Therapeutic alternatives in cutaneous T-cell lymphoma

Mycosis fungoides

Mycosis fungoides (MF) constitutes the most frequent cutaneous T-cell lymphoma. Sezary syndrome is considered by some authors to be an erythrodermic leukemic variant of MF, but is classified separately in the new WHO-EORT classification of cutaneous lymphomas. MF usually occurs in old adults with a 2:1 male to female ratio. Its prognosis is variable and strongly conditioned by the extent and type of skin involvement and presence of extracutaneous disease. Patients with stage IA-disease have an excellent prognosis with an overall long-term life expectancy that is similar to an age-, sex-, and race-matched control population. Almost all patients with stage IA MF will die from causes other than MF, with a median survival >33 years. Only 9% of these patients will progress to more extended disease. Patients with stage IB or IIA have a median survival greater than 11 years. These patients with T2 disease have a likelihood of disease progression of 24% and nearly 20% die of MF. Subgroups with stage IB or IIA have similar prognosis. Patients with cutaneous tumors or generalized erythroderma have a median survival of 3 and 4.5 years, respectively. The majority of these patients will die of MF. Extracutaneous dissemination is observed in less than 10% of patients with patch or plaque disease and in 30-40% of patients with tumors or generalized erythrodermatous involvement. Extracutaneous involvement is directly correlated to the extent of cutaneous disease. The most commonly involved organs are lung, spleen, liver, and gastrointestinal tract. Patients with extracutaneous disease at presentation involving either lymph nodes or viscera have a median survival of <1.5 years. Patients with plaque-type or erythrodermic MF may develop cutaneous tumors with large cell histology, often expressing CD30, which share a common clonal origin as observed in their preexisting MF and are associated with a less favourable outcome.

Mycosis fungoides ? a review of the management of 28 patients and of the recent literature

BACKGROUND

Mycosis fungoides is an uncommon cutaneous T-cell lymphoma characterized by malignant monoclonal proliferation of T-helper lymphocytes. Its course is variable with a potential for lymphatic and hematogenous involvement. We report the investigations, staging, treatment, follow-up, and outcome of 28 patients. This is the first such study reported from Ireland.

METHODS

Twenty-eight patients with mycosis fungoides (14 women, 14 men; average age, 52.5 years) were reviewed over 12 years in the dermatology clinic which assesses an average of 4500 patients per year. All mycosis fungoides patients were referred from their family physicians. The diagnosis was made in all cases from a combination of clinical findings, histology, and immunohistochemistry. TNM staging revealed 11 patients at diagnosis stage IA (T1), 12 at stage IB (T2), four at stage IIB (T3), and one at stage III (T4).

RESULTS

The usual male preponderance was not found. Eight patients needed multiple biopsies to establish the diagnosis. Detailed investigations were not useful in the early stages. Patients were followed up over a 12-year period. Thirteen patients died as a result of cutaneous lymphoma. Two patients with stage IA disease progressed rapidly and died, a feature reported in only 10% of patients at this stage. Five patients showed unusual features, including a long history prior to presentation, the development of the rarely reported bullous mycosis fungoides, and aggressive disease beginning at a young age.

CONCLUSIONS

Mycosis fungoides is rare; we reviewed 28 patients over 12 years. The prognosis is poor at the later stages; 13 patients died. Two patients who died were unusual in that they rapidly progressed from stage IA disease; however, in the majority of patients with this stage, the prognosis is excellent. Detailed investigations were unhelpful in early stage disease. Close clinical follow-up is essential to identify disease progression.

Bath‐water PUVA Therapy with 8‐Methoxypsoralen in Mycosis Fungoides

PUVA therapy is widely used for early stage mycosis fungoides. While the efficacy of PUVA with oral 8-methoxypsoralen (8-MOP) is well documented, the use of its topical variation, bath-water PUVA therapy with 8-MOP has not been studied. The purpose of this study was to assess the effect of 8-MOP bath-water PUVA therapy in adult patients with early stage mycosis fungoides. We retrospectively evaluated the outcomes of bath-water delivery of 8-MOP (1 mg l(-1)) in 16 patients with early stage mycosis fungoides. In all patients complete response was achieved after a mean duration of 63 days requiring 29 treatments and a mean cumulative UVA dose of 33 J cm(-2). The time to relapse after complete clinical clearance was 45.6 (+/-9.2) weeks. In comparison, oral PUVA therapy with 8-MOP resulted in complete response after 64.5 days (25.8 treatments) with a mean relapse-free period of 30 (+/-3.5) weeks. We conclude that bath-water PUVA therapy with 8-MOP is a valuable photo-therapeutic alternative, which should be considered for patients in whom systemic psoralen cannot be used.

