Corynebacterium jeikeium sepsis after 8-methoxypsolaren photopheresis for cutaneous T-cell lymphoma

We describe a patient with cutaneous T-cell lymphoma who developed Corynebacterium jeikeium sepsis after experimental treatment with 8-methoxypsolaren. The epidemiology and clinical features of C. jeikeium infection are discussed. The patient was successfully treated with intravenous vancomycin without recurrence.

Cutaneous T-cell lymphomas (including rare subtypes). Current concepts. II

BACKGROUND

Cutaneous T-cell lymphomas (CTCL) represent about the 80% of skin lymphomas and comprise a heterogeneous group of diseases with respect to clinical presentation, outcome, histologic and immunophenotypic features. In the recent years, data have been accumulated indicating that clinical and biological differences exists between primary nodal and primary extranodal lymphomas.

INFORMATION SOURCES

On such bases, the cutaneous lymphoma classification by the EORTC (European Organization for Cancer Research and Treatment) but also the recent general lymphoma classification, by the WHO (World Health Organization), have dedicated special attentions to the cutaneous lymphomas including the T and NK-cell subtypes. This paper reviews the most significative subtypes of T-cell lymphoma that affect the skin primarily or secondarily.

STATE OF THE ART

Apart from mycosis fungoides with its variants forms and the Sezary's syndrome, we have focused on the CD30+ primary cutaneous lymphoproliferative disorders (PCLD) (25% of all CTCL), a fascinating spectrum of disease, extending from lymphomatoid papulosis (LyP) trough to CD30+ large cell lymphoma. These disorders have in common large atypical CD30+ cells and a frequent spontaneous regression of the skin lesions associated with a relatively favourable outcome (excellent in LyP). The identification of this group of skin disorders is crucial for the patients since most of CD30+ PCLD are indolent diseases that do not warrant aggressive treatment. Others types of CTCL include the heterogeneous category of peripheral T-cell lymphoma not otherwise specified (NOS), subcutaneous panniculitis-like T-cell lymphoma and the still controversial group of the cytotoxic lymphomas.

PERSPECTIVES

Notably, the latter two subtypes have special relevance to the clinicians because (i) subcutaneous panniculitis-like T-cell lymphoma may be associated with the hemophagocytic syndrome; (ii) skin lesions in cytotoxic lymphomas may represent the first manifestation of an otherwise systemic disease.

Complete Remission of Previously Intractable Peripheral Cutaneous T-Cell Lymphoma of the Lower Extremity Using Isolated Hyperthermic Limb Perfusion with Melphalan (1-Phenylalanine Mustard)

The patient is a 74-year-old woman first diagnosed with a peripheral cutaneous T-cell lymphoma (PCTCL) in April of 1994. Initially she presented with subcutaneous indurated areas in the right forearm, scapula, and submadibular region. After chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), she went into remission for 2 years before relapse of her PCTCL localized to the right lower extremity. Persistent isolated disease in the extremity since then led to numerous chemotherapy regimens and localized radiation therapy. Due to dramatic limb threatening progression of the disease in 2001, she underwent isolated hyperthermic limb perfusion with melphalan (1-phenylalanine mustard). Although limb preservation could not be achieved, this treatment resulted in complete clinical and pathological regression of the lesions of the perfused extremity.

Graft-versus-lymphoma effect in refractory cutaneous T-cell lymphoma after reduced-intensity HLA-matched sibling allogeneic stem cell transplantation

Cutaneous T-cell lymphomas (CTCL) are rare diseases that, in their advanced stages or in transformation, have a poor prognosis. Autologous stem cell transplantation (Au-SCT) after high-dose therapy has yielded disappointing results. Allogeneic transplantation (allo-SCT) provides the potential advantage of an immune-mediated graft-versus-lymphoma (GVL) effect. Reduced-intensity allo-SCT potentially offers a GVL effect, but with diminished toxicity related to the induction regimen; however, published experience with this approach in CTCL is limited. We report a series of three patients (age 35-49) with advanced, refractory (n=2) or transformed (n=1) CTCL who underwent reduced-intensity allo-SCT in the context of active disease. All three survived the peri-transplant period and, despite later having disease relapse, all exhibited evidence of a GVL effect. Relapses of the disease were in the context of immune suppression for graft-versus-host disease (GVHD), and when immune suppression was reduced, responses were regained. A comparison is made of these results to those in a review of the published literature to date. We conclude that while a GVL can be achieved for CTCL with reduced-intensity allogeneic transplantation, the clinical benefits are short lived and novel approaches are required to obtain sustained remissions.

