Management of cutaneous lymphoma

[The history of lymphoma classifications with special consideration of cutaneous lymphomas]

For modern evidence-based medicine, classification systems are necessary to guarantee a uniform approach for therapy and for estimating prognosis. The comparability of clinical studies and international communication require a common language and are only possible with modern international classification systems. But because all classifications are artificial, they only mirror the current state of knowledge and may change dramatically over decades. This review discusses the history of lymphoma classifications systems with a special focus on the topic of primary cutaneous lymphomas, emphasizing special problems in terminology.

Primary cutaneous T-cell-rich B-cell lymphoma in a zosteriform distribution associated with Epstein-Barr virus infection

T-cell-rich B-cell lymphoma (TRBL) is a lately recognized B-cell lymphoma variant characterized by a minor population of neoplastic B cells existing in a background of predominant polyclonal T cells. We report an 86-year-old man with primary cutaneous TRBL associated with Epstein-Barr (EB) virus infection. Clinically, palpable scaly erythemas were distributed in a zosteriform pattern on the right abdomen. Histologically, massive cellular infiltrates were located in the upper- and mid-dermis. Higher magnification showed that the cellular infiltration was composed mainly of abnormal mononuclear, large lymphoid cells with clear cytoplasm and scattered mitoses and small lymphocytes, which represented in excess of 75% of all the infiltrating cells. Immunohistochemical staining revealed that the large cells were positive for the B cell marker, CD20, but negative for the T cell marker, CD3. On the other hand, the small cells were positive for CD3, but negative for CD20. Polymerase chain reaction (PCR) revealed EB virus DNA in the skin lesion. Primary cutaneous TRBL has only been reported in 15 cases worldwide. To our knowledge, this is the first case of primary cutaneous TRBL in a zosteriform distribution reported in the literature and the second case of primary cutaneous TRBL associated with the EB virus infection. We postulate that the EB virus may be a contributory pathogenetic event leading to monoclonal B-cell proliferation.

Autologous peripheral blood stem cell transplantation in tumor-stage mycosis fungoides: predictors of disease-free survival

Nine patients with mycosis fungoides (age range 27-67) underwent autologous peripheral blood stem cell transplantation (PBSCT). All patients had tumor-stage disease, and four had lymph node involvement. Eight patients exhibited a peripheral blood T cell clone using PCR/SSCP analysis of the TCR gamma gene, six prior to harvest and two at the time of harvest. Mobilization of CD34+ stem cells was achieved with etoposide and G-CSF. Harvested cells were positively selected for CD34. After negative selection for CD4 and CD8, only two samples became PCR negative. Conditioning prior to reinfusion of stem cells was achieved with various combinations of total skin electron beam (TSEB), total body irradiation (TBI), and chemotherapy, depending upon the patient's prior exposure to radiotherapy. One patient failed to engraft and died of candidal septicemia 15 days posttransplant. The other eight patients achieved complete remission, but this was short-lived in four (median disease-free survival [DFS] = 2 months) and prolonged in three (median DFS 11 months). Those with a short DFS were distinguished by rapid tumor onset prior to transplant but not by stage at transplant. Loss of a detectable T cell clone after manipulation of the harvest did not discriminate between the two groups, but rapid relapsers had been subjected to a greater degree of T cell depletion, possibly indicating a compromised cytotoxic response post-PBSCT. The median survival of the cohort is four years from tumor onset, 15 months from PBSCT, and 27 months from the date a peripheral blood clone was first detected in the presence of tumor-stage disease. Rapid relapse was associated with poor overall survival. Our data demonstrate the value of PBSCT for inducing remission in tumor-stage mycosis fungoides. Reinfusion of neoplastic cells could be avoided by harvesting stem cells at an earlier stage in the disease process, preferably before a T cell clone is detectable in the peripheral blood. Alternatively T cell depletion should be restricted to the CD4 subset.

Rituximab in cutaneous B-cell lymphoma: a report of two cases

We report two patients with primary cutaneous B-cell lymphoma who were treated with rituximab, a new anti-CD20 monoclonal antibody. The first patient, who had a diffuse large B-cell lymphoma of the lower leg, achieved an 85% improvement. The second patient, who had a primary cutaneous B-cell lymphoma, which had undergone high-grade transformation and systemic spread, achieved a minor response of approximately 30%. Both patients subsequently relapsed. The first patient achieved complete clearance with a second course of rituximab given with systemic chemotherapy, but again relapsed. Treatment with rituximab has been reported to produce response rates of 48% in relapsed systemic low-grade or follicular lymphoma, but there are no previous reports of the use of rituximab in primary cutaneous B-cell lymphoma.

Pentostatin in T-cell malignancies--a phase II trial of the EORTC. Leukemia Cooperative Group

PURPOSE

Within this phase II EORTC trial, we have investigated the safety and efficacy of pentostatin in lymphoid malignancies. We have previously reported the results in T- and B-cell prolymphocytic leukemia, B-cell chronic lymphocytic leukemia (B-CLL) and hairy cell leukemia. This report focuses on the outcome in T-cell malignancies: T-CLL, Sézary syndrome (Sézary), mycosis fungoides (MF) and T-zone lymphoma (TZL).

PATIENTS AND METHODS

Of the 92 patients with these diagnoses enrolled, 76 were evaluable for response and toxicity, i.e., 25 of 28 with T-CLL, 21 of 26 with Sézary, 22 of 26 with MF, and 8 of 12 with TZL. All patients had progressive and advanced disease. Pentostatin was administered at a dosage of 4 mg/m2 every week for the first 3 weeks, then 4 mg/m2 every 14 days for another 6 weeks, followed by maintenance therapy of 4 mg/m2 monthly for a maximum of 6 months.

RESULTS

Response rates (complete and partial responses) in patients with Sézary (n = 22) or MF (n = 21) were 33% and 23%, respectively, and in patients with T-CLL (n = 21) or TZL (n = 8) 8% and 25%, respectively. Sixteen (21%) patients died during the first ten weeks of treatment: twelve of progressive disease, two of infectious complications with progressive disease, one of myocard infarction and one of renal failure related to administration of i.v. contrast. Major toxicity (grade 3-4) included infection in 11% of patients, nausea/vomiting in 4%, diarrhea in 3%. Hematologic toxicity was mild to non-existent.

CONCLUSIONS

We conclude that pentostatin is active in Sézary and MF but showed marginal activity in T-CLL or TZL. Toxicities are mild to moderate at the dose schedule administered. Due to its relatively specific lympholytic effect and its favorable toxicity spectrum, pentostatin might be especially useful for the palliative treatment of T-cell malignancies.