Mycosis fungoides - a retrospective study of 40 cases in Hong Kong

BACKGROUND

Mycosis fungoides is rare in Hong Kong and oriental data on the disease are lacking.

METHODS

This is a multiclinic, 13-year, retrospective study to determine the clinicopathologic characteristics, treatment, and disease outcomes of 40 patients with mycosis fungoides/Sézary syndrome seen in the Social Hygiene Service, Hong Kong.

RESULTS

There were 27 males and 13 females with a mean age at diagnosis of 56.4 years. Based on figures in the Social Hygiene Service alone, the incidence in Hong Kong was estimated to be 0.044 per 100,000. Eighty-five per cent of patients presented with skin-limited disease, and pruritus was absent in 40% of patients. A mean of 1.48 biopsies was needed to establish the diagnosis, and only 58% of the mycosis fungoides skin biopsies were reported to be histologically diagnostic of the disease. Atypical lymphocytes, epidermotropism, interface changes, and Pautrier's microabscesses were the four most frequently encountered features that attained statistical significance. Sixty-nine per cent of patients were treated with psoralen-UVA as their initial therapy, and the complete response and relapse rates were 78.3% and 66.6%, respectively. Disease progression to more advanced stages was only seen in 15% of patients. The 5-year survival rates for the whole group and for stage IA and IB patients were 88.8% and 100%, respectively.

CONCLUSION

Mycosis fungoides is rare amongst Hong Kong Chinese and the majority present with skin-limited nonprogressive disease.

Topical photodynamic therapy for patients with therapy-resistant lesions of cutaneous T-cell lymphoma

Photodynamic therapy after topical application of 5-aminolevulinic acid is an effective therapy for nonmelanoma epithelial skin cancers. It has also been used for some cases of cutaneous T-cell lymphoma. We treated 4 patients with different cutaneous T-cell lymphomas with photodynamic therapy. Those patients had previously reached a partial remission with more conventional therapies, but single lesions had remained. In all of these cases a complete remission of these lesions was achieved. We, therefore, suggest that photodynamic therapy can be a useful additional treatment modality for patients with therapy-resistant lesions of cutaneous T-cell lymphoma.

Sézary syndrome and seronegative polyarthritis: treatment with extracorporeal photochemotherapy

We describe a patient with therapy-resistant cutaneous T-cell lymphoma, Sézary syndrome variant, in association with concurrent polyarthritis and vitiligo, who was successfully treated with extracorporeal photochemotherapy (ECP). The combination of Sézary syndrome with seronegative rheumatoid arthritis is rare. In our patient the T-cell lymphoma was refractory to standard treatments that included psoralen-UVA, lymph node irradiation, and polychemotherapy. ECP has been shown to be effective in the treatment of selected cases of Sézary syndrome. There is a strong suggestion that ECP as a monotherapy can provide a significant benefit for other T-cell-mediated diseases including rheumatoid arthritis. In spite of a disease duration of 10 years, a very low CD8 cell count (2% of lymphocytes), a very high CD4 cell count (94%), and multiple unsuccessful chemotherapeutic trials before initiation of ECP, our patient achieved a long-lasting complete remission of both diseases with normalization of the CD4+ and CD8+ T-lymphocyte subsets. Concurrent developing vitiligo was unaffected by ECP.

A case of follicular mycosis fungoides with follicular mucinosis: a rare association

Follicular mycosis fungoides (FMF) is a rare cutaneous T cell lymphoma characterized by an atypical lymphoid infiltrate spreading within and around hair follicles without epidermotropism or follicular mucin deposits. Its occasional presentation with minimal epidermal involvement and/or follicular mucinosis suggests the need for uniform histologic criteria. We describe a new case of FMF associated with follicular mucinosis and discuss its morphologic spectrum of presentation.

Follicular mycosis fungoides: a case report and review of the literature

BACKGROUND

Follicular mycosis fungoides is an unusual variant of mycosis fungoides (MF). Unlike classic MF where atypical lymphocytes show a predilection for the epidermis (epidermotropism), follicular MF displays a malignant lymphocytic infiltrate tropic for hair follicles (folliculotropism). This malignant lymphocytic infiltrate results in follicular disruption typically manifesting clinically as plaques, comedones and follicular papules.

METHODS

This report describes a 40-year-old patient with follicular MF presenting as nodules on the face and chest. Histologic examination of the patient's biopsy revealed a folliculocentric infiltrate of atypical lymphocytes with sparing of the epidermis.