Mechanism of action of extracorporeal photochemotherapy in chronic graft-versus-host disease

Chronic graft-versus-host disease (GvHD) affects 50% of long-term bone marrow transplant survivors and remains a cause of major long-term morbidity in these patients despite aggressive therapy. Extracorporeal photochemotherapy (ECP), considered as an effective treatment for patients with erythrodermic cutaneous T-cell lymphoma (CTCL), has recently been used successfully in the treatment of GvHD. One of the most intriguing aspects of ECP is its ability to induce two apparently opposite effects: activation of the immune system against neoplastic cells (as in CTCL) and downregulation of the activity of T-cell clones in autoimmune diseases (as in systemic sclerosis, systemic lupus erythematosus and pemphigus vulgaris) and autoallogeneic immune responses (as in GvHD and allograft rejection). Only a better and more complete understanding of the various mechanisms involved will enable this interesting new therapy to be made more effective and selective.

Current management strategies for cutaneous T-cell lymphoma

Cutaneous T-Cell Lymphoma is a group of lymphomas characterized by a malignant proliferation of skin homing T cells. Prognosis is generally good and treatment is based on the stage of the disease with the goal of inducing remission. Patients with disease limited to the skin in the form of patches and plaques respond best to "skin directed therapy" with topical agents including corticosteroids, nitrogen mustard, carmustine, bexarotene gel, as well as phototherapy with ultraviolet B light, PUVA, or photodynamic therapy. Tazarotene and imiquimod show potential in the treatment of early CTCL. Patients with disease resistant to treatment or with advanced disease require more aggressive therapy in the form of total skin electron beam radiation, biologic response modifiers including interferon alpha, bexarotene, denileukin diftitox, extracorporeal photochemotherapy or combination therapy. The use of chemotherapy is used primarily for palliation. Allogeneic hematopoetic stem cell transplantation may represent a successful treatment for treatment resistant disease.

Interaction of cutaneous lymphoma cells with reactive T cells and dendritic cells: implications for dendritic cell-based immunotherapy

BACKGROUND

Cutaneous T-cell lymphomas (CTCLs) are a heterogeneous group of skin neoplasms that originate from T lymphocytes. An anti-CTCL T-cell immunity has been described but seems to be inefficient to clear CTCL cells. It is not known whether cutaneous dendritic cells (DCs) perpetuate the proliferation of the malignant CTCL cell clone or play a role in the control of this usually slowly progressing disease.

OBJECTIVES

To characterize CTCL cell properties in the control of anti-CTCL T cells and to pave the way for a DC-based immunotherapy for CTCL.

METHODS

We studied the interaction of a CTCL cell line with DCs and with allogeneic T cells.

RESULTS

We found an antigen non-specific capacity of viable but not apoptotic CTCL cells to hamper CD4+ and CD8+ T-cell proliferation in a dose-dependent manner, indicating a suppressive potential of CTCL cells. Both viable and apoptotic CTCL cells were phagocytosed by immature DCs but only apoptotic CTCL cells induced an upregulation of DC maturation markers to a degree which enabled classification of these DCs as semimature. CTCL cells did not respond with proliferation when encountering allogeneic, mature DCs either loaded with CTCL cell material or unloaded, indicating a role for DCs in the induction of anti-CTCL T-cell immunity rather than in perturbation of clonal proliferation. For the loading of DCs with CTCL material lysate seems to be optimal as apoptotic cells were not phagocytosed extensively and necrotic CTCL material induced a partial cellular toxicity in DCs. DCs loaded with CTCL material were cryopreservable without significant loss of DC viability, surface marker expression or allostimulatory activity.

CONCLUSIONS

Together, these data argue in favour for a DC-based immunotherapy for CTCL patients and provide an experimental protocol for preparing CTCL cell-loaded DCs.

Current status of cutaneous T-cell lymphoma: molecular diagnosis, pathogenesis, therapy and future directions

Primary cutaneous T-cell lymphomas (CTCL) represent a heterogeneous group of neoplasms characterized by skin-homing malignant T-lymphocytes. In contrast to primary extracutaneous (nodal) lymphomas, CTCL is characterized by a prolonged clinical course with a different clinical behavior and outcome. Disease progression, however, involves the recirculation compartments, i.e. lymph nodes and peripheral blood, and may finally spread to the visceral organs. Advances in T-cell receptor gene rearrangement techniques support the clinical diagnosis in early stages of CTCL by improved sensitivity and specificity of molecular diagnosis. The pathogenesis of CTCL is characterized by an altered immune biology and the accumulation of genetic mutations during disease progression. Although there is an initial response to standard therapy, including photochemotherapy, interferons, and retinoids, all patients will eventually relapse, and therefore treatment of CTCL continues to be palliative. New therapeutic drugs including bexarotene, DAB(389)IL-2 and IL-12 have demonstrated clinical responses; and new experimental therapeutic directions, e.g. stem cell transplantation and vaccination strategies may be applied with the intention to cure.

