1
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Lee H. Mycosis fungoides and Sézary syndrome. Blood Res 2023; 58:66-82. [PMID: 37105561 PMCID: PMC10133849 DOI: 10.5045/br.2023.2023023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Mycosis fungoides (MF) and Sézary syndrome (SS) are a distinct disease entity of cutaneous T-cell lymphoma with heterogenous clinical features and prognosis. MF mainly involves skin and usually shows an indolent and favorable clinical course. In patients with advanced-stage disease, extracutaneous involvement including lymph nodes, viscera, and blood, or large cell transformation may be observed. SS is a leukemic form of advanced-stage MF, characterized by generalized erythroderma. Early-stage MF can be treated with skin-directed therapy. However, patients with refractory or advanced-stage disease are associated with severe symptoms or poor prognosis, requiring systemic therapy. Recent progress in understanding the pathogenesis of MF/SS has contributed to advances in the management of these rare diseases. This review aims to describe the clinical manifestations, diagnosis, risk stratification, and treatment strategy of MF/SS, focusing on the recent updates in the management of these diseases.
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Affiliation(s)
- Hyewon Lee
- Division of Hemato-Oncology, Department of Internal Medicine, and Center for Hematologic Malignancy, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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2
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Hristov AC, Tejasvi T, Wilcox RA. Cutaneous T-cell lymphomas: 2023 update on diagnosis, risk-stratification, and management. Am J Hematol 2023; 98:193-209. [PMID: 36226409 PMCID: PMC9772153 DOI: 10.1002/ajh.26760] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 02/04/2023]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell neoplasms involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or the blood involvement are generally approached with systemic therapies, including biologic-response modifiers, histone deacetylase inhibitors, or antibody-based strategies, in an escalating fashion. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Alexandra C. Hristov
- Departments of Pathology and Dermatology, 2800 Plymouth Road, Building 35, Ann Arbor, MI 48109-2800
| | - Trilokraj Tejasvi
- Department of Dermatology, 1910 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Ryan A. Wilcox
- Correspondence to: Ryan Wilcox, MD, PhD, Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, 1500 E. Medical Center Drive, Room 4310 CC, Ann Arbor, MI 48109-5948, Phone: (734) 615-9799, Fax: (734) 936-7376,
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3
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Gökşin Ş, İmren IG, Cenk H, Kaçar N, Duygulu Ş. The Use of Interferon‐α2a as Monotherapy in Stage
IB
Patients with Mycosis Fungoides: A Retrospective Chart Review of Patient Outcomes. Dermatol Ther 2022; 35:e15344. [DOI: 10.1111/dth.15344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/28/2021] [Accepted: 01/27/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Şule Gökşin
- Pamukkale University Medical Faculty, Dermatology Department Denizli
| | - Işıl Göğem İmren
- Pamukkale University Medical Faculty, Dermatology Department Denizli
| | - Hülya Cenk
- Pamukkale University Medical Faculty, Dermatology Department Denizli
| | - Nida Kaçar
- Pamukkale University Medical Faculty, Dermatology Department Denizli
| | - Şeniz Duygulu
- Pamukkale University Medical Faculty, Dermatology Department Denizli
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4
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STING Signaling and Skin Cancers. Cancers (Basel) 2021; 13:cancers13225603. [PMID: 34830754 PMCID: PMC8615888 DOI: 10.3390/cancers13225603] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/03/2021] [Accepted: 11/08/2021] [Indexed: 12/15/2022] Open
Abstract
Recent developments in immunotherapy against malignancies overcome the disadvantages of traditional systemic treatments; however, this immune checkpoint treatment is not perfect and cannot obtain a satisfactory clinical outcome in all cases. Therefore, an additional therapeutic option for malignancy is needed in oncology. Stimulator of interferon genes (STING) has recently been highlighted as a strong type I interferon driver and shows anti-tumor immunity against various malignancies. STING-targeted anti-tumor immunotherapy is expected to enhance the anti-tumor effects and clinical outcomes of immunotherapy against malignancies. In this review, we focus on recent advancements in the knowledge gained from research on STING signaling in skin cancers. In addition to the limitations of STING-targeted immunotherapy, we also discuss the clinical application of STING agonists in the treatment of skin cancer.
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5
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Hristov AC, Tejasvi T, Wilcox RA. Cutaneous T-cell lymphomas: 2021 update on diagnosis, risk-stratification, and management. Am J Hematol 2021; 96:1313-1328. [PMID: 34297414 PMCID: PMC8486344 DOI: 10.1002/ajh.26299] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 11/08/2022]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell neoplasms involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multi-disciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or blood involvement are generally approached with systemic therapies, including biologic-response modifiers, histone deacetylase inhibitors, or antibody-based strategies, in an escalating fashion. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Alexandra C. Hristov
- Departments of Pathology and Dermatology, North Campus Research Complex, Ann Arbor, Michigan, USA
| | - Trilokraj Tejasvi
- Director Cutaneous Lymphoma program, Department of Dermatology, A. Alfred Taubman Health Care Center, Ann Arbor, Michigan, USA
| | - Ryan A. Wilcox
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, USA
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6
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Brumfiel CM, Patel MH, Puri P, Besch-Stokes J, Lester S, Rule WG, Khera N, Sluzevich JC, DiCaudo DJ, Comfere N, Bennani NN, Rosenthal AC, Pittelkow MR, Mangold AR. How to Sequence Therapies in Mycosis Fungoides. Curr Treat Options Oncol 2021; 22:101. [PMID: 34570278 DOI: 10.1007/s11864-021-00899-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT Choice of therapy in mycosis fungoides is based on both patient- and lymphoma-specific factors, such as disease characteristics, comorbidities, symptoms and effect on quality of life, potential associated toxicities of therapy, response and tolerance to prior lines of therapy, and convenience and practicality. Generally, we sequence therapies from least toxic, targeted, nonimmunosuppressive to more toxic, immunosuppressive and from single agent to multiple agents, as necessary. If more toxic, immunosuppressive agents are required to alleviate disease burden or symptoms, we generally use them just long enough to control the disease, then transition to a maintenance regimen with less toxic, less immunosuppressive agents.