RESULTS AND CONCLUSIONS

Our case is discussed in the context of previously reported cases of follicular MF; we also include a review of all cases of follicular MF published to date that meet the strict criterion for this diagnosis.

Expression of apoptosis markers on peripheral blood lymphocytes from patients with cutaneous T-cell lymphoma during extracorporeal photochemotherapy

The mechanisms of extracorporeal photochemotherapy (ExP) therapeutic activity in cutaneous T-cell lymphomas (CTCLs) are not yet well understood, even though it has been suggested that a major mechanism may be induction of apoptosis. In vitro studies demonstrate that UVA-induced apoptosis is mediated by CD95-Fas expression and inhibited by Bcl-2 up-regulation and that UVA irradiation is able to down-regulate Bcl-2 expression. High-resolution multiparameter flow-cytometric analyses were used to evaluate Bcl-2/CD95-Fas expression on phenotypically identifiable circulating clonal T cells from 7 patients with CTCL (4 with Sézary syndrome and 3 with mycosis fungoides with peripheral involvement) before and during ExP, in an attempt to ascertain whether Bcl-2/CD95-Fas status can be related to the hematologic response. A Bcl-2 normal phenotype before ExP or a normalization in Bcl-2 expression during ExP were related to a better clinical response, whereas a persistent Bcl-2 high expression was a negative prognostic factor. On the other hand, no response was found in patients with a CD95-Fas-negative phenotype, whereas the expression of CD95-Fas was associated with hematologic remission. Although further studies are needed to confirm these preliminary results, this study suggests that Bcl-2 and CD95-Fas expression could be evaluated, together with the other known clinical and immunologic factors, as additional parameters related to clinical response in patients with CTCL undergoing ExP.

Extracorporeal photopheresis in cutaneous T-cell lymphoma. Inconsistent data underline the need for randomized studies

Edelson et al.7 first reported the use of extracorporeal photopheresis (ECP) to treat cutaneous T-cell lymphoma (CTCL) in 1987, and since then several studies reporting response rates and survival data have appeared in the literature. Several modes of action have been proposed for ECP. In CTCL there is an accumulating body of evidence to show that 8-methoxypsoralen-treated cells display increased quantities of antigenic peptides at their cell surfaces, and this in turn leads to an enhanced cytotoxic response against the neoplastic T-cell population. This mechanism requires the presence of malignant cells in the peripheral circulation, and may account for the observation that ECP produces higher response rates in erythrodermic CTCL than at other stages of disease. However, patients with inflammatory skin diseases such as reactive erythroderma may also respond to ECP, and it is therefore crucial that a diagnosis of Sézary syndrome is confirmed by demonstrating a clonal population of T cells in the peripheral blood. Unfortunately, most studies have not employed T-cell receptor gene analysis routinely, and this may account for the different response rates and survival data reported with ECP in the literature. To date, ECP has not been tested in a randomized study against conventional forms of therapy.

PUVA therapy: current concerns in Japan

Photochemotherapy using methoxsalen in combination with long-wave ultraviolet light (PUVA) is an essential modality in the treatment of various skin diseases. Major therapeutic regimens include oral, topical and water-delivery methods. An adequate regimen should be chosen regarding cases of disease, extent of involvement and the age of patients. In Japan, however, treatment techniques and protocols have not yet been standardized. PUVA therapy may be a first choice in the early stages of mycosis fungoides and a second choice or an adjunctive measure in other diseases, such as psoriasis, vitiligo and atopic dermatitis, which have been disabling or resistant to conventional treatments. Japanese guidelines for PUVA therapy of psoriasis are being prepared to be produced. Risks and benefits must be weighed and the patient orientation is necessary to complete the treatment and also to minimize side-effects. Although possible risks for skin cancers in Japanese patients have been reported to be much lower, a careful monitoring of the patient's skin changes is recommended. While action mechanisms are not completely understood, recent investigations suggest that both antiproliferative and immunomodulatory effects are involved. This review article deals with the recent progress in clinical and basic research on PUVA therapy, focusing on our current concerns.