Síndrome hemofagocítico y linfoma cutáneo de células T

Haemophagocytic syndrome is a rare disorder of immune regulation. Clinical features are fever, haemophagocytosis, hepatosplenomegaly, pancytopenia, lymph nodes enlargement, hypertriglyceridaemia and coagulopathy. Systemic findings may also include pulmonary infiltrates, renal failure and an inappropriate antidiuretic state. It has been described associated to many diseases, like lymphomas, most of them T-cell lymphomas, infections and systemic diseases, among other entities. Haemopoietic cells are actively ingested by monocytes and macrophages in lymph nodes, bone marrow, liver and spleen. This is a diagnostic criteria for haemophagocytic syndrome. The treatment of haemophagocytic syndrome is difficult and requires intensive supportive therapy, treatment of coagulopathy disorders, high-dose corticosteroids and immunosuppressive treatment, although in most cases there is no response to treatment and the evolution is fatal. The T-cell lymphomas that involve subcutaneous tissue and simulate panniculitis are classified recently as primary cutaneous T-cell lymphomas, and their presentation as inflammatory nodules of the legs are uncommon.

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.

Nasal natural killer/T cell lymphoma with cutaneous involvement: case report and Chinese literature review reported in China mainland

Nasal natural killer (NK)/T cell lymphoma is an Epstein-Barr virus (EBV) associated lymphoma that arises in the nasal area and aggressively invades surrounding tissues. Our patient was a 48-year-old male who had had nasal obstruction and nasal discharge for 2 years and infiltrating plaques and necrosis on his nasal dorsum for three months. He developed fever and fatigue two weeks before admission. Biopsy from both skin and nasal mucosa revealed atypical medium-sized tumor cells infiltrating into the dermis. Immunohistochemical studies revealed that the tumor cells were UCHL-1, cytoplasmic CD3, CD56, TIA-1, and granzyme B positive, and CD8 and CD20 negative. In situ hybridization for EBV-DNA was positive. Clonal TCRb and TCRg gene rearrangement were negative. The patient was treated with cyclophosphamide, vincristine, and prednisone (COP) and with local radiotherapy, but he died 20 days later. We reviewed the cases of nasal NK/T cell lymphoma reported in mainland China in the Chinese literature during the last 5 years.

Blastic natural killer cell leukaemia with skin involvement: a case report

Natural killer cell leukaemia is generally accompanied by extramedullary involvement. CD4+ natural killer cell leukaemia frequently manifests with cutaneous involvement. The disease pursues a very aggressive course with no long-term survivors reported. We present a patient with CD4+ natural killer cell leukaemia with skin, bone marrow and peripheral blood involvement who is still on remission at the end of 2 years.

Cutaneous T-cell lymphomas: a review with emphasis on new treatment approaches

Primary cutaneous T-cell lymphomas represent a wide variety of non-Hodgkin lymphomas that are characterized by a distinct clinical presentation. Advanced molecular and biological techniques have enhanced the recognition of cutaneous T-cell lymphomas. The most common subtypes of cutaneous T-cell lymphomas are the epidermotropic variants mycosis fungoides and Sézary syndrome. At present, a stage-adjusted therapy is the best concept available, since early aggressive treatment options did not improve the prognosis of patients with cutaneous T-cell lymphomas. Accurate diagnostic and clinical assessment as well as identification of prognostic factors provides a helpful basis for treatment strategies. Current medical literature on diagnosis, prognosis, and treatment is reviewed with emphasis on new biologic response-modifying treatment options.

The use of cytokines, fusion proteins and antibodies to treat cutaneous T-cell lymphoma

It has long been known that certain immune augmenting therapeutics, particularly interferon alpha, can exert profound salutary effects on the clinical progress of patients with cutaneous T-cell lymphoma. Emerging evidence that the host immune response may play an important role in the control of this disorder has led to the clinical application of other cytokines including interleukin-12 and interferon gamma. In this review, the authors will summarize current knowledge regarding the use of cytokines, fusion proteins and antibodies for the treatment of cutaneous T-cell lymphoma.

