies with allogeneic stem cell transplantation in patients with advanced primary cutaneous T-cell lymphomas.

SEARCH METHODS

The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to May 2011), Internet-databases of ongoing trials (www.controlled-trials.com; www.clinicaltrials.gov), conference proceedings of the American Society of Clinical Oncology (ASCO, 2009 to present) and the American Society of Hematology (ASH, 2009 to present). We also contacted members of the European Organisation for Research and Treatment of Cancer (EORTC) Cutaneous Lymphoma Task Force to check for ongoing study activities. We handsearched citations from identified trials and relevant review articles. In addition, randomised controlled trials from the European Group for Blood and Marrow Transplantation (EBMT) and International Conference on Cutaneous T-cell Lymphoma, ASCO and ASH up to 2010 were handsearched.

SELECTION CRITERIA

Genetically randomised controlled trials (RCT) comparing alloSCT plus conditioning therapy regardless of agents with conventional therapy as treatment for advanced CTCL were eligible to be included.

DATA COLLECTION AND ANALYSIS

From eligible studies data would have been extracted by two review authors and assessed for quality. Primary outcome measures were overall survival, secondary criteria were time to progression, response rate, treatment-related mortality, adverse events and quality of life.

MAIN RESULTS

We found 2077 citations but none were relevant genetically or non-genetically randomised controlled trials. All 41 studies that were thought to be potentially suitable were excluded after full text screening for being non-randomised, not including CTCL or being review articles.

AUTHORS' CONCLUSIONS

We planned to report evidence from genetically or non-genetically randomised controlled trials comparing conventional therapy and allogeneic stem cell transplantation. However, no randomised trials addressing this question were identified. Nevertheless, prospective genetically randomised controlled trials need to be initiated to evaluate the precise role of alloSCT in advanced CTCL.

[Apheresis in dermatologic diseases]

This report discusses the different types of apheresis used to treat skin diseases and focuses specifically on photopheresis or ECP (extracorporeal photochemotherapy). ECP is a systemic immunomodulatory therapy used successfully to treat many different, mainly autoimmune diseases such as cutaneous T-cell lymphomas, graft-versus-host disease, systemic sclerosis, atopic dermatitis, and pemphigus vulgaris. It has also proved effective against graft rejection after transplant. The exact mechanism by which the ECP performs its therapeutic activity is not yet entirely clear. However, at least 2 mechanisms have been identified that may explain the therapeutic effect. Firstly, ECP is able to induce downregulation of the self-allogeneic immune response that occurs in graft-versus-host disease, systemic sclerosis and atopic dermatitis, and secondly, it can stimulate an immune response against the neoplastic clones in patients with cutaneous T-cell lymphomas. At the Dermatology Clinic of the University of Siena, more than 100 patients with different immune-mediated diseases were treated with ECP. The results obtained are very interesting and our 20 years of experience confirm that the treatment is well tolerated. ECP can therefore be considered of great utility in the modulation of the immune system.

Primary cutaneous small- to medium-sized CD4+ pleomorphic T-cell lymphoma: a retrospective case series and review of the provisional cutaneous lymphoma category

BACKGROUND AND OBJECTIVE

Primary cutaneous small- to medium-sized CD4+ pleomorphic T-cell lymphoma (PCSM-TCL) is a rare and provisional subcategory of cutaneous T-cell lymphoma, associated with a favorable prognosis. We present five cases of PCSM-TCL and review the literature to address questions surrounding its diagnosis and treatment.

METHODS

A retrospective review was conducted of 353 patients with non-mycosis fungoides cutaneous lymphomas evaluated at the M.D. Anderson Cancer Center Cutaneous Lymphoma Clinic over 10 years. A retrospective search of the English literature using PubMed was conducted to identify additional cases.

RESULTS

Only five patients had a diagnosis of PCSM-TCL. Three patients had unique multifocal presentations that responded well to topical therapy or excision. One patient with localized disease initially treated with radiation therapy had an aggressive relapse requiring systemic therapy. One patient had an isolated nodule that fully resolved with excision. The review of the English literature found 232 additional cases. The presentation of PCSM-TCL was heterogeneous and included solitary/localized papules, nodules, plaques, and tumors. Multiple differential diagnoses were considered and PCSM-TCL diagnosis was based on histopathologic features and clinical correlation. Treatment of solitary/localized lesions included excision or radiation therapy. Multifocal lesions were uncommon and associated with an aggressive course requiring systemic chemotherapy.

CONCLUSIONS

The heterogeneous presentation, variable histologic overlap with other lymphoproliferative disorders, and uncertain prognosis of PCSM-TCL creates diagnostic and management dilemmas for clinicians. For treatment, a distinction should be made between indolent and aggressive subtypes. Further investigation is needed to determine if PCSM-TCL is indeed a distinct lymphoma category and, additionally, if aggressive subtypes should remain part of the same diagnostic category.