DAB389IL2 diphtheria fusion toxin produces clinical responses in tumor stage cutaneous T cell lymphoma

Four patients with late stage cutaneous T cell lymphoma (IB-IVA) who had failed at least two previous therapies were treated with DAB389IL2 at 9 or 18 microg/kg as 15-min intravenous infusions daily for 5 days every 3 weeks for eight cycles. Mild vascular leak syndrome (VLS) with transient edema, hypoalbuminemia, weight gain, and myalgias was observed in two of the patients lasting 7-10 days and only occurring on the first cycle. One stage IB patient had a pathologic complete remission (CR) lasting 11+ months from treatment initiation, one stage IIB patient had a complete clinical remission (CCR) lasting >6 months with complete clearing of a large tumor lasting >18 months, and one stage IIB and the one stage IVA patient had partial remissions (80-99% reduction in tumor masses) lasting 5 months. While IL2 receptor (IL2R) was expressed on 20-50% of tumor cells prior to therapy, recurrent tumor was IL2R negative in three of the patients. DAB389IL2 at tolerable doses decreased tumor burden in each of these four standard treatment refractory CTCL patients and may offer an important alternative to standard palliative chemotherapy regimens.

Extracorporeal photochemotherapy induces apoptosis of infiltrating lymphoid cells in patients with mycosis fungoides in early stages. A quantitative histological study

Extracorporeal photochemotherapy (ExP) is a well-tolerated new form of chemoimmunotherapy, which is considered to be effective for cutaneous T-cell lymphoma (CTCL) and the treatment of choice for Sézary syndrome. Improvements have also been seen in patients with non-erythrodermic mycosis fungoides (MF) in the early stages, even when tumour cells are not detectable in the peripheral blood. In this study, we used ExP as a monotherapy in seven patients who had early stage (Ib) MF, and who were no longer responsive to or had contraindications for other therapies. We observed a clinical improvement in the disease after 12 months of treatment: one patient showed a complete response, five a partial response, and one remained stable. In each patient we compared skin biopsies of large plaque lesions before and after the treatment. We undertook a histological evaluation of the infiltrate. The lymphoid cell proliferation and death rates were quantified using the following parameters; lymphoid cell density (LCD), Ki67 + lymphoid cell nuclei percentage (Ki67 + Lcn percentage), and apoptotic index (AI). Significant decreases in the lymphoid cell infiltrate and in cell proliferation, and a significant increase in AI were observed after therapy. The mean LCD decreased from 187 +/- 33 to 34 +/- 17.7, Ki67 + Lcn mean percentage decreased from 16.9 +/- 3.9 to 4.9 +/- 2.4, and the AI mean value increased from 0.05 +/- 0.03 to 2.41 +/- 1.54. Our results suggest a role for apoptosis in the improvement of the skin lesions and are in line with some reports on the mode of action of ExP. Although the way in which ExP works needs to be clarified further, it does seem to stimulate a CD8+ cell-mediated anticlonotypic activity against circulating pathogenic clones. Furthermore, a release of tumour necrosis factor alpha (TNF-alpha) by circulating monocytes has been demonstrated after ExP. Both are known to induce cell death by apoptosis.

Extracorporeal photochemotherapy restores Th1/Th2 imbalance in patients with early stage cutaneous T-cell lymphoma

Extracorporeal photochemotherapy (ECP) has been shown to be a potent activator of peripheral blood macrophages because it causes a marked release of macrophage-dependent proinflammatory cytokines, and it is therefore currently considered to be a safe and non-toxic immunomodulatory treatment. On this basis we studied the function of peripheral blood mononuclear cells (PBMC) in eight patients with early stage (Ib) cutaneous T-cell lymphoma (CTCL), before and 1 year after ECP, together with their clinical and histological responses. In particular we evaluated in vitro phytohaemagglutinin (PHA)-stimulated proliferation and production of interleukin-4 (IL-4) and interferon-gamma (IFN-gamma) as well as lipopolysaccharide (LPS)-induced production of IL-12. Before treatment we observed that PBMC of patients produced significantly higher levels of IL-4 and lower levels of IFN-gamma and IL-12 than those of healthy control subjects. After 1 year of ECP, IL-4, IFN-gamma and IL-12 production no longer differed from that of control subjects. Moreover, we observed a good clinical result matched by histological response. Our data confirm that early-stage CTCL patients show a predominantly type-2 immune response that might be responsible for several immunological abnormalities found in this disease. We have demonstrated that ECP reverses the T-helper type 1/T-helper type 2 (Th1/Th2) imbalance and may therefore be considered an efficient biological response modifier.

Total skin electron beam therapy followed by adjuvant psoralen/ultraviolet-A light in the management of patients with T1 and T2 cutaneous T-cell lymphoma (mycosis fungoides)

PURPOSE

Patients with mycosis fungoides [cutaneous T-cell lymphoma (CTCL)] may benefit from adjuvant therapy after completing total skin electron beam therapy (TSEBT). We report the results for T1/T2 CTCL patients treated with adjuvant oral psoralen plus ultraviolet light (PUVA) with respect to overall survival (OS), disease-free survival (DFS), salvage of recurrence, and toxicity.