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Affiliation(s)
- Caitlin M Brumfiel
- Department of Dermatology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Meera H Patel
- Department of Dermatology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Pranav Puri
- Department of Dermatology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Jake Besch-Stokes
- Department of Dermatology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Scott Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Nandita Khera
- Division of Hematology Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - David J DiCaudo
- Department of Dermatology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Nneka Comfere
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - N Nora Bennani
- Division of Hematology Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Mark R Pittelkow
- Department of Dermatology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Aaron R Mangold
- Department of Dermatology, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ, 85259, USA.
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7
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Sanches JA, Cury-Martins J, Abreu RM, Miyashiro D, Pereira J. Mycosis fungoides and Sézary syndrome: focus on the current treatment scenario. An Bras Dermatol 2021; 96:458-471. [PMID: 34053802 PMCID: PMC8245718 DOI: 10.1016/j.abd.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/23/2020] [Accepted: 12/06/2020] [Indexed: 11/28/2022] Open
Abstract
Cutaneous T-cell lymphomas are a heterogeneous group of lymphoproliferative disorders, characterized by infiltration of the skin by mature malignant T cells. Mycosis fungoides is the most common form of cutaneous T-cell lymphoma, accounting for more than 60% of cases. Mycosis fungoides in the early-stage is generally an indolent disease, progressing slowly from some patches or plaques to more widespread skin involvement. However, 20% to 25% of patients progress to advanced stages, with the development of skin tumors, extracutaneous spread and poor prognosis. Treatment modalities can be divided into two groups: skin-directed therapies and systemic therapies. Therapies targeting the skin include topical agents, phototherapy and radiotherapy. Systemic therapies include biological response modifiers, immunotherapies and chemotherapeutic agents. For early-stage mycosis fungoides, skin-directed therapies are preferred, to control the disease, improve symptoms and quality of life. When refractory or in advanced-stage disease, systemic treatment is necessary. In this article, the authors present a compilation of current treatment options for mycosis fungoides and Sézary syndrome.
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Affiliation(s)
- José Antonio Sanches
- Dermatology Clinic Division, Faculty of Medicine, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Jade Cury-Martins
- Dermatology Clinic Division, Faculty of Medicine, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Denis Miyashiro
- Dermatology Clinic Division, Faculty of Medicine, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Juliana Pereira
- Hematology Clinic Division, Faculty of Medicine, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
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8
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Kamijo H, Miyagaki T. Mycosis Fungoides and Sézary Syndrome: Updates and Review of Current Therapy. Curr Treat Options Oncol 2021; 22:10. [PMID: 33415447 DOI: 10.1007/s11864-020-00809-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT While most patients with early-stage mycosis fungoides (MF) follow an indolent course, patients with advanced-stage MF/Sézary syndrome (SS) have a poor prognosis with a median survival of less than 5 years. Although there are a number of treatments currently available, achieving and maintaining a durable response remain challenging, especially in advanced-stage MF/SS. The choice of frontline therapy is dependent on the stage of disease. For early-stage MF, the treatment concept is to control skin lesions mainly by skin-directed therapies, such as topical therapies, phototherapies, and radiotherapies. For advanced-stage MF/SS, systemic treatments by biological or targeted therapies including bexarotene and interferon either alone or in combination are tried first, with more immunosuppressive chemotherapies being reserved for refractory or rapidly progressive disease. Recent improvements in biological or targeted therapies include brentuximab vedotin and mogamulizumab. When biopsy samples have 10% or more CD30-positive malignant cells, brentuximab vedotin, an anti-CD30 antibody conjugated to monomethyl auristin E, can be a desirable treatment option. For cases with blood involvement, mogamulizumab, an antibody binding to C-C chemokine receptor 4, is effective with high response rates. In the refractory setting, alemtuzumab, histone deacetylase inhibitors, pralatrexate, gemcitabine, and doxorubicin are considered as the treatment option. Because only allogeneic hematopoietic stem cell transplantation can offer a chance of cure with durable complete remission, advanced-stage patients with a markedly short life expectancy should be evaluated for eligibility. Given that there are few randomized controlled studies in the literature, it is necessary to investigate which therapy is preferable for each patient with MF/SS by comparative prospective trials.
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Affiliation(s)
- Hiroaki Kamijo
- Department of Dermatology, University of Tokyo Graduate School of Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Tomomitsu Miyagaki
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
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9
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Ohtsuka M, Hamada T, Miyagaki T, Shimauchi T, Yonekura K, Kiyohara E, Fujita H, Izutsu K, Okuma K, Kawai K, Koga H, Sugaya M. Outlines of the Japanese guidelines for the management of primary cutaneous lymphomas 2020. J Dermatol 2020; 48:e49-e71. [PMID: 33245165 DOI: 10.1111/1346-8138.15707] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 10/31/2020] [Indexed: 01/06/2023]
Abstract
Since the publication of the Japanese "Guidelines for the management of cutaneous lymphomas" in 2011, the World Health Organization (WHO) classification of hematolymphoid neoplasms and the WHO-European Organisation for Research and Treatment of Cancer classification for primary cutaneous lymphomas were updated and a number of novel systemic drugs for cutaneous T-cell lymphoma had been approved in Japan. In 2020, we revised the Japanese guidelines for the management of cutaneous lymphomas with consideration of the recent advances in the understanding of the pathophysiology and classification of cutaneous lymphomas together with the update of treatment strategies reflecting the advent of novel drugs. In addition to a brief explanation of epidemiology, diagnosis, staging system, prognosis and management of each subtype of cutaneous lymphomas, the recommendations for nine clinical questions regarding treatment options that can vary even among experts are also described. A systematic review process and determination of recommendations in answer to each clinical question have been performed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation scheme by a multidisciplinary expert panel consisting of dermatologists, a hematologist and a radiation oncologist. In this article, we present the outlines of the revised Japanese "Guidelines for the management of cutaneous lymphomas".