Cutaneous T-cell lymphoma: 2011 update on diagnosis, risk-stratification, and management

DISEASE OVERVIEW

Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis fungoides (MF) or Sézary syndrome (SS).

DIAGNOSIS

The diagnosis of MF or SS requires the integration of clinical and histopathologic data.

RISK-ADAPTED THERAPY

Tumor, node, metastasis, and blood (TNMB) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral, or blood involvement are generally approached with biologic-response modifiers, denileukin diftitox, and histone deacetylase inhibitors before escalating therapy to include systemic, single-agent chemotherapy. Multiagent chemotherapy may be used for those patients with extensive visceral involvement requiring rapid disease control. In highly-selected patients with disease refractory to standard treatments, allogeneic stem-cell transplantation may be considered.

High expression of Dicer reveals a negative prognostic influence in certain subtypes of primary cutaneous T cell lymphomas

BACKGROUND

Aberrant expression of microRNAs (miRNAs) has been implicated in oncogenesis of various tumors and primary cutaneous T cell lymphomas. Dicer, a ribonuclease III-like enzyme is essential for miRNA processing.

OBJECTIVE

We initiated a retrospective study to characterize the alterations in the expression profile of Dicer in patients with primary cutaneous T cell lymphomas (CTCL).

METHODS

A total of 50 consecutive patients with primary CTCL were studied, with the majority having mycosis fungoides (n=34). Five patients had primary cutaneous CD 30+ anaplastic large cell lymphoma, four patients each had lymphomatoid papulosis and primary cutaneous CD4-positive small/medium T-cell lymphoma, one primary cutaneous γδ T cell lymphoma, one Sézary syndrome and another subcutaneous panniculitis-like T cell lymphoma of αβ-phenotype. Immunohistochemistry was performed on paraffin sections using a commercially available antibody against Dicer. Intensity of expression was correlated with clinical parameters including disease specific survival (DSS) and time to progression (TTP).

RESULTS

After a median follow-up of 74 months (range: 1-271), 12/50 patients (24%) have died. Univariate and multivariate analysis for disease-specific survival showed Dicer expression and stage as a negative predictive factor in the sole group of MF patients (n=34) as well as in the heterogeneous group of patients (n=50), but not gender, histological subtype, primary localization of disease, age and recurrence of lymphoma (p>0.05).

CONCLUSION

Our data suggest Dicer expression as a possible molecular marker in patients with MF and apparently indicate that miRNA(s) might be of clinical relevance in CTCL.

Overview of Cutaneous T-Cell Lymphoma: Prognostic Factors and Novel Therapeutic Approaches

The cutaneous T-cell lymphomas (CTCL) comprise a heterogeneous group of entities. The WHO classification distinguishes indolent low-risk entities, including mycosis fungoides/Sézary syndrome (MF/SS), from aggressive entities, including peripheral T-cell lymphoma and its variants and HTLV-1 associated acute T-cell leukemia/lymphoma. Mycosis fungoides represents the most benign of the cutaneous T-cell lymphomas, with 10-year relative survival ranging from 100% to 41%, depending on the degree of skin involvement. Probability of progression to extracutaneous disease within 20 years of diagnosis can be up to 40%, depending on stage. Treatment strategies for early stage CTCL include topical therapies with or without interferon-alpha or oral agents, while advanced stage patients often progress and are treated with chemotherapy and novel agents. Multiagent cytotoxic regimens are palliative with no demonstrated survival benefit. Among the novel therapies for CTCL is bexarotene, a retinoid X-receptor (RXR)-selective agonist, which has demonstrated efficacy in advanced refractory CTCL. Other novel agents include the interleukin (IL)-2 fusion toxin (ONTAK), pentostatin (a potent adenosine deaminase inhibitor), histone deacetylase inhibitors such as depsipeptide, NF-kappaB inhibitors, cytokine receptor antagonists, immunomodulatory therapies and allogeneic stem cell therapy. The value of new therapeutic approaches to CTCL urgently needs to be assessed.

