CD56-positive haematological neoplasms of the skin: a multicentre study of the Cutaneous Lymphoma Project Group of the European Organisation for Research and Treatment of Cancer

BACKGROUND

Cutaneous lymphomas expressing CD56, a neural cell adhesion molecule, are characterised in most cases by a highly aggressive clinical course and a poor prognosis. However, prognostic subsets within the CD56+ group have been difficult to identify due to the lack of uniform clinicopathological and immunophenotypical criteria.

METHODS

A multicentre study was conducted by the Cutaneous Lymphoma Task Force of the European Organisation for Research and Treatment of Cancer to define prognostic parameters and establish diagnostic and therapeutic guidelines for CD56+ haematological neoplasms presenting primarily in the skin.

RESULTS

Four different subtypes of lymphoproliferations with CD56 expression were identified: (1) haematodermic neoplasm; (2) skin infiltration as the first manifestation of CD56+ acute myeloid leukaemia; (3) nasal-type extranodal natural killer/T-cell lymphoma; and (4) "classical" cases of cutaneous T-cell lymphoma (CTCL) with co-expression of the CD56 molecule. Patients in the first three groups had a poor outcome (93% died) with a median survival rate of 11 months (95% CI 2-72 months), whereas all patients with CD56+ CTCL were alive at the last follow-up.

CONCLUSION

Results show that CD56+ cutaneous lymphoproliferative disorders, with the exception of CD56+ CTCL have a very poor prognosis. It is therefore clinically important to separate CD56+ CTCL from the remaining CD56+ haematological disorders.

The down-regulation of IL1alpha and IL6, in monocytes exposed to extracorporeal photopheresis (ECP)-treated lymphocytes, is not dependent on lymphocyte phosphatidylserine externalization

Extracorporeal photopheresis (ECP) has been successfully used to treat some inflammatory conditions. Following ECP, lymphocytes become apoptotic and untreated monocytes, exposed to post-ECP lymphocytes, reduce proinflammatory cytokine secretion. This study attempted to establish if this monocyte immunosuppression was linked to phosphatidylserine externalization (detected using Annexin V) on the apoptotic lymphocytes. Using density gradient and magnetic separation, lymphocytes were isolated from three cutaneous T-cell lymphoma and nine chronic graft versus host disease (cGvHD) patients pre-ECP and prior to re-infusion (post-ECP). The collected lymphocytes were cultured overnight and Annexin V levels determined. Peripheral blood was taken from the same patient 20 h later and the monocytes were isolated. The 'fresh' monocytes were introduced to each 20 h pre- and post-ECP lymphocyte culture, stimulated with lipopolysaccharide (LPS) and Brefeldin A and subsequently tested for intracellular tumour necrosis factor alpha, interleukin 1 alpha (IL1alpha), IL1beta, IL6 and IL8. For cGvHD patients, the relative levels of IL1alpha and IL6 were reduced in the untreated, LPS-stimulated monocytes exposed to post-ECP lymphocytes. However, the down-regulation of IL1alpha and IL6 did not correlate to levels of Annexin V-positive lymphocytes. ECP-treated lymphocytes can reduce the ability of LPS-stimulated monocytes to produce some proinflammatory cytokines; however, this effect is not dependent on phosphatidylserine externalization.

Future perspectives in the treatment of cutaneous T-cell lymphoma (CTCL)

Over the last 20 years the treatment of cutaneous T-cell lymphoma has been in a state of continual change. New therapies are constantly emerging as the search continues for more effective and tolerable disease-specific agents that satisfy medical needs. Therapies under investigation include topical retinoids, fusion molecules like denileukin diftitox, pegylated interferon, interleukin-2, and interleukin-12. Pegylated liposomal doxorubicin, gemcitabine, and chlorodeoxyadenosine also appear to have clinical potential. Other identified agents include vaccines and monoclonal antibodies. This article reviews some of the most recent clinical innovations.