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Affiliation(s)
- Mikio Ohtsuka
- Department of Dermatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Toshihisa Hamada
- Department of Dermatology, Takamatsu Red Cross Hospital, Takamatsu, Japan
| | - Tomomitsu Miyagaki
- Department of Dermatology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Takatoshi Shimauchi
- Department of Dermatology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kentaro Yonekura
- Department of Dermatology, Imamura General Hospital, Kagoshima, Japan
| | - Eiji Kiyohara
- Department of Dermatology, Osaka University School of Medicine, Suita, Japan
| | - Hideki Fujita
- Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Koji Izutsu
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuhiro Kawai
- Department of Dermatology, Kido Hospital, Niigata, Japan
| | - Hiroshi Koga
- Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Makoto Sugaya
- Department of Dermatology, International University of Health and Welfare, Narita, Japan
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10
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Hristov AC, Tejasvi T, Wilcox RA. Mycosis fungoides and Sézary syndrome: 2019 update on diagnosis, risk-stratification, and management. Am J Hematol 2019; 94:1027-1041. [PMID: 31313347 DOI: 10.1002/ajh.25577] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 01/04/2023]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas (CTCL) are a heterogenous group of T-cell neoplasms involving the skin, the majority of which may be classified as Mycosis fungoides (MF) or Sézary syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multi-disciplinary approach to treatment. For patients with disease limited to the skin, skin-directed therapies are preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or blood involvement are generally approached with systemic therapies. These include biologic-response modifiers, histone deacetylase (HDAC) inhibitors, or antibody-based strategies, in an escalating fashion. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Alexandra C. Hristov
- Departments of Pathology and DermatologyUniversity of Michigan Ann Arbor Michigan
| | | | - Ryan A. Wilcox
- Division of Hematology/Oncology, Department of Internal MedicineUniversity of Michigan Rogel Cancer Center Ann Arbor Michigan
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11
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Ramelyte E, Dummer R, Guenova E. Investigative drugs for the treatment of cutaneous T-cell lymphomas (CTCL): an update. Expert Opin Investig Drugs 2019; 28:799-809. [PMID: 31398295 DOI: 10.1080/13543784.2019.1654995] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Cutaneous T-cell lymphoma (CTCL) is a heterogeneous group of skin-homing T-cell neoplasms, which represent approximately 75% of all primary cutaneous lymphomas. Mycosis fungoides and Sézary syndrome are the most common CTCL. Early stage disease follows a protracted course, carries a 5-year disease specific survival of 97% and can be treated with skin-directed therapies. Widespread, advanced disease has a 5-year OS of less than 25% and necessitates systemic treatment. Allogeneic stem cell transplantation is a potentially curative treatment option for advanced CTCL, however, transplant-related morbidity and mortality must be considered and a risk-benefit assessment performed on individual basis. Areas covered: Herein, we provide a review of investigative drugs in early-stage trials for the treatment of cutaneous CTCL, including topically applied immunomodulators such as replicating herpes virus or toll-like receptor 7/8 agonist resiquimod and systemic therapies with monoclonal antibodies, such as anti-CD47, recombinant cytotoxic interleukin 2 fusion protein anti-KIR3DL2 antibody and anti-miR-155 antibody. Expert Opinion: Among the reviewed drugs, resiquimod shows promising clinical efficacy with good tolerability in early CTCL. In refractory or relapsed disease, intratumoral anti-CD47-, anti-CCR4- and anti-KIR3DL2-antibodies show high response rates, however, latter two also show considerable toxicity. Larger trials are needed to better evaluate the discussed therapies.
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Affiliation(s)
- Egle Ramelyte
- Department of Dermatology, University Hospital of Zurich , Zurich , Switzerland.,Faculty of Medicine, University of Zurich , Zurich , Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital of Zurich , Zurich , Switzerland.,Faculty of Medicine, University of Zurich , Zurich , Switzerland
| | - Emmanuella Guenova
- Department of Dermatology, University Hospital of Zurich , Zurich , Switzerland.,Faculty of Medicine, University of Zurich , Zurich , Switzerland
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12
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Abstract
Adequate therapeutic management of cutaneous T-cell lymphoma (CTCL) requires the identification of the exact CTCL stage and entity within the current WHO classification. There is no curative therapy for CTCL yet, so that treatment currently aims at improving symptoms and quality of life as well as reducing relapse rates. The treatment has to be stage-adapted. Therapeutic options comprise skin-directed as well as systemic treatment. In early stages, phototherapy and local steroids are the first-line therapeutic options. For the therapy of higher stages, interferon alpha and the RXR-specific retinoid bexarotene are used as first-line medications. Second-line treatment comprises monochemotherapy with agents like gemcitabine or liposomal doxorubicine. Nevertheless, the high relapse rates in higher stages make novel alternative treatment options necessary. As future therapy, especially the fusion protein brentuximab-vedotin directed against CD30 shows promising potential in clinical studies.
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Affiliation(s)
- J P Nicolay
- Klinik für Dermatologie, Venerologie und Allergologie, Medizinische Fakultät Mannheim, Ruprecht-Karls-Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Deutschland.
| | - C Assaf
- Klinik für Dermatologie und Venerologie, HELIOS Klinikum Krefeld, Krefeld, Deutschland
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13
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Abstract
PURPOSE OF REVIEW Cutaneous T-cell lymphoma (CTCL) is a rare form of non-Hodgkin lymphoma. Globally, the most common subtypes of CTCL are mycosis fungoides and Sézary syndrome. CTCL can confer significant morbidity and even mortality in advanced disease. Here we review the current and potential future treatments for advanced-stage CTCL. RECENT FINDINGS Heterogeneity of treatment choice has been demonstrated both in US and non-US centers. Systemic treatment choice is currently guided by prognostic features, incorporating stage, immunophenotypic and molecular findings, and patient-specific factors such as age and comorbidities. Randomized controlled studies are uncommon, and the literature is composed predominantly of retrospective, cohort, and early-phase studies. International consensus guidelines are available; however, the lack of comparative trials means that there is no clear algorithmic approach to treatment. This review article reports on the systemic treatment options in current use for advanced CTCL, and on the possible future therapies, acknowledging that an algorithmic approach is not yet forthcoming to guide treatment prioritization.