Vaccine therapy for cutaneous T-cell lymphoma

We demonstrated that percutaneous peptide immunization by way of skin with impaired barrier function is a simple and noninvasive strategy to generate effective immune responses against tumors. This therapeutic strategy seems to be beneficial for the treatment of skin-associated malignancies, including CTCL, because specific CTLs are considered to be well-induced in lymph nodes that neighbor barrier-disrupted skin (Fig. 3). There remain unsolved issues concerning (1) the ability of cytokines and growth factors to enhance efficacy of this therapy and (2) the time schedule of clinical trials. It was recently shown that application of antigenic protein or its coding DNA to skin with increased permeability yields antigen-specific antibody responses. Because the skin represents an easily accessible site for immunization and vaccination, percutaneous immunization using corneum barrier-disrupted skin is an alternative to injection of CTL-inducing molecules and can readily be exploited for cancer treatment in humans. The effective induction of CTLs suggests that the method that uses barrier-disrupted skin can potentially be applied to treatments of virus and helminth infections with the use of certain antigenic peptides.

Phototherapy for cutaneous T-cell lymphoma

Phototherapy has been utilized for decades in the treatment of various dermatologic conditions, including cutaneous T-cell lymphoma (CTCL). Currently, a number of light sources are available, and selection of the specific modality is based on a number of factors, the most important of which is disease stage. The efficacy of broadband ultraviolet B (UVB) is limited to the patch stage, while psoralen and ultraviolet A (PUVA) is capable of clearing plaques and, sometimes, early tumors. Narrowband UVB is also effective for early stages and has practical advantages over PUVA, but more studies are needed to more fully evaluate its role in CTCL. Long-wave ultraviolet A (UVA1) has likewise shown efficacy, supported by findings of apoptosis induction in UVA1-treated cells. Long-term remissions have been reported for PUVA, but in the majority of cases, maintenance therapy was necessary. Although beneficial as monotherapy for early stages of the disease, phototherapy is also a useful adjunct to other modalities such as interferons, retinoids and electron beam therapy. Studies are ongoing to refine protocols for combination therapy, with the goal of improving efficacy, while minimizing adverse effects.

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.

High-dose therapy and bone marrow transplantation in cutaneous T-cell lymphoma

Although most patients who have cutaneous T-cell lymphoma have an indolent clinical course, patients who have cutaneous tumors, lymph node or visceral involvement, or peripheral blood involvement generally have rapidly progressive disease with shorter survival. In those patients with poor prognostic features, conventional combination chemotherapy is usually ineffective. High-dose chemotherapy with autologous hematopoietic stem cell transplant (HSCT) results in high remission rates, but the recurrence is inevitable and rapid. Allogeneic HSCT, in contrast, provides durable long-term remissions and is currently the only potentially curative therapy.

Prognosis, clinical outcomes and quality of life issues in cutaneous T-cell lymphoma

Although the need for a specific QOL index for MF/SS has been recognized, little work has been done in this area. QOL instruments should address general health concepts, as well as specific issues that are relevant to patients who have MF/SS; a combination of two instruments may be appropriate. Confirming the validity, reliability, and responsiveness to change of a combination of QOL instruments, such as SKINDEX-29 and FACT-G, in patients who have MF/SS will be relevant. For patients who have MF/SS, focusing our efforts on improving the disease and their QOL should translate into improvements that are meaningful to them. Thus, our goal should be to incorporate the findings of QOL research into practice and use the results to guide our practices, as they relate to therapy. Some important considerations are: We must be explicit about what will be done with the information that is obtained about an individual's QOL. We should consider what additional knowledge QOL measures provide that we could not otherwise have. We should be ready for unexpected results, as exemplified by instances where aggressive therapy could result in improved QOL. Although challenges exist in moving forward QOL research in CTCL, the words of wisdom of Tannock bring the concept of QOL into perspective: "When cure remains elusive, it is time to start treating the patient, not just the tumor." A final consideration is that we should not forget the dimension of spirituality, which is especially relevant to patients who have advanced MF/SS. Spirituality is characterized by the capacity to seek purpose and meaning, to have faith, to love, to forgive, and to see beyond current circumstances. Spirituality enables a person to rise above suffering. Unfortunately, research on spirituality is scarce, in part, because of the difficulty in assessing spiritual suffering. Nevertheless, physicians who are caring for patients who have advanced MF/SS should acknowledge the spiritual dimension as an integral component of the dying process.