Staging and management of cutaneous T-cell lymphoma

Cutaneous T-cell lymphoma (CTCL) accounts for two-thirds of cases of primary cutaneous lymphoma. Most variants of CTCL are indolent lymphoma, the most common being mycosis fungoides. In addition, Sézary syndrome, the leukaemic variant, has an aggressive clinical course. Accurate diagnosis and staging is critical in determining the prognosis of those with CTCL. The tumour, node, metastasis and blood stage needs to be documented and used to determine an overall stage from IA to IVB. Management of patients should be carried out by a multidisciplinary team. A full clinical examination should be made at all visits. Thorough investigations are needed at diagnosis and should be repeated during disease progression to allow initial staging and restaging. Treatment of patients with early-stage disease (IA-IIB) should be limited to skin-directed therapy. More advanced or resistant disease may be treated with systemic therapies such as extracorporeal photopheresis, immunotherapy, monoclonal antibody therapy, novel retinoids or chemotherapy, and where possible, patients should be entered into clinical trials.

Les lymphomes T épidermotropes comme modèles de progression tumorale

Primary cutaneous T cell lymphomas (CTCL) represent the most frequently occurring group of extra-nodal T cell lymphomas, originating from skin-homing memory T cells. Sezary syndrome (SS) is a leukemic variant of CTCL that presents with erythroderma, lymphadenopathies and presence of malignant T cells in peripheral blood. SS has an unfavourable prognosis, and is refractory to current treatments. Progress in understanding the pathogenesis and tumor progression of SS is limited. In the past few years, we have identified and reported several CTCL-associated antigens, CD158k/KIR3DL2, CD85j/ILT2, and SC5/vimentin. KIR3DL2 is the first phenotypic marker of Sezary cells that can be used for the diagnostic and follow-up of Sezary syndrome. The SC5 antibody is the only monoclonal antibody reacting with vimentin on the surface of viable Sezary cells. CTCL are characterized by a predominance of Th2 cytokines. The recent suggestion that CTCL cells could be regulatory T (Tr) cells remains controversial. Gene expression studies suggest that in the future we may develop new diagnostic and prognostic tools, and identify subsets of patients who would benefit from more appropriate treatment protocols. Future challenges are to render tumor cells sensitive to apoptosis by inhibiting specific signalling pathways such as the constitutively activated NF-KB pathway, to identify specific surface kinase receptors and to develop specific inhibitors, to develop humanized monoclonal antibodies directed against tumor specific antigens, able to kill tumor cells via complement-dependent and antibody-dependent cytotoxicity, and to stimulate innate immunity.

Standard and experimental therapy in cutaneous T-cell lymphomas

Cutaneous T-cell lymphomas are a heterogeneous group of lymphoproliferative disorders, characterized by the accumulation of clonal lymphocytes in the skin. Skin-directed therapies are the preferred first-line modalities. There are interesting new developments in topical therapy using retinoids and gene-therapy products such as adenovirus- interferon (IFN)-gamma. Systemic treatment uses biologicals such as fusion molecules, monoclonal antibodies and immune response modifiers (IFNs and retinoids), and well-tolerated antiproliferative drugs such as methotrexate. Evidence-based treatment recommendation exists but is hampered by the lack of large multicenter randomized trials.

Mycosis fungoides palmaris et plantaris--an unusual variant of cutaneous T-cell lymphoma

Mycosis fungoides (MF) represents a low-risk, cutaneous, non-Hodgkin, T-cell lymphoma with a wide spectrum of clinicopathological manifestations and therefore may mimic a number of other dermatoses. Sometimes the clinical diversity makes the diagnosis of MF, and especially its atypical forms, challenging. We report on an 18-year old male patient, who had been previously diagnosed with palmoplantar eczema. Clinical, histopathological, immunohistochemical and molecular findings revealed an atypical case of MF.

Primary Cutaneous T-Cell Lymphomas

Primary cutaneous T-cell lymphomas (CTCLs) encompass a clinically and biologically heterogeneous group of non-Hodgkin lymphomas (NHLs) defined by clonal proliferation of skin-homing malignant T lymphocytes and natural killer cells. They account for up to 75% to 80% of all cutaneous lymphomas. The current WHO-EORTC classification of cutaneous lymphomas with primary cutaneous manifestations lists 13 entities. The most common subtypes—mycosis fungoides, Sézary syndrome, primary cutaneous anaplastic large cell lymphoma, and lymphomatoid papulosis—which represent approximately 95% of CTCLs, will be discussed in the following review. Each entity has unique biological characteristics and clinical course. Topical and/or systemic therapies are employed based on the stage of the disease and the tempo of progression.