Dendritic cells and cutaneous T-cell lymphomas

Dendritic cells (DCs) are potent antigen-presenting cells that help orchestrate the innate and adaptive immune systems to induce tolerance and immunity. They are diversified in their phenotypes, stages of maturation, degrees of activation, and functions. Several subtypes of DCs exist among human lymphoid tissues, non-lymphoid tissues, and in peripheral blood. In the skin, three types of DCs are described: Langerhans cells (LCs), dermal dendritic cells (DDCs), and plasmacytoid dendritic cells (pDCs). In the peripheral blood, myeloid dendritic cells (mDCs) and plasmacytoid dendritic cells are well described. Dysfunctional DCs are found in many autoimmune disorders, allergies, and cancers. In this paper, we focus on DCs as related to cutaneous T cell lymphomas (CTCLs). Abnormal DC number and defective DC function are found in the blood of patients with advanced stage Sézary syndrome (SS), a leukemic variant of CTCLs. Extracorporeal photopheresis (ECP), an effective therapy for erythrodermic CTCLs, is thought to work by inducing apoptosis of tumor cells and monocytes-derived DCs. DC vaccination has been carried out successfully in some patients with CTCLs when combined with immune modifiers like toll like receptor agonists, which may enhance the function of DCs. However, DCs may perform a dual role in the pathogenesis of CTCLs. Immature DCs (langerhans cells) could promote the survival of malignant T cells. Further understanding of DCs and their role in CTCLs can help us to uncover the pathogenesis of this disease and to further explore the therapeutic uses of DCs.

Cutaneous malignancy in adolescents

There is compelling epidemiologic evidence that cutaneous malignancies, most notably malignant melanoma and cutaneous T-cell lymphoma, are increasing in incidence. The adolescent population is also affected by this rise in incidence, but can represent both a unique diagnostic and therapeutic challenge. Herein we present up-to-date epidemiology, clinical presentation, risk factors for development, and management options for malignant melanoma, basal cell carcinoma, squamous cell carcinoma, and cutaneous T-cell lymphoma as each pertains to the adolescent population. Prevention in this age group is particularly addressed. One unifying theme that emerges is that a high degree of clinical suspicion and vigilance must be maintained to recognize these entities early on in their presentations.

Therapeutic advances in cutaneous T-cell lymphoma

A variety of novel therapeutic modalities have recently become available for patients with cutaneous T cell lymphoma (CTCL). In particular, with recent FDA approvals of the three new agents vorinostat (Zolinza), romidepsin (Istodax), and pralatrexate (Folotyn) CTCL treatment has been transformed. Here, we offer a brief overview of these agents and discuss their place in the spectrum of current therapies for CTCL.

[Hypopigmented mycosis fungoides in children: a clinicopathological study of 6 cases]

OBJECTIVE

To explore the clinical and histopathological manifestations, therapy and prognosis of hypopigmented mycosis fungoides (HMF) in children.

METHODS

Six pediatric cases of HMF from February 2008 to October 2009 were reviewed and analyzed at our hospital.

RESULTS

There were 5 males and 1 female with a average age of 11 years old (range: 9-14). The lesions appeared poorly-demarcated hypopigmented macula and patches disseminated over the trunk and extremities, scales and infiltrated papules over the hypopigmented lesions or invasive erythemas arose and enlarged gradually. Histologically, there was an epidermal infiltration of atypical lymphocytes. The immunohistochemical staining revealed a pattern of T lymphoma and a predominance of CD8+ T cell. All patients were of T2N0M0/IB except for one at the stage of T1N0M0/IA. Two patients received narrow band ultraviolet B (NB-UVB), one NB-UVB plus alpha interferon, another NB-UVB plus alpha interferon and topical steroid, one Chinese traditional herbal regimen while the last one none. And NB-UVB alone or plus alpha interferon achieved a clinical complete response (CR). The herbal regimen failed to cure the lesions but achieved no response. The non-treated patient progressed gradually. The average follow-up was 16 months (range: 9-28). The progression-free rate was 83.3% and the overall survival rate 100%.

CONCLUSIONS

Visceral and lymph note involvements are rare in HMF of children. The prognosis of early-stage treatment is satisfactory. NB-UVB alone or plus alpha interferon achieves a clinical CR in most early-stage patients.

[Epitheliotropic lymphomas: better identification for improved treatment]

Mycosis fungoides is the most frequent cutaneous T cell lymphoma. Mycosis fungoides-related cutaneous T cell lymphomas include folliculotropic mycosis fungoides, with or without mucinosis, pagetoid reticulosis and granulomatous slack skin. Sezary syndrome is characterized by pruriginous erythroderma, adenopathies, atypical lymphocytes in the blood and a more aggressive course. B cell lymphomas represent 25 % of cutaneous lymphomas. Primary cutaneous follicle center cell lymphomas are the most frequent. They are often located on the head and trunk and have an indolent course. Primary cutaneous marginal zone B-cell lymphomas, which are more frequently multicentric and located on the limbs, also have an indolent course. In contrast, primary cutaneous diffuse large B-cell lymphomas, leg type, and primary cutaneous intravascular large B-cell lymphomas have a more aggressive course. Treatment must be adapted to each case. Unnecessarily aggressive treatments must be avoided in patients with indolent lymphomas.