METHODS AND MATERIALS

Between 1974 and 1993, TSEBT was administered to a total of 213 patients with CTCL. Records were reviewed retrospectively, and a total of 114 patients were identified as having T1 or T2 disease. Radiotherapy was provided via a 6-MeV linac to a total of 36 Gy, 1 Gy/day, 4 days/week, for 9 weeks. Beginning in 1988, patients were offered adjuvant PUVA within 2 months of completing TSEBT. This was started at 0.5-2 J/m2, 1-2 treatments/week, with a taper over 3-6 months. Therapy then continued once per month. There were 39 T1 and 75 T2 patients. Six T1 (15%) and eight T2 (11%) patients were treated with adjuvant PUVA. A further 49% of the 114 patients received adjuvant systemic therapy, 3% received spot external beam, 4% received adjuvant ECP, 2% received topical nitrogen mustard, 22% received a combination of therapies exclusive of PUVA, and 9% received no adjuvant therapy. Patients were balanced in all subgroups based on pre-TSEBT therapy. The median age of the cohort was 58 (range 20-88), with a median follow-up time of 62 months (range 3-179).

RESULTS

Within 1 month after completing of TSEBT, 97% of T1, and 87% of T2 patients had achieved a complete remission. Stratified by adjuvant therapy, none of six T1 and one of eight T2 patients who received adjuvant PUVA failed within the first 3 years after completion of TSEBT. A total of 43% of the T1 and T2 patients receiving other or no adjuvant treatment failed within the same time course. The 5-year OS for the entire cohort was 85%. Those who received PUVA had a 5-year OS of 100% versus a 5-year OS for the non-PUVA group of 82% (p < 0.10). The 5-year DFS for the entire cohort was 53%. Those who received PUVA had a 5-year DFS of 85% versus a 5-year DFS for the non-PUVA group of 50% (p < 0.02). By T stage, those with T1 receiving PUVA exhibited no relapses, whereas those with T1 not treated with PUVA had a crude relapse rate of 36%. Median DFS was not reached at 103 months for the T1 adjuvant PUVA patients versus 66 months for the non-PUVA patients (p < 0.01). For those with T2, crude relapse rates were 25% and 55%, respectively, with DFS of 60 (median DFS not reached) and 20 months (p < 0.03). The 5-year DFS for patients salvaged with PUVA was 50%. Toxicity of adjuvant and salvage PUVA therapy was acceptable, with only two patients requiring a reduction in PUVA dosage.

CONCLUSION

PUVA can maintain remissions in patients with CTCL after TSEBT. There is a significant benefit in DFS but no statistically significant improvement in OS. Prospective, randomized data are needed to confirm these results. PUVA is also effective as a salvage therapy after TSEBT in early-stage patients with recurrence, with acceptable toxicity.

Interleukin-2 fusion protein: an investigational therapy for interleukin-2 receptor expressing malignancies

DAB389IL-2 is an interleukin-2 receptor (IL-2R) specific fusion protein with a molecular weight of 58 kD containing the enzymatic and translocation domains of diphtheria toxin (DT) and human IL-2. This fusion protein is able to direct the cytocidal action of the DT enzymatic region only to cells which bear the IL-2R. The human IL-2R exists in three forms: low, intermediate and high affinity. The high-affinity form is believed to be the biologically relevant form on mature, activated T-lymphocytes, B-lymphocytes and monocytes. DAB389IL-2 is able to bind selectively to the high-affinity IL-2R in a concentration-dependent manner, and once bound is internalised via receptor-mediated endocytosis. Upon acidification of the formed vesicle, the enzymatic portion of the fusion protein is believed to pass into the cytosol where it ultimately inhibits protein synthesis by inactivation of elongation factor-2, resulting in cell death. The constitutive expression of the IL-2R on certain leukaemic and lymphomatous cells of T and B cell origin has been reported to occur in patients with chronic lymphocytic leukaemia, cutaneous T cell lymphoma (CTCL), Hodgkin's disease and non-Hodgkin's lymphomas (NHLs). A multicentre DAB389IL-2 dose-escalation study of patients with IL-2R expressing lymphomas has been conducted. A 10-fold range of doses were evaluated on a five-daily dose schedule. Patients received up to six courses, with an additional two courses permitted for patients with partial responses that appeared to be still improving after six courses. Most adverse experiences were transient and mild. Preliminary assessment of response indicated five complete responses (CR, duration ongoing at 20, 11, 7, 5 and 4 months) and seven partial responses (PR, duration 3-20 months) in the 35 patients with CTCL. One CR (duration > 20 months) in a patient with NHL (Lennett's lymphoma) and two PR (duration 9 and 2 months) in 17 patients with B-cell NHL have been observed. Based on the mode of action of DAB389IL-2, its safety profile, and the patient responses associated with the phase I/II clinical trials, a phase III programme in CTCL patients has been initiated and plans for additional trials in NHL patients are targeted for 1996.

