Cyclosporine in the treatment of cutaneous T cell lymphoma

Transient CD30+ nodal transformation of cutaneous T-cell lymphoma associated with cyclosporine treatment

BACKGROUND

Mycosis fungoides (MF) may evolve from pre-existing chronic atopic or psoriasiform dermatitis and the histology can be equivocal. Early patch and plaque lesions of MF may evolve into tumors, disseminate to lymph nodes, bone marrow, and internal organs, and/or undergo transformation to a large cell size.

METHODS

A patient with a history of "atopic dermatitis" followed by "psoriasis" rapidly developed exfoliative erythroderma and axillary lymphadenopathy following treatment with cyclosporine. At presentation, biopsy specimens of skin lesions and lymph nodes and staging were obtained. We present the treatment and follow-up of this patient and review the medical literature for similar cases.

RESULTS

Multiple skin biopsy specimens from lesions revealed changes consistent with low-grade, cutaneous, T-cell lymphoma (MF) without evidence of large cell transformation and psoriasiform epidermal hyperplasia. CD30+ large cell transformation was present in the lymph node. Adenopathy and erythroderma resolved without systemic therapy following discontinuation of cyclosporine and treatment with psoralen/ultraviolet A (PUVA), isotretinoin, interferon-alpha, and antimicrobials.

CONCLUSIONS

This case documents a close relationship between atopy, psoriasis, and the development of cutaneous T-cell lymphoma, and illustrates that an immunosuppressive agent, cyclosporine, can dramatically alter the course of the disease.

Successful treatment of lymphomatoid granulomatosis using cyclosporin-A after failure of intensive chemotherapy

We report the successful and maintained response of lymphomatoid granulomatosis using a new approach to therapy, cyclosporin-A, after failure of aggressive multiagent chemotherapy.

Cyclosporine treatment of refractory T-cell lymphomas

BACKGROUND

Cyclosporine (cyclosporin A, CSA) prolongs the survival of transplanted organs by reducing the transcription of cytokines, especially interleukin-2, that are thought to mediate T-cell expansion and subsequent graft rejection. Recently, CSA has been suggested as a potentially effective agent in the treatment of T-cell neoplasms. As a result, a Phase II trial of CSA was done in patients with refractory T-cell lymphomas.

METHODS

Patients with peripheral T-cell lymphoma (PTCL) or cutaneous T-cell lymphoma (CTCL) who had disease progression after at least one previous therapy were eligible for participation. CSA was administered orally at a dose of 7.5 mg/kg twice daily, and the patients were followed for disease response and toxicity.

RESULTS

A total of 16 patients were treated. Five patients had PTCL, and 11 had CTCL. Most patients were pretreated extensively with chemotherapy and/or radiation therapy. No responses occurred in patients with PTCL. Two of 11 patients with CTCL responded to therapy. Both patients who responded to CSA had recurrent disease that approached baseline levels within 1 week of discontinuing therapy. A second response occurred in both patients after reinstitution of therapy. Although most patients were removed from the study because of disease progression, renal toxicity was significant.

CONCLUSIONS

Most patients with refractory T-cell lymphomas did not respond to CSA, suggesting that these malignancies are not interleukin-2 dependent or, alternatively, that CSA did not reach its intracellular target. In the two responding patients, the pattern of repeated rapid regression of disease after CSA administration and subsequent rapid recurrence after a temporary halt in therapy suggested that CSA was cytostatic rather than cytocidal or that the clinical remissions were mediated by the antiinflammatory effects of the drug.

Therapeutic alternatives in cutaneous T-cell lymphoma

Mycosis fungoides and Sézary syndrome, collectively referred to as cutaneous T-cell lymphoma, are non-Hodgkin's lymphomas that initially appear in the skin. Early-stage disease, limited to the skin, is best treated with sequential topical therapies such as topical nitrogen mustard, psoralen phototherapy (PUVA), or total-skin electron beam therapy. Photopheresis is the first line of therapy for the patient with erythroderma. Systemic therapy is generally reserved for patients with refractory disease and patients who initially present with extracutaneous involvement. Although there are several treatment options for cutaneous T-cell lymphoma, there have been few randomized comparative trials.