Primary and metastatic malignant tumors of the scalp: an update

In recent years there have been a number of interesting advances in several topics relating to the diagnosis and treatment of cutaneous lesions with particular applicability to primary and metastatic malignancies of the scalp. In this article we provide a general update of advances in this field, and cover the more salient points relating to a variety of malignant tumors that have been reported to appear on the scalp as primary or metastatic lesions. A search and review of the literature on PubMed was made to identify and discuss relevant points relating to diagnosis and treatment of primary and metastatic tumors of the scalp. We describe the anatomy of the scalp, epidemiology of scalp tumors, theories of field cancerization and field therapy, photodynamic therapy, excisional surgical techniques and reconstruction, lymphoscintigraphy, chemoprevention, as well as details relating to atypical fibroxanthoma, Brooke-Spiegler syndrome, nevus sebaceus, cutaneous lymphoma, and metastatic disease. There is a very broad differential diagnosis for scalp nodules, which includes many different benign and malignant diseases, and treatment should be tailored accordingly. Given the potential for poor prognosis with some of the more aggressive malignancies that can be found in this anatomic area, the importance of a thorough physical examination cannot be emphasized enough, and early detection is critical to provide patients with the best chance for a favorable outcome.

The role of phototherapy in cutaneous T-cell lymphoma

Cutaneous T-cell lymphoma (CTCL) is a type of non-Hodgkin's lymphoma characterized by the malignant proliferation of T lymphocytes in the skin. Phototherapy has been proven an effective treatment modality for CTCL, in particular early stage disease (patch and plaque). Specifically, broadband ultraviolet B (BB-UVB), psoralen and ultraviolet A (PUVA), and more recently narrowband UVB (NB-UVB) are the skin-directed phototherapies typically utilized. Phototherapy poses the risk of sunburn, photoaging and photocarcinogenesis. Combination therapies with IFN-alpha, retinoids (acitretin and isotretinoin) and rexinoid (bexarotene) are adjunctive systemic therapies that facilitate enhanced therapeutic response and often allow for lower doses of phototherapy. Extracorporeal photopheresis (ECP) has also been shown to be effective in more advanced stage disease.

The role of maintenance phototherapy in cutaneous T-cell lymphoma

Phototherapy is well-recognized as effective therapy in early stage cutaneous T-cell lymphoma (patch and plaque), often resulting in complete clearance of clinical disease and subsequent remission. Although not curable, long-term remission can often be attained utilizing maintenance phototherapy, consisting of a course of less frequent treatments over time. Herein, the authors review the literature regarding the role of maintenance phototherapy in cutaneous T-cell lymphoma (CTCL) and its success in prolonging clinical remission and disease-free survival in CTCL.

The role of hematopoietic stem-cell transplantation in cutaneous T-cell lymphoma

Cutaneous T-cell lymphoma represents a broad spectrum of disorders with various manifestations, clinical courses, and therapeutic considerations. Mycosis fungoides is the most common form of cutaneous T-cell lymphoma, the skin being affected by erythematous patches, plaques, or tumors. The related Sézary syndrome is a more aggressive form of cutaneous T-cell lymphoma with cutaneous and leukemic manifestations. Recent advances in the understanding of the molecular and biologic behavior of T cells in these disorders have facilitated the development of novel treatments, using biologic agents, phototherapeutic methods, and irradiation techniques. Nevertheless, there remains a continued need to develop new therapeutic options, particularly for patients with advanced-stage and treatment-refractory disease. At present, hematopoietic stem-cell transplantation has the best chance for expanding the therapeutic armamentarium of cutaneous T-cell lymphoma. In advanced-stage mycosis fungoides and the Sézary syndrome, stem cell transplantation may result in sustained remissions and improvement of progression-free survival. However, physicians have to be aware of severe clinical problems like graft-versus-host disease as well as increased risk of infection and secondary cancers. In this review, we focus on the role of hematopoietic stem cell transplantation for the therapy of mycosis fungoides and the Sézary syndrome.

Pruritus in cutaneous T-cell lymphomas: frequent, often severe and difficult to treat

Pruritus has a well-known association with Hodgkin's disease and other nodal lymphomas; indeed it often reveals the disease. Pruritus is also an important symptom of cutaneous T-cell lymphomas. Lymphoma-associated itch is thus both frequent and severe, but its pathophysiology remains unclear. Few studies have evaluated the efficacy of therapeutic agents in the management of cutaneous T-cell lymphoma-related pruritus. The main objective of treatment remains disease control. Pruritus management is generally based on the physician's experience. Treatment is very difficult, especially in Sézary syndrome. We present here management strategies for cutaneous lymphoma-associated pruritus.