Management of cutaneous lymphoma

The foregoing underlines the advances which have been made in our understanding of cutaneous lymphoma and the areas where further research is needed. With a few noteable exceptions the aim of therapy in CTCL is palliative rather than curative and treatment success is measured in terms of disease-free interval. There is still no evidence that any chemotherapeutic regimen prolongs survival. A possible exception is the effect of photopheresis in Sézary syndrome but our own experience differs from that in the USA and underlines the need to identify patients with clonal disease when defining subjects for study. The combination of genotypic analysis and new treatment methods offers exciting new prospects in the management of patients with cutaneous lymphoma.

Non-Hodgkin's lymphomas (NHL)

This synthesis of the literature on radiotherapy for non-Hodgkin's lymphomas is based on 158 scientific articles, including 16 randomized studies, 18 prospective studies, and 90 retrospective studies. These studies involve 14,137 patients. Non-Hodgkin's lymphomas are highly radiosensitive, and local recurrence following radiotherapy is unusual. Radiotherapy probably cures approximately 50% of both low-grade and high-grade malignant NHL at stage I. Involved field is apparently sufficient, however, higher doses are required for high-grade malignant lymphomas. Chemotherapy is recommended for stage II. Consolidation radiotherapy after chemotherapy may increase the number of complete remissions. The value of adjuvant radiotherapy has not been confirmed. Radiotherapy plays a limited role at stages III and IV. Radiotherapy is clearly indicated for extranodal localized disease in the skin and in the orbit of the eye. It is important to identify groups and subgroups in whom radiotherapy alone is sufficient, ie, the risk for distant recurrence is small. MALT lymphoma belongs to this group. Radiotherapy is often valuable in palliative situations.

Extracorporeal photopheresis for the treatment of cutaneous T-cell lymphoma--the Düsseldorf and Munich experience

Extracorporeal photopheresis (ECP) using UVA irradiation of enriched lymphocytes in the presence of 8-methoxypsoralen as a photoactivatable substrate was originally introduced as a therapeutic regimen for cutaneous T-cell lymphoma (CTCL). Whereas ECP has previously been reported to be useful primarily for erythrodermic lymphoma, our purpose was to obtain data on safety and efficacy of ECP in patients suffering from different stages of CTCL. We report on 17 patients, 3 with erythroderma and 14 with plaque or tumor stages. In contrast to other studies our patients were treated predominantly with ECP alone; only a few patients received concomitant therapy. These data have not been published previously, except for preliminary data on four patients. Of the 17 patients, 12 (70%) responded to ECP. In seven patients at least 50% of skin lesions disappeared (defined as partial response) and in five patients at least 25% of skin lesions disappeared (defined as minor response). In two patients the disease remained stable and in three patients the disease progressed under the ECP treatment. No complete remission was observed. Partial responses were achieved not only in patients with early CTCL (stage Ib) but also in those with far progressed tumours (stage IVa). After treatment for 6 months partial responders showed an increase in the number of NK cells in their peripheral blood (P < 0.01). We cannot confirm a relationship between this treatment and CD8 cell counts, as reported by others. Overall, our results indicate that ECP is a safe and effective regimen for the treatment of all stages of CTCL.

Cytokine profile of tumor cells in mycosis fungoides: successful treatment with intra-lesional interferon-gamma combined with chemotherapy

Two cases of mycosis fungoides (MF) in the tumor stage were treated with intra-lesional interferon-gamma (IFN-gamma) therapy. After systemic chemotherapy, intra-lesional recombinant interferon-gamma was applied to the residual tumors. Intra-lesional IFN-gamma was sufficiently effective in the treatment of MF tumors, especially small-sized ones. Reverse transcriptase polymerase chain reaction (RT-PCR) analysis of messenger RNA expression of cytokines commonly detected interleukin-6 (IL-6) and IFN-gamma in the tumor cells before intra-lesional IFN-gamma. However, in our study, tumor cells in these cases did not exhibit the definitive cytokine patterns of Th1 or Th2.

Systemic chemotherapy and extracorporeal photochemotherapy for T3 and T4 cutaneous T-cell lymphoma patients who have achieved a complete response to total skin electron beam therapy

PURPOSE

To evaluate the impact of systemic adjuvant therapies on relapse-free (RFS) and overall survival (OS) of cutaneous T-cell lymphoma (CTCL) patients treated with total skin electron beam therapy (TSEBT).

METHODS AND MATERIALS

Between 1974 and 1990, TSEBT (36 Gy at 1 Gy/day; 9 weeks; 6 MeV electrons) was administered with curative intent to a total of 163 CTCL (mycosis fungoides) patients using six fields supplemented by orthovoltage boosts (120 kvp, 1 Gy x 20) to the perineum, soles of feet, and apical scalp (120 kvp, 2 Gy x 3). In this group, all patients who achieved a clinical complete response or a good partial response were offered one of two competing regimens of either adjuvant doxorubicin/cyclophosphamide or adjuvant extracorporeal photochemotherapy (ECP).

RESULTS

When the results for the group who achieved a complete response (CR) to TSEBT were analyzed, OS for T1 and T2 patients was excellent (85-90% at 5-10 years) and not improved by either adjuvant regimen. However, T3 and T4 patients who received either adjuvant doxorubicin/cyclophosphamide (75% at 3 years) or adjuvant ECP (100% at 3 years) had better overall survival than those who received neither adjuvant regimen (approximately 50% at 5 years). The difference between the OS curves for those who received ECP vs. those who received no adjuvant therapy approached statistical significance (p < 0.06), while a significant survival benefit from the addition of chemotherapy for TSEBT complete responders was not observed. Neither adjuvant therapy provided benefit with respect to relapse free survival after TSEBT.

CONCLUSIONS

These results suggest that an adjuvant nontoxic regimen of extracorporeal photochemotherapy may prolong survival in advanced stage CTCL patients who have achieved a complete remission after TSEBT. The combination of doxorubicin/cyclophosphamide had no significant impact on overall survival in those patients who achieved CR to TSEBT, and neither adjuvant therapy had an impact on relapse free survival for all T-stages. Such results are the basis for the current development of a prospective, randomized trial studying the impact of ECP after TSEBT in patients with advanced stage CTCL.

Extracorporeal photopheresis--a new approach for the treatment of cutaneous T cell lymphomas

Extracorporeal photochemotherapy (extracorporeal photopheresis, ECP) is going to become a new alternative in the treatment of cutaneous T cell lymphomas (CTCL), autoimmune disorders, and transplant rejections. After the first promising results in the treatment of CTCL reported in 1987 by Edelson et al. increasing numbers of CTCL patients in a growing number of ECP centers throughout the United States, Europe, and Japan have been successfully treated. Today, it seems that in particular Sézary's syndrome and the erythrodermic variant of mycosis fungoides (MF) respond very well to ECP. Compared to historical controls of MF with lymph node involvement, the median survival of the ECP-treated patients increased from 30 months to up to 60 months. It is our experience that the tumor stage of MF, however, cannot be treated with ECP alone, but is successfully controlled by combination regimens, for example with recombinant interferon alpha. CTCL patients heavily pretreated by polychemotherapy and severe endogenous or iatrogenic immunsuppression do not respond sufficiently and are not good candidates for ECP. The adverse reactions under ECP are well controlled and very low in number. In particular, general immunosuppression by ECP has not been reported so far.

Systemic treatment for cutaneous lymphomas

Primary malignant T cell lymphomas of the skin form a heterogenous group. Relevant classifications were recently made to separate different entities by various criteria. This is of great importance, because one should only rely on those therapeutical trials in which patients were included according such classifications. In this paper, we will mainly focus on therapeutic modalities for mycosis fungoides, which is the most frequent cutaneous T cell lymphoma and which may serve as a model disease. In principle, local (e.g., psoralens and ultraviolet A, PUVA) and systemic therapies (e.g., interferon-alpha 2a) can be applied. Very recently, we were able to demonstrate that even in initial stages of mycosis fungoides, the T cell clone is not restricted to the skin, but rather is present in low amounts in the peripheral blood. Therefore, systemic therapeutic modalities alone or in combination with local strategies (interferon-alpha 2a and acitretin/PUVA and interferon-alpha 2a) should be more effective, which will be proven by currently running clinical trials.

Combination therapy of cutaneous T cell lymphoma with interferon alpha-2a and photochemotherapy

The efficacy of a combination treatment with interferon alpha-2a and photochemotherapy was investigated in 16 patients with cutaneous T cell lymphoma. During the initial treatment, interferon alpha-2a was given subcutaneously at maximum dose of 9 million IU. Simultaneously, photo-chemotherapy with a maximum single dose of 3.0 J/cm2 was applied. After a complete or partial remission had been achieved, the dose of interferon was continued as permanent treatment at 3-9 million IU a week. Photochemotherapy was maintained twice a week for a minimum of 2 months and then stopped depending on the course of the disease. The combination treatment was well tolerated and all patients responded to the initial therapy. Three patients were withdrawn at an early stage of therapy, as they developed erythrodermia after photochemotherapy. The permanent treatment led to a complete remission in ten out of 13 patients and to a partial remission in three patients. During the follow-up period (now 10-40 months), therapy was stopped in four patients because of progression and in one patient because of newly diagnosed Hodgkin's disease. In another three patients, who developed local recurrences, a repetition of the initial treatment schedule was necessary to keep them in remission.

Impact of non-CTCL dermatologic diagnoses and adjuvant therapies on cutaneous T-cell lymphoma patients treated with total skin electron beam radiation therapy

PURPOSE

To evaluate the impact of pre-cutaneous T-cell lymphoma dermatologic diagnoses and adjuvant therapies on the relapse-free and overall survivals of patients treated with total skin electron beam therapy.

METHODS AND MATERIALS

Between 1974 and 1990, 164 patients were evaluated by members of Yale University School of Medicine departments of Dermatology and Therapeutic Radiology and treated with total skin electron beam therapy to a total dose of 3600 cGy. Patients who achieved a clinical complete response were offered doxorubicin/cyclophosphamide chemotherapy, extracorporeal photopheresis, or no systemic adjuvant therapy. The effects of TNM stage, antecedent non-T-cell lymphoma dermatologic diagnoses, and systemic adjuvant therapies were analyzed for their impact on relapse-free and overall survival.

RESULTS

In this cohort of patients, an antecedent dermatologic diagnosis of follicular mucinosis or lymphomatoid papulosis was significantly associated with a shorter relapse-free survival for T1 and T2 patients, while antecedent "non-specific" dermatitides were associated with a somewhat better relapse-free survival. When the impact of systemic adjuvant therapies was analyzed, neither systemic doxorubicin/cyclophosphamide chemotherapy nor systemic extracorporeal photopheresis were found to delay cutaneous relapse.

CONCLUSION

Our results suggest that antecedent follicular mucinosis and lymphomatoid papulosis may be associated with short relapse-free survival in T1 and T2 patients treated with total skin electron beam therapy. They also imply that neither adjuvant chemotherapy nor extracorporeal photopheresis delay cutaneous relapse after total skin electron beam therapy.

Interferon treatment of cutaneous T-cell lymphoma

In this report we have reviewed studies on the clinical effect of the interferon (IFN) treatment of 304 patients suffering from cutaneous T-cell lymphoma (CTCL). Intramuscular, subcutaneous or intralesional administration of recombinant IFN has been used as monotherapy or as part of combination therapy. In general, IFN has proved to be a relatively effective agent in the treatment of CTCL, and the best responses have been achieved in the early stages of the disease. In CTCL the overall response rate to IFN including complete, partial and minor responses is 70%. Neither the doses nor the routes of administration in these studies has any statistically significant influence on the clinical response to IFN treatment. Continuous low-dose IFN therapy, presumably in combination with psoralen and UVA light (PUVA), is recommended. This review concludes that the clinical stage of disease before treatment is the only known predictive parameter concerning the clinical response to IFN treatment in patients with CTCL.

Home UV phototherapy of early mycosis fungoides: long-term follow-up observations in thirty-one patients

BACKGROUND

In 1982 we reported our preliminary observations on the use of home UV phototherapy for patch and early plaque phase mycosis fungoides (MF).

OBJECTIVE

Our purpose was to present follow-up data of the original 31 patients, covering an interval of up to 15 years.

METHODS

All patients used a commercially available UV phototherapy unit that contained four Westinghouse FS40 fluorescent lamps for daily exposures of their non-sun-exposed skin regions.

RESULTS

A complete clinical and histologic response to home phototherapy occurred in 23 patients (74%) with a maximum duration of the response from 5 months to more than 15 years (median 51 months). After maintenance phototherapy was discontinued, seven patients (23%) had a sustained disease-free interval lasting more than 58 months (median > 90 months). This indicates that cure may have been achieved in a minority of patients. Phototherapy was well tolerated without evidence of significant photodamage or photocarcinogenicity.

CONCLUSION

These observations indicate that home phototherapy may be a therapeutic option for treatment of selected patients with early MF.