[Association of polymorphic variants in endothelin-1 (EDN1) genes with the therapy of patients with cutaneous T-cell lymphomas]

BACKGROUND

The cutaneous T-cell lymphomas (CTCL) are diseases characterised by cutaneous infiltrates of malignant, clonally expanded T-cells. Because individual genetic determination of angiogenetic and antioxidant properties of blood vessels could take part in responsibility to phototherapy in CTCL patients, the association of two frequent polymorphisms in endothelin-1 gene with phototherapy was tested.

METHODS AND RESULTS

77 patients with CTCL, diagnosed and treated at the First Dermatological Clinic of St. Ann's Faculty Hospital Bmo (46 men and 31 women, median age 62, range 28-82 years) were included in the study. Diagnosis of CTCL according to the clinical picture was verified histologically. The genotype distributions and allelic frequencies between CTCL with phototherapy and those without phototherapy were compared. The 4A4A variant of -3A/-4A EDN1 is more frequent in patients treated with phototherapy (8/30 vs. 1/38, OR=10.13; P=0.01). The GA and AA genotypes of G8002A EDN1 polymorphism are more frequent in CTCL patients treated with phototherapy compared to those without it (15/23 vs. 7/32, OR=2.98; P=0.03).

CONCLUSIONS

Some polymorphic variants in EDN1 genes, a homozygote -4A-4A in -3A/-4A EDN1 and genotypes GA and GG in G8002A EDN1) seem to carry an advantage for phototherapy effectiveness in patients with CTCL.

Significant impact of cutaneous T-cell lymphoma on patients' quality of life

BACKGROUND

Cutaneous T-cell lymphoma (CTCL) can have a profound impact on a patient's health-related quality of life; however, little is known about its actual impact. The authors evaluated patients' perspectives on the impact of CTCL on physical functioning, lifestyle, emotional well being, and satisfaction with treatment.

METHODS

A 4-page, self-administered questionnaire was mailed and made available online in March 2005 to the entire United States membership of the Mycosis Fungoides Foundation (n = 930 members). Outcome measures were patients' perspectives on the psychosocial impact of CTCL and the management of their disease.

RESULTS

The response rate was 68%, and 93.6% of respondents were white. The majority of respondents had mycosis fungoides (89%). Respondents were bothered by skin redness (94%) and by the extent of symptoms that affected their choice of clothing (63%). For most patients, the disease had a functional impact, rendering them tired or affecting their sleep. Health distress was reported by almost all respondents, with 94% reporting that they worried about the seriousness of their disease and 80% worrying about dying from the disease. Sixty-two percent of respondents reported that their disease made them feel unattractive, 85% reported that their treatment made their disease seem more manageable, but 61% reported that they felt burdened financially by their disease.

CONCLUSIONS

The high response rate and patients' responses to the survey provided compelling evidence that patients believed CTCL had a profound and severe impact on their functioning, emotional, and social well being. A striking health distress was prevalent in almost all respondents. Although the majority of patients reported that treatments made their disease more manageable, a significant proportion reported that they felt burdened financially by their disease.

Diffuse large cell non-Hodgkin's lymphoma, CD30+, T-cell phenotype

A 63-year-old Chinese man presented with an eczematous dermatitis that progressed into a multifocal nodular eruption. Histopathologic examination demonstrated a nodular and diffuse infiltrate in the reticular dermis, which was composed of lymphocytes, macrophages with granulomatous inflammation, and numerous eosinophils. Reactive lymphoid follicles with germinal centers also were present. Immunohistochemistry showed CD30 and LCA. ALK-1 and CD20 were negative. A diagnosis of CD30+ cutaneous T-cell lymphoma was made, and the patient is currently undergoing staging of his disease. Treatment options include excision of nodules, radiation therapy, and systemic chemotherapy.