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14
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Janiga J, Kentley J, Nabhan C, Abdulla F. Current systemic therapeutic options for advanced mycosis fungoides and Sézary syndrome. Leuk Lymphoma 2018; 59:562-577. [PMID: 29308723 DOI: 10.1080/10428194.2017.1347650] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Mycosis fungoides (MF) and Sézary syndrome (SS) are the most common cutaneous T-cell lymphomas (CTCLs). Both lack curative options, and advanced-stage carries a poor prognosis. Whilst there are a number of treatments available, achieving and maintaining a durable remission remains challenging. We review current systemic treatment options as monotherapy for advanced-stage MF (IIB-IV), appraising their mechanism of action, analyzing their efficacy, and describing toxicities. Individually, reported overall response rates (ORR) vary widely in the literature and duration of responses are typically short, ranging from 7.5 to 22.4 months. Combined therapy is frequently used in an effort to boost responses, although prospective studies comparing combinations to single agent therapies are rarely conducted. While recent translational research has led to increased understanding of the immunopathogenesis of MF and SS and the development of new treatments, current standard of care therapies are not curative and have low ORR for advanced-stage disease.
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Affiliation(s)
- Jenna Janiga
- a Stritch School of Medicine , Loyola University , Chicago , IL , USA
| | - Jonathan Kentley
- b Department of Dermatology , Royal London Hospital, Barts Health NHS Trust , London , UK
| | - Chadi Nabhan
- c Cardinal Health Specialty Solutions , Waukegan , IL , USA
| | - Farah Abdulla
- d Department of Medicine, Section of Dermatology , University of Chicago Medicine and Biological Sciences , Chicago , IL , USA
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15
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Wilcox RA. Cutaneous T-cell lymphoma: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol 2017; 92:1085-1102. [PMID: 28872191 DOI: 10.1002/ajh.24876] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multi-disciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or blood involvement are generally approached with biologic-response modifiers or histone deacetylase inhibitors prior to escalating therapy to include systemic, single-agent chemotherapy. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Ryan A. Wilcox
- Division of Hematology/Oncology; University of Michigan Comprehensive Cancer Center; Ann Arbor Michigan 48109-5948
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16
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Virmani P, Hwang SH, Hastings JG, Haverkos BM, Kohnken B, Gru AA, Mishra A, Fabbro SK, Horwitz SM, Porcu P. Systemic therapy for cutaneous T-cell lymphoma: who, when, what, and why? Expert Rev Hematol 2016; 10:111-121. [DOI: 10.1080/17474086.2017.1270201] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Pooja Virmani
- Department of Medicine, Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Susan H. Hwang
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Justin G. Hastings
- Department of Internal Medicine, Division of Dermatology, The Ohio State University, Columbus, OH, USA
| | | | - Becca Kohnken
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
- Department of Veterinary Biosciences, Ohio State University, Columbus, OH, USA
| | - Alejandro A Gru
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | - Anjali Mishra
- Department of Internal Medicine, Division of Dermatology, The Ohio State University, Columbus, OH, USA
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Stephanie K. Fabbro
- Department of Internal Medicine, Division of Dermatology, The Ohio State University, Columbus, OH, USA
| | - Steve M. Horwitz
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pierluigi Porcu
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH, USA
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
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17
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Ma H, Abdul-Hay M. T-cell lymphomas, a challenging disease: types, treatments, and future. Int J Clin Oncol 2016; 22:18-51. [PMID: 27743148 PMCID: PMC7102240 DOI: 10.1007/s10147-016-1045-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/26/2016] [Indexed: 02/06/2023]
Abstract
T-cell lymphomas are rare and aggressive malignancies associated with poor outcome, often because of the development of resistance in the lymphoma against chemotherapy as well as intolerance in patients to the established and toxic chemotherapy regimens. In this review article, we discuss the epidemiology, pathophysiology, current standard of care, and future treatments of common types of T-cell lymphomas, including adult T-cell leukemia/lymphoma, angioimmunoblastic T-cell lymphoma, anaplastic large-cell lymphoma, aggressive NK/T-cell lymphoma, and cutaneous T-cell lymphoma.
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Affiliation(s)
- Helen Ma
- Department of Internal Medicine, New York University, New York, NY, USA
| | - Maher Abdul-Hay
- Department of Internal Medicine, New York University, New York, NY, USA. .,Perlmutter Cancer Center, New York University, New York, NY, USA.
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18
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Abstract
Cutaneous T-cell lymphomas (CTCLs) are a heterogeneous group of extranodal lymphomas involving the skin. Diagnosis of the two main subtypes of CTCL-mycosis fungoides (MF) and Sézary syndrome (SS)-is based on the International Society for Cutaneous Lymphomas/European Organization for Research and Treatment of Cancer (ISCL/EORTC) classification system, which utilizes clinical, histopathological, molecular biologic, and immunopathologic features. Risk stratification, based on TNMB (tumor, node, metastasis, and blood) staging, provides prognostic information, with limited-stage disease conferring the longest median overall survival. Skin-directed therapies are preferred in the management of limited-stage disease, whereas advanced-stage disease requires systemic therapies. As the mechanisms of CTCL pathogenesis are increasingly understood, new monoclonal antibodies, checkpoint inhibitors, immunomodulatory agents, and small molecules are under investigation and may provide additional therapeutic options for those with advanced CTCL. This review examines the current landscape of targeted therapies in the treatment of CTCLs.
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Affiliation(s)
- Sumana Devata
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Comprehensive Cancer Center, 3A17 N. Ingalis Bldg, 300 N. Ingalis St. SPC 5419, Ann Arbor, MI, 48109-5419, USA.
| | - Ryan A Wilcox
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Comprehensive Cancer Center, 1500 East Medical Center Drive, 4310 CC, Ann Arbor, MI, 48109-5936, USA
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Wilcox RA. Cutaneous T-cell lymphoma: 2016 update on diagnosis, risk-stratification, and management. Am J Hematol 2016; 91:151-65. [PMID: 26607183 PMCID: PMC4715621 DOI: 10.1002/ajh.24233] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 11/03/2015] [Indexed: 12/11/2022]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral, or blood involvement are generally approached with biologic-response modifiers or histone deacetylase inhibitors before escalating therapy to include systemic, single-agent chemotherapy. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Ryan A. Wilcox
- Division of Hematology/Oncology, University of Michigan Cancer Center, 1500 E. Medical Center Drive, Room 4310 CC, Ann Arbor, MI 48109-5948
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20
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Spaccarelli N, Rook AH. The Use of Interferons in the Treatment of Cutaneous T-Cell Lymphoma. Dermatol Clin 2015; 33:731-45. [PMID: 26433845 DOI: 10.1016/j.det.2015.05.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Interferons are polypeptides that naturally occur in the human body as a part of the innate immune response. By harnessing these immunomodulatory functions, synthetic interferons have shown efficacy in combating various diseases including cutaneous T-cell lymphoma. This article closely examines the qualities of interferon alfa and interferon gamma and the evidence behind their use in the 2 most common types of cutaneous T-cell lymphomas, namely, mycosis fungoides and Sézary syndrome.
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Affiliation(s)
- Natalie Spaccarelli
- Department of Dermatology, Hospital of the University of Pennsylvania, 3600 Spruce Street, Philadelphia, PA 19104, USA.
| | - Alain H Rook
- Department of Dermatology, Hospital of the University of Pennsylvania, 3600 Spruce Street, Philadelphia, PA 19104, USA
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21
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Hughes CFM, Newland K, McCormack C, Lade S, Prince HM. Mycosis fungoides and Sézary syndrome: Current challenges in assessment, management and prognostic markers. Australas J Dermatol 2015; 57:182-91. [DOI: 10.1111/ajd.12349] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/05/2015] [Indexed: 12/24/2022]
Affiliation(s)
- Charlotte FM Hughes
- Division of Haematology and Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
| | - Kate Newland
- Department of Dermatology; St Vincent's Hospital Department of Medicine; Melbourne Victoria Australia
| | - Christopher McCormack
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
- Department of Dermatology; St Vincent's Hospital Department of Medicine; Melbourne Victoria Australia
| | - Stephen Lade
- Division of Pathology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - H Miles Prince
- Division of Haematology and Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
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22
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Duvic M. Choosing a systemic treatment for advanced stage cutaneous T-cell lymphoma: mycosis fungoides and Sézary syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:529-544. [PMID: 26637769 DOI: 10.1182/asheducation-2015.1.529] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Madeleine Duvic
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, TX
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23
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Wilcox RA. Cutaneous T-cell lymphoma: 2014 update on diagnosis, risk-stratification, and management. Am J Hematol 2014; 89:837-51. [PMID: 25042790 DOI: 10.1002/ajh.23756] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, and blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or blood involvement are generally approached with biologic-response modifiers or histone deacetylase inhibitors prior to escalating therapy to include systemic, single-agent chemotherapy. Multiagent chemotherapy (e.g., CHOP) may be employed for those patients with extensive visceral involvement requiring rapid disease control. In highly selected patients, allogeneic stem-cell transplantation may be considered.
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Affiliation(s)
- Ryan A. Wilcox
- Division of Hematology/Oncology; University of Michigan Cancer Center; Ann Arbor Michigan
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24
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Systematic review of combination therapies for mycosis fungoides. Cancer Treat Rev 2014; 40:927-33. [PMID: 24997678 DOI: 10.1016/j.ctrv.2014.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/29/2014] [Accepted: 06/08/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND A variety of therapeutic options are available for mycosis fungoides, the most prevalent subtype of cutaneous T cell lymphomas, but thus far, no regimen has been proven to be curative. A combination of treatments is a well-established strategy to increase the therapeutic efficacy. However, data from clinical trials analyzing such combinations for the treatment of mycosis fungoides are scarce. OBJECTIVE To analyze the available evidence on combination therapies with emphasis on the combination of psoralen with UVA phototherapy (PUVA), interferon-alpha and bexarotene with another treatment. METHODS Systematic literature review of the databases Embase, Cochrane, Medline, and Medline in Process. RESULTS Combination of PUVA with interferon-alpha or retinoids did not result in an increased overall response rate. Addition of methotrexate but not retinoids to interferon-alpha may increase the overall response rate. Bexarotene was investigated in one trial each with vorinostat, methotrexate or gemcitabine, whereby only methotrexate possibly enhanced the effect of bexarotene. CONCLUSION For mycosis fungoides, no combination treatment has been demonstrated to be superior to monotherapy. Based on our analysis, we conclude that in certain clinical situations, patients may benefit from a combination of PUVA with interferon-alpha or a retinoid or a combination of the latter two. Furthermore, patients in advanced stages may benefit from the combination of methotrexate and interferon-alpha or bexarotene. Finally, the combination of bexarotene with either vorinostat or gemcitabine did not increase the overall response rate but resulted in more pronounced side effects and cannot be recommended.
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Jawed SI, Myskowski PL, Horwitz S, Moskowitz A, Querfeld C. Primary cutaneous T-cell lymphoma (mycosis fungoides and Sézary syndrome): part II. Prognosis, management, and future directions. J Am Acad Dermatol 2014; 70:223.e1-17; quiz 240-2. [PMID: 24438970 DOI: 10.1016/j.jaad.2013.08.033] [Citation(s) in RCA: 205] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 08/13/2013] [Accepted: 08/16/2013] [Indexed: 12/20/2022]
Abstract
Both mycosis fungoides (MF) and Sézary syndrome (SS) have a chronic, relapsing course, with patients frequently undergoing multiple, consecutive therapies. Treatment is aimed at the clearance of skin disease, the minimization of recurrence, the prevention of disease progression, and the preservation of quality of life. Other important considerations are symptom severity, including pruritus and patient age/comorbidities. In general, for limited patch and plaque disease, patients have excellent prognosis on ≥1 topical formulations, including topical corticosteroids and nitrogen mustard, with widespread patch/plaque disease often requiring phototherapy. In refractory early stage MF, transformed MF, and folliculotropic MF, a combination of skin-directed therapy plus low-dose immunomodulators (eg, interferon or bexarotene) may be effective. Patients with advanced and erythrodermic MF/SS can have profound immunosuppression, with treatments targeting tumor cells aimed for immune reconstitution. Biologic agents or targeted therapies either alone or in combination--including immunomodulators and histone-deacetylase inhibitors--are tried first, with more immunosuppressive therapies, such as alemtuzumab or chemotherapy, being generally reserved for refractory or rapidly progressive disease or extensive lymph node and metastatic involvement. Recently, an increased understanding of the pathogenesis of MF and SS with identification of important molecular markers has led to the development of new targeted therapies that are currently being explored in clinical trials in advanced MF and SS.
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Affiliation(s)
- Sarah I Jawed
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, New York
| | - Patricia L Myskowski
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, New York
| | - Steven Horwitz
- Lymphoma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, New York
| | - Alison Moskowitz
- Lymphoma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, New York
| | - Christiane Querfeld
- Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, New York.
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26
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Vandersee S, Terhorst D, Humme D, Beyer M. Treatment of indolent primary cutaneous B-cell lymphomas with subcutaneous interferon-alfa. J Am Acad Dermatol 2014; 70:709-715. [PMID: 24433874 DOI: 10.1016/j.jaad.2013.11.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 11/13/2013] [Accepted: 11/14/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND Interferon-alfa is used in the treatment of primary cutaneous B-cell lymphoma (PCBCL). Therapy with interferon-alfa has thus far been reported solely in case reports and small case series, mostly describing intralesional use. OBJECTIVE We sought to evaluate efficacy, response rate, time to response, duration of response, and safety of subcutaneously administered interferon-alfa for the treatment of cutaneous B-cell lymphoma. METHODS We conducted a retrospective chart analysis of patients given the diagnosis of PCBCL and treated with interferon-alfa subcutaneously at a tertiary referral center. RESULTS Fifteen patients with indolent subtypes of PCBCL were identified. The overall response rate was 66.7%; all responding patients went into complete remission. Response was not significantly associated with the maximum tolerated dose. Within the median follow-up time of 40 months, 90% of the responders experienced a relapse; median duration of response was 15.5 months. Adverse events were predominantly mild and in no case led to cessation of therapy. LIMITATIONS Retrospective nature of the analysis and small number of patients because of scarcity of the disease are limitations. CONCLUSION Treatment of indolent PCBCL with subcutaneously injected interferon-alfa demonstrated good response rates and tolerability. Response was not dose dependent. Relapses were observed in nearly all responding patients raising the question of interferon-alfa maintenance therapy in PCBCL.
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MESH Headings
- Adult
- Aged
- Biopsy, Needle
- Cohort Studies
- Dose-Response Relationship, Drug
- Drug Administration Schedule
- Female
- Follow-Up Studies
- France
- Humans
- Immunohistochemistry
- Injections, Subcutaneous
- Interferon-alpha/adverse effects
- Interferon-alpha/therapeutic use
- Kaplan-Meier Estimate
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/mortality
- Lymphoma, B-Cell/pathology
- Male
- Middle Aged
- Neoplasm Invasiveness/pathology
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/pathology
- Neoplasm Staging
- Retrospective Studies
- Risk Assessment
- Skin Neoplasms/drug therapy
- Skin Neoplasms/mortality
- Skin Neoplasms/pathology
- Statistics, Nonparametric
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- Staffan Vandersee
- Skin Cancer Centre Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Dorothea Terhorst
- Skin Cancer Centre Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany; Centre d'Immunologie Marseille-Luminy, INSERM-CNRS-Université de la Mediterannée, Marseille, France
| | - Daniel Humme
- Skin Cancer Centre Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marc Beyer
- Skin Cancer Centre Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany
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27
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Martino M, Fedele R, Cornelio G, Moscato T, Imbalzano L, Ressa G, Massara E, Bresolin G. Extracorporeal photopheresis, a therapeutic option for cutaneous T-cell lymphoma and immunological diseases: state of the art. Expert Opin Biol Ther 2012; 12:1017-30. [PMID: 22587646 DOI: 10.1517/14712598.2012.688025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Extracorporeal photopheresis (ECP) has been extensively used for the treatment of immune-mediated diseases for over 20 years and has a consistent and predictable safety profile with long-term use. Documenting the efficacy of ECP as therapeutic treatment has long been a matter of importance for physicians. AREAS COVERED The authors reviewed publications in this field with the goal of providing an overview of this therapeutic approach. EXPERT OPINION ECP is efficacious in a high percentage of those cutaneous T-cell lymphoma patients who have circulating malignant T cells in the context of a still-near-normal immune competence. From the side of graft-versus-host disease (GVHD), the use of ECP showed a clinical benefit in patients with steroid-refractory acute GVHD (aGVHD) and it is believed that ECP deserves to be evaluated as part of a combination strategy in first-line therapy of aGVHD. In chronic GHVD, the published data show that ECP can be effective in extensive and long-standing disease even when treatment is initiated at an advanced stage after conventional immunosuppressive and corticosteroid therapy has failed. ECP should be considered most beneficial for patients with predominantly mucocutaneous chronic GVHD. The fields of application of the procedure could be vast, and could also include autoimmune and metabolic diseases. The most important methodological issues which affect ECP evaluation is that the large majority of data about ECP result from single-arm observational series and the significant efficacy is mainly based on small and retrospective studies. ECP has never been proved to offer any survival advantage in a context of a randomized trial and the above-mentioned limitation also affects the accuracy of many biological modifications observed during ECP. Starting from these considerations, the need of a prospective randomized study becomes increasingly urgent.
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Affiliation(s)
- Massimo Martino
- Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Bianchi-Melacrino-Morelli, 89100 Reggio Calabria, Italy.
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28
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Tse E, Kwong YL. Treatment algorithms for mature T-cell and natural killer-cell neoplasms. Future Oncol 2012; 7:1101-12. [PMID: 21919697 DOI: 10.2217/fon.11.84] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Mature T-cell and natural killer (NK)-cell lymphomas are rare neoplasms, differing geographically in frequencies. T-cell lymphomas are more common in Asia than in western countries, and NK-cell lymphomas occur almost exclusively in Asia and South America. The rarity of these lymphomas means that treatment algorithms of T-cell and NK-cell lymphomas have not been well established. Angioimmunoblastic T-cell lymphoma, anaplastic large cell lymphoma and peripheral T-cell lymphoma, not otherwise specified, are the more commonly encountered T-cell lymphomas. Treatment with anthracycline-based regimens designed for aggressive B-cell lymphomas gives unsatisfactory results. Cutaneous T-cell lymphomas may remain indolent, but outcome is poor for advanced diseases. Novel therapies, including monoclonal antibodies, nucleoside analogs, histone deacetylase inhibitors and small molecules targeting cellular signaling pathways, are being explored alone or in combination with chemotherapy. High-dose chemotherapy with hematopoietic stem cell transplantation (HSCT) is recommended for high-risk cases. NK-cell lymphomas exhibit the multidrug resistance phenotype due to P-glycoprotein expression, so that anthracycline-based regimens are ineffective. Non-multidrug resistance-dependent regimens and L-asparaginase-based protocols have been shown to be highly active. Autologous HSCT is not routinely performed. The role of allogeneic HSCT is being examined.
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Affiliation(s)
- Eric Tse
- Department of Medicine, Queen Mary Hospital, Hong Kong
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29
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Wilcox RA. Cutaneous T-cell lymphoma: 2011 update on diagnosis, risk-stratification, and management. Am J Hematol 2011; 86:928-48. [PMID: 21990092 DOI: 10.1002/ajh.22139] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis fungoides (MF) or Sézary syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY Tumor, node, metastasis, and blood (TNMB) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral, or blood involvement are generally approached with biologic-response modifiers, denileukin diftitox, and histone deacetylase inhibitors before escalating therapy to include systemic, single-agent chemotherapy. Multiagent chemotherapy may be used for those patients with extensive visceral involvement requiring rapid disease control. In highly-selected patients with disease refractory to standard treatments, allogeneic stem-cell transplantation may be considered.
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Affiliation(s)
- Ryan A Wilcox
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Cancer Center, Ann Arbor, 48109-5948, USA. rywilcox@med. umich.edu
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30
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Wong HK, Mishra A, Hake T, Porcu P. Evolving insights in the pathogenesis and therapy of cutaneous T-cell lymphoma (mycosis fungoides and Sezary syndrome). Br J Haematol 2011; 155:150-66. [PMID: 21883142 DOI: 10.1111/j.1365-2141.2011.08852.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cutaneous T-cell lymphomas (CTCL) are a heterogeneous group of malignancies derived from skin-homing T cells. The most common forms of CTCL are Mycosis Fungoides (MF) and Sezary Syndrome (SS). Accurate diagnosis remains a challenge due to the heterogeneity of presentation and the lack of highly characteristic immunophenotypical and genetic markers. Over the past decade molecular studies have improved our understanding of the biology of CTCL. The identification of gene expression differences between normal and malignant T-cells has led to promising new diagnostic and prognostic biomarkers that now need validation to be incorporated into clinical practice. These biomarkers may also provide insight into the mechanism of development of CTCL. Additionally, treatment options have expanded with the approval of new agents, such as histone deacetylase inhibitors. A better understanding of the cell biology, immunology and genetics underlying the development and progression of CTCL will allow the design of more rational treatment strategies for these malignancies. This review summarizes the clinical epidemiology, staging and natural history of MF and SS; discusses the immunopathogenesis of MF and the functional role of the malignant T-cells; and reviews the latest advances in MF and SS treatment.
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Affiliation(s)
- Henry K Wong
- Division of Dermatology, The Ohio State University, Columbus, OH 43221, USA.
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31
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Hüsken A, Tsianakas A, Hensen P, Nashan D, Loquai C, Beissert S, Luger T, Sunderkötter C, Schiller M. Comparison of pegylated interferon α-2b plus psoralen PUVA versus standard interferon α-2a plus PUVA in patients with cutaneous T-cell lymphoma. J Eur Acad Dermatol Venereol 2011; 26:71-8. [DOI: 10.1111/j.1468-3083.2011.04011.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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32
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Sézary syndrome: Immunopathogenesis, literature review of therapeutic options, and recommendations for therapy by the United States Cutaneous Lymphoma Consortium (USCLC). J Am Acad Dermatol 2011; 64:352-404. [DOI: 10.1016/j.jaad.2010.08.037] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 08/10/2010] [Accepted: 08/30/2010] [Indexed: 11/19/2022]
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33
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Erter J, Alinari L, Darabi K, Gurcan M, Garzon R, Marcucci G, Bechtel MA, Wong H, Porcu P. New targets of therapy in T-cell lymphomas. Curr Drug Targets 2010; 11:482-93. [PMID: 20196721 DOI: 10.2174/138945010790980376] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 10/09/2009] [Indexed: 12/23/2022]
Abstract
T-cell lymphomas (TCL) are characterized by poor response to chemotherapy and generally poor outcome. While molecular profiling has identified distinct biological subsets and therapeutic targets in B-cell lymphomas, the molecular characterization of TCL has been slower. Surface markers expressed on malignant T-cells, such as CD2, CD3, CD4, CD25, and CD52 were the first TCL-specific therapeutic targets to be discovered. However, the presence of these receptors on normal T-cells means that monoclonal antibody (mAb)- or immunotoxin (IT)-based therapy in TCL inevitably results in variable degrees of immunosuppression. Thus, although some mAbs/IT have significant activity in selected subsets of TCL, more specific agents that target signaling pathways preferentially activated in malignant T-cells are needed. One such novel class of agents is represented by the histone deacetylase (HDAC) inhibitors. These molecules selectively induce apoptosis in a variety of transformed cells, including malignant T-cells, both in vitro and in vivo. Several HDAC inhibitors have been studied in TCL with promising results, and have recently been approved for clinical use. Immunomodulatory drugs, such as interferons and Toll Receptor (TLR) agonists have significant clinical activity in TCL, and are particularly important in the treatment of primary cutaneous subtypes (CTCL). Although most classical cytotoxic drugs have limited efficacy against TCL, agents that inhibit purine and pyrimidine metabolism, known as nucleoside analogues, and novel antifolate drugs, such as pralatrexate, are highly active in TCL. With improved molecular profiling of TCL novel pharmacological agents with activity in TCL are now being discovered at an increasingly rapid pace. Clinical trials are in progress and these agents are being integrated in combination therapies for TCL, both in the relapsed/refractory setting as well as front line.
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Affiliation(s)
- Jack Erter
- Division of Hematology - Oncology, The Ohio State University, Comprehensive Cancer Center, B-320 Starling Loving Hall, 320 West 10th Avenue, Columbus, OH, 43210, USA
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34
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Biggioggero M, Gabbriellini L, Meroni PL. Type I interferon therapy and its role in autoimmunity. Autoimmunity 2010; 43:248-54. [DOI: 10.3109/08916930903510971] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Sheng Y, Chen L, Huang Z, Mu Z, Kong J, Luo Y, Yang Q. Granulomatous Slack Skin: Assessment of Disease Progression and Treatment Response Using Positron Emission Tomography/Computed Tomography. ACTA ACUST UNITED AC 2009; 9:455-8. [DOI: 10.3816/clm.2009.n.089] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Mestel D, Beyer M, Steinhoff M, Sterry W. Treatment of Cutaneous Lymphomas: Today and Tomorrow. ACTAS DERMO-SIFILIOGRAFICAS 2009; 100 Suppl 1:18-32. [DOI: 10.1016/s0001-7310(09)73165-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Gniadecki R, Assaf C, Bagot M, Dummer R, Duvic M, Knobler R, Ranki A, Schwandt P, Whittaker S. The optimal use of bexarotene in cutaneous T-cell lymphoma. Br J Dermatol 2007; 157:433-40. [PMID: 17553039 DOI: 10.1111/j.1365-2133.2007.07975.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The management goal in cutaneous T-cell lymphomas (CTCLs) is to improve symptoms and induce remission. Early-stage disease is generally treated with skin-directed therapies. However, if these do not control the disease, systemic therapy becomes necessary. Bexarotene, a novel rexinoid, is an oral, noncytotoxic drug that has been approved in Europe for the treatment of refractory advanced-stage CTCL and in the U.S.A. for refractory CTCL. We provide guidance on the use of bexarotene in the management of CTCL, based on data from phase II/III clinical trials and the authors' clinical experience, and suggest how the potential of the drug can be maximized. The clinical trial results with bexarotene are reviewed, especially in comparison with interferon-alpha, which is the other commonly used noncytotoxic systemic therapy for CTCL. A treatment algorithm for bexarotene in refractory CTCL is suggested. As bexarotene may take time to achieve a maximum response, this algorithm recommends that therapy should be continued for a sufficient period to allow for a delayed onset of action. In addition, possible combination therapies with bexarotene are discussed. We conclude that bexarotene is effective in the management of CTCL, and has the advantage of oral administration. An on-going randomized clinical trial comparing psoralen plus ultraviolet A (PUVA) with PUVA plus bexarotene will provide valuable information about this combination regimen in early-stage disease, but further data are needed on the relative efficacies of other combination therapies with bexarotene in CTCL.
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Affiliation(s)
- R Gniadecki
- Department of Dermatology, University of Copenhagen, Bispebjerg Hospital, Bispebjerg bakke 23, DK-2400 Copenhagen, Denmark.
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Huber MA, Staib G, Pehamberger H, Scharffetter-Kochanek K. Management of refractory early-stage cutaneous T-cell lymphoma. Am J Clin Dermatol 2006; 7:155-69. [PMID: 16734503 DOI: 10.2165/00128071-200607030-00002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
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.
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Affiliation(s)
- Margit A Huber
- Department of Dermatology, Division of General Dermatology, Vienna Medical University, Vienna, Austria.
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Trautinger F, Knobler R, Willemze R, Peris K, Stadler R, Laroche L, D'Incan M, Ranki A, Pimpinelli N, Ortiz-Romero P, Dummer R, Estrach T, Whittaker S. EORTC consensus recommendations for the treatment of mycosis fungoides/Sézary syndrome. Eur J Cancer 2006; 42:1014-30. [PMID: 16574401 DOI: 10.1016/j.ejca.2006.01.025] [Citation(s) in RCA: 314] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Accepted: 01/09/2006] [Indexed: 02/07/2023]
Abstract
Several reviews and guidelines on the management of mycosis fungoides and Sézary syndrome (MF/SS) have been published; however, treatment strategies for patients with MF/SS vary from institution to institution and no European consensus has yet been established. There are few phase III trials to support treatment decisions for MF/SS and treatment is often determined by institutional experience. In order to summarise the available evidence and review 'best practices' from each national group, the European Organisation for Research and Treatment of Cancer (EORTC) Cutaneous Lymphoma Task Force met in September 2004 to establish European guidelines for the treatment of MF/SS. This article reviews the treatment regimens selected for inclusion in the guidelines and summarises the clinical data for treatments appropriate for each stage of MF/SS. Guideline recommendations are presented according to the quality of supporting data, as defined by the Oxford Centre for Evidence-Based Medicine. Skin-directed therapies are the most appropriate option for early-stage MF/SS and most patients can look forward to a normal life expectancy. Patients with advanced disease should be encouraged to participate in clinical trials and maintenance of quality of life should be paramount.
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Affiliation(s)
- Franz Trautinger
- Division of Special and Environmental Dermatology, Department of Dermatology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna A-1090, Austria
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Abstract
Interferons (IFNs) are widely used for the treatment of various medical diseases. They have marked immunomodulatory effects, and many reports have been published associating IFN therapy with the induction of autoimmune phenomena and other disorders of immune regulation such as sarcoidosis. The clinical presentation of IFN-induced sarcoidosis (IIS) is insidious and can be confused with common constitutional side effects of these drugs. The age of onset of IIS is later than that of naturally occurring sarcoidosis. The most common organs involved are the lungs and skin. In the majority of cases, IIS follows a benign course. As we show in an illustrative case report, complete resolution after discontinuation of IFN therapy can be expected. This review summarises 65 cases of IIS reported in the literature and highlights the pathophysiology, clinical features, diagnostic modalities and therapeutic options for this increasingly recognised phenomenon.
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Affiliation(s)
- S Alazemi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Miami School of Medicine, Miami, FL 33101, USA
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Dréno B. Interféron alpha et lymphome cutané T épidermotrope. Ann Dermatol Venereol 2005. [DOI: 10.1016/s0151-9638(05)79616-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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McFarlane V, Friedmann PS, Illidge TM. What's new in the management of cutaneous T-cell lymphoma? Clin Oncol (R Coