Proceedings of the International Consensus Conference on Cutaneous T-cell Lymphoma (CTCL) Treatment Recommendations. Boston, Massachusetts, Oct. 1 and 2, 1994

Granulomatous slack skin disease: a review, in comparison with mycosis fungoides

Granulomatous slack skin (GSS) is a rare cutaneous disorder characterized by the evolution of circumscribed erythematous loose skin masses, especially in the body folds, and histologically by a loss of elastic fibers and granulomatous T-cell infiltrates. This disease is often associated with preceding or successive lymphoproliferative malignancies, especially Mycosis Fungoides (MF) and Hodgkin's Disease (HD). Whether Granulomatous Slack Skin Disease is a benign disorder, an unusual host reaction or a precursor of malignant lymphoma or an indolent Cutaneous T-cell Lymphoma (CTCL) in itself, is still a controversy. This article reviews its literature on the etiology, clinical findings, and treatment of Granulomatous Slack Skin Disease. It also concentrates on its association with Hodgkin's disease and its comparison with Mycosis Fungoides and Sezary Syndrome.

Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis

The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. Beginning with the 2007 ASFA Special Issue (fourth edition), the subcommittee has incorporated systematic review and evidence-based approach in the grading and categorization of indications. This Fifth ASFA Special Issue has further improved the process of using evidence-based medicine in the recommendations by refining the category definitions and by adding a grade of recommendation based on widely accepted GRADE system. The concept of a fact sheet was introduced in the Fourth edition and is only slightly modified in this current edition. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. The article consists of 59 fact sheets devoted to each disease entity currently categorized by the ASFA as category I through III. Category IV indications are also listed.

Emerging drugs in cutaneous T cell lymphoma

BACKGROUND

Mycosis fungoides (MF) represents the most common type of primary cutaneous T cell-lymphomas (CTCL), which are characterized by a clonally proliferation of malignant CD4+ lymphocytes in the skin.

OBJECTIVE

Skin-directed treatment regimens, like phototherapy and corticosteroids, are commonly used in early stages; systemic treatments and chemotherapies are used in advanced stages. Because conventional treatments usually end in a transient remission without curative results, there is a high need for new therapeutic strategies with acceptable side effects.

METHODS

Literature and reference research was done by using the data bank PubMed, and updates of ongoing studies were taken out of ASCO and ASH annual meeting abstracts.

RESULTS/CONCLUSIONS

This article gives an overview of the various medications in current use, with emphasis on emerging drugs with novel therapeutic targets.

Review of extracorporeal photopheresis in early-stage (IA, IB, and IIA) cutaneous T-cell lymphoma

BACKGROUND

Extracorporeal photopheresis (ECP) has been used for nearly 20 years for the treatment of cutaneous T-cell lymphoma (CTCL). A substantial body of literature reports that this form of photoimmunotherapy improves or stabilizes the course of disease in a subset of patients across all stages. However, current clinical approach usually reserves ECP for patients who do not respond to other treatments or for patients with late-stage disease or Sézary syndrome (SS).

METHODS

A comprehensive Pubmed/Medline literature search was performed to identify studies reporting the use and efficacy of ECP in early stage (IA, IB, and IIA) CTCL. Information regarding prognostic factors and survival of early-stage patients treated with ECP was also obtained and summarized.

RESULTS

The heterogenous nature of the reports and lack of any prospective randomized trials made evaluation of response to treatment difficult. However, the current literature contains at least 124 early-stage patients treated with ECP or ECP plus adjuvant therapy from 1987-2007 in 16 different reports. Response rates of treatment for this patient population with ECP and ECP plus adjuvant therapy varied from 33-88%.

CONCLUSIONS

Given the very low side effect profile of ECP compared with other therapies and its demonstrated efficacy, this treatment modality is possibly beneficial for patients with earlier stages of CTCL. Randomized prospective studies are needed to establish the role of ECP in this disease subset.

Expression of proliferation markers and cell cycle regulators in T cell lymphoproliferative skin disorders

BACKGROUND

Abnormal cell proliferation, which results from deregulation of the cell cycle, is fundamental in tumorigenesis.

OBJECTIVES

To investigate the expression of proliferation markers and cell cycle regulators in a range of T cell lymphoproliferative skin diseases.

METHODS

We studied skin specimens of 51 patients with parapsoriasis (PP), mycosis fungiodes (MF), or lymphomatoid papulosis (LyP). Immunohistochemistry was performed for Ki-67, proliferating cell nuclear antigen (PCNA), minichromosome maintenance protein 7 (MCM7), and p21.

RESULTS

MF with stage IIB-IV and LyP showed a significantly greater number of Ki-67-positive cells than PP (P=0.02 and 0.001) and MF I-IIA (P=0.019 and 0.003), respectively. MCM7 staining revealed significantly higher labeling indices for MF IIB-IV and LyP when compared to PP (P=0.002 and 0.04) and MF I-IIA (P=0.0005 and 0.01), respectively. Compared to PP and MF I-IIA, MF IIB-IV was associated with significantly higher labeling indices for PCNA (P=0.006 and 0.0004). p21 staining was significantly increased in MF IIB-IV and LyP when compared to PP (P=0.006 and 0.003) and MF I-IIA (P=0.003). However, p21 staining was all in all very weak.

CONCLUSIONS

Ki-67 and PCNA seem to be useful immunohistological parameters for the correlation with the clinical stage of MF. In the differentiation and prognostication of T cell lymphoproliferative skin disorders, MCM7 may serve as a novel biomarker which is, in contrast to Ki-67 and PCNA, stable throughout the cell cycle.

Guidelines on the use of therapeutic apheresis in clinical practice—Evidence-based approach from the apheresis applications committee of the American society for apheresis

The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. This elaborate process had been undertaken every 7 years resulting in three prior publications in 1986, 1993, and 2000 of "The ASFA Special Issues." This article is the integral part of the Fourth ASFA Special Issue. The Fourth ASFA Special Issue is significantly modified in comparison to the previous editions. A new concept of a fact sheet has been introduced. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. A detailed description of the fact sheet is provided. The article consists of 53 fact sheets devoted to each disease entity currently categorized by the ASFA. Categories I, II, and III are defined as previously in the Third Special Issue. However, a few new therapeutic apheresis modalities, not yet approved in the United States or are currently in clinical trials, have been assigned category P (pending) by the ASFA Clinical Categories Subcommittee. The diseases assigned to category IV are discussed in a separate article in this issue.

Management of refractory early-stage cutaneous T-cell lymphoma

Cutaneous T-cell lymphoma (CTCL) is a heterogeneous group of non-Hodgkin's lymphomas that manifest primarily in the skin. Mycosis fungoides is recognized as the most common type of CTCL. Patients with early-stage CTCL usually have a benign and chronic disease course. However, although there is a wide array of therapeutic options for early-stage CTCL, not all patients respond to these individual therapies, resulting in refractory cutaneous disease over time. Refractory early-stage CTCL poses an important therapeutic challenge, as one of the principal treatment goals is to keep the disease confined to the skin, thereby preventing disease progression. Much of the focus of current research has been on the evaluation of already available skin-directed therapies and biologic response modifiers and combination regimens thereof, such as the combination of psoralen and UVA (PUVA) with interferon-alpha or retinoids. Recent novel developments include oral bexarotene, a retinoid X receptor-selective retinoid that has activity in all stages of CTCL and has been shown to be effective in patients with refractory early-stage disease as well as advanced-stage disease. Likewise, the topical gel formulation of bexarotene has proved to be an important therapeutic option in patients with refractory or relapsed lesions. Oral bexarotene and topical bexarotene have been approved by the US FDA for the treatment of refractory CTCL. Systemic chemotherapy is typically reserved for advanced-stage CTCL and is usually not recommended for early-stage, skin-limited disease. However, recent exploratory studies indicate that low-dose methotrexate may represent an overall well tolerated therapy in a subset of patients with refractory early-stage CTCL, as may pegylated liposomal doxorubicin, which is currently being investigated in this specific clinical setting. Another recently FDA-approved therapy is the interleukin-2 fusion toxin denileukin diftitox, which is now well established to play a role in the treatment of refractory CTCL, including early-stage extensive plaque disease. The value of other agents, such as topical tazarotene, topical methotrexate, and topical imiquimod, and of novel immunomodulatory approaches including monoclonal antibodies, still needs to be assessed for refractory early-stage CTCL.

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.

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.

Topical bexarotene therapy for patients with refractory or persistent early-stage cutaneous T-cell lymphoma: results of the phase III clinical trial

OBJECTIVES

We sought to determine the safety and efficacy of topical bexarotene (Targretin; Ligand Pharmaceuticals, La Jolla, Calif) gel 1% in patients with refractory or persistent early-stage cutaneous T-cell lymphoma.

METHODS

We conducted a multinational, open-label, phase III study of 50 patients with stage IA to IIA cutaneous T-cell lymphoma. The primary end point classification was the overall complete and partial response rate by the higher of 2 measures: the Physician's Global Assessment of Clinical Condition or the Composite Assessment of Index Lesion Disease Severity.

RESULTS

The overall response rates for the Physician's Global Assessment of Clinical Condition, Composite Assessment of Index Lesion Disease Severity, and primary end point classification were 44%, 46%, and 54%, respectively. The most common adverse events possibly related to study medication were mild to moderate irritant dermatitis, pruritus, pain (ie, primarily burning at application site), and skin disorder (eg, skin inflammation, excoriation, and new lesions). There were no serious treatment-related adverse events.

CONCLUSIONS

Topical bexarotene gel was generally well tolerated and demonstrated substantial efficacy in patients with refractory or persistent early-stage cutaneous T-cell lymphoma.

Viral infection, atopy and mycosis fungoides: a European multicentre case-control study

Mycosis fungoides (MF) is a rare disease with an unknown aetiology, although it has been suggested that infections may play a role. The present study investigates whether infections, atopic disorders and some other diseases are risk indicators for MF. A European multicentre case-control study involving seven rare cancers, including MF, was conducted from 1995 to 1998. Patients between 35 and 69 years of age diagnosed with MF (n = 140) were recruited, and the diagnoses were verified by a reference pathologist, who classified 83 cases as definitive and 35 cases as possible; 22 cases were not accepted. Of the 118 accepted cases, 104 patients were interviewed (including 76 definitive cases and 28 possible cases). These 76 definitive cases were used for this study. A common set of controls to serve all case groups were interviewed, representing a total of 4574 controls. The latter included 1008 colon cancer patients and 3566 subjects selected from population registers. Information on infections, skin pathology and clinical history 5 years before the diagnosis of MF was used to estimate odds ratios (ORs) derived from logistic regression-modelling, which included gender, age and country. The highest ORs for MF were found in patients who reported a history of psoriasis 5 years before MF was diagnosed (OR 7.2, 95% CI: 3.6-14.5). Urticaria had an OR of 1.4 (95% CI: 0.6-3.6). Infections and atopic diseases were not closely associated with MF. Some diseases correlated to MF. Whether this has a causal background or reflects early diagnostic uncertainty is not known.

Extracorporeal photochemotherapy--the Columbia Presbyterian experience

BACKGROUND

Cutaneous T Cell Lymphoma (CTCL) is a lymphoma of skin homing usually CD4 + lymphocytes. There are numerous treatments available both for the early as well as the more advanced stages of the disease. Extracorporeal photochemotherapy is a well-accepted form of treating CTCL. The purpose of our study was to review the experience of treating 20 CTCL patients with extracorporeal photochemotherapy (ECP) at Columbia Presbyterian Medical Center over a seven-year period.

METHODS

The study was conducted as a retrospective chart review of these 20 patients. Summarized demographic characteristics included age at diagnosis, gender, and race. We analyzed the overall response by categorizing patients as having complete response, partial response, stable disease, and progressive disease. We also analysed the predictive value for three factors: peripheral blood CD4 : CD8 (< 10, > 10), LDH level (normal, elevated), and erythrodermic status (erythrodermic or nonerythrodermic). The potential prognostic variables were evaluated for linear association with response using Mantel-Haenszel chi-square tests. All statistical tests were two-sided with alpha = 0.05. The tests were considered to be exploratory and no adjustments for multiple testing were made.

RESULTS

There was a significant linear association between response and CD4 : CD8. Patients with a ratio < 10 were more likely to respond than patients with a ratio > 10. There was a marginally significant linear association between response and LDH level. Patients whose LDH was not elevated at the start of treatment, tended to have a better response to ECP compared to patients with an elevated LDH. There was a suggestion of an association between erythroderma and response although this was not statistically significant. The majority of patients with erythroderma were responders compared to the majority of non-erythrodermic patients who were non-responders. The treatment was well tolerated with minimal side-effects.

CONCLUSION

Apparent predictors of good response to ECP include erythroderma, a relatively low (closer to normal) peripheral CD4 : CD8, and a normal LDH. This report confirms reports from other institutions indicating that CTCL patients who are erythrodermic with a relatively intact immune system are optimal candidates for ECP.

Mycosis fungoides palmaris et plantaris or acral pagetoid reticulosis?

There has been ongoing debate about the nature of Woringer-Kolopp disease (unilesional pagetoid reticulosis). Despite the histologic resemblance to mycosis fungoides, these lesions are typically solitary and indolent. Recently, cutaneous plaques of epidermotropic lymphocytes restricted to acral sites resembling Woringer-Kolopp disease were reported to show T-cell clonality, leading to the designation mycosis fungoides palmaris et plantaris. We describe a similar case of recurrent plaques on palms and soles of a 45-year-old man that persisted for >14 years without other cutaneous or systemic disease. Histologically, the lesions were comprised of epidermotropic atypical lymphocytes with sparse dermal infiltrates. Immunohistochemically, the majority of intraepidermal lymphocytes labeled as CD8-positive suppressor/cytotoxic T cells and expressed alphaE beta7 (CD103), an integrin associated with epitheliotropism. Polymerase chain reaction studies revealed similar clonal gene rearrangements of T-cell receptors beta and gamma in tissue from both palm and sole. In view of these findings, the diagnosis of mycosis fungoides palmaris et plantaris may be appropriate. To date, however, the lesions have remained localized and continue to resolve spontaneously. As such, the behavior is similar to what has been described as pagetoid reticulosis. Long-term follow-up will be necessary to determine the biologic potential of this disease.