Dystrophic Xanthomatosis in Primary CD30-Positive Cutaneous T-Cell Lymphoma

The development of xanthomatous changes in lesions of primary cutaneous T-cell lymphomas (CTCL) is a rare event. It is usually observed in regressing skin tumours or plaques spontaneously or after a specific treatment. The pathogenetic mechanisms implicated in these changes are poorly understood. We are reporting 2 cases of extensive dystrophic xanthomatous changes, developing in regressing lesions of primary cutaneous CD30-positive T-cell lymphoproliferative disorders. Previously reported cases of primary CTCL developing secondary (dystrophic) xanthomata are reviewed.

Post-transplant cutaneous T-cell lymphomas

Post-transplant cutaneous lymphomas are rare. Cutaneous T-cell lymphomas account for 30% of these lymphomas. The clinical appearance of the skin lesions is identical to cutaneous lymphomas observed in non-immunosuppressed patients, with infiltrated plaques, nodular and ulcerated tumors, but with an increased frequency of erythroderma. Standard histology and immunohistochemistry are also consistent with the features of mycosis fungoides and CD30+ cutaneous lymphomas observed in the general population. However, the pronostic differs from the usually favourable outcome of cutaneous T-cell lymphomas, as 8 out of the 13 patients of our series died, in less than 1 year for 6 of them. This unfavourable course appears to be the same as that observed for systemic T-cell lymphoma in transplant recipients. In contrast to post-transplant B-cell lymphomas (systemic and primary cutaneous), the link to a virus has not been demonstrated. The prognosis is also less favourable for post-transplant cutaneous T-cell lymphomas than for post-transplant cutaneous B-cell lymphomas.

The spectrum of cutaneous T-cell lymphomas: new insights into biology and therapy

PURPOSE OF REVIEW

Cutaneous T-cell lymphomas represent clinically and biologically a heterogeneous group of non-Hodgkin lymphomas according to the new revised European Organization for Research and Treatment of Cancer and World Health Organization consensus classification for cutaneous lymphomas. Recent progress in immune and molecular biology and novel therapeutic targets have increased our understanding of these diseases and have led to novel treatment approaches. This review outlines the most recent advances.

RECENT FINDINGS

New immunologic and molecular findings may influence tumor phenotype and growth and provide a biologic basis for novel treatment approaches. Several reports have focused on new prognostic markers. Among the novel therapies for cutaneous T-cell lymphoma, interleukin-2 fusion toxins, monoclonal antibodies, histone deacetylase inhibitors, and immunomodulatory cytosine-phosphorothiolated guanine oligomers have shown promising results and are under further investigation.

SUMMARY

This review provides an update of recent findings of immunologic, molecular, and cytogenetic features and treatment approaches for patients with cutaneous T-cell lymphoma with special emphasis on mycosis fungoides and Sezary syndrome.

[Triple secondary malignancy of gingiva, palate and esophagus after an allogeneic bone marrow transplantation for cutaneous T-cell lymphoma]

A 31-year-old man was diagnosed as having cutaneous T-cell lymphoma in January 1994. He received an allogeneic bone marrow transplantation (BMT) from an HLA-matched sibling donor in May 1995, because of refractoriness to chemotherapy. The patient had been treated with immunosuppressants including prednisolone and cyclosporin A for chronic graft-versus-host disease (GVHD) of the extensive type following acute GVHD. Five years after the BMT, he developed moderately differentiated squamous cell carcinoma (SCC) on the mandibular gingival mucosa and underwent surgical resection. Furthermore, 6 years after the BMT well differentiated SCC developed on his palate and was resected. Concurrently, he was diagnosed as having esophageal cancer (poorly differentiated SCC) and underwent a subtotal esophagotomy. One year later he had a recurrence of the esophageal cancer with dysphagia and was treated with radiation and chemotherapy. He remains free of triple cancer and lymphoma. It is suggested that total body irradiation, immunosuppressants, and chronic GVHD are associated with a risk of secondary malignancies following allogeneic BMT. These factors might have contributed to the onset of triple cancer in our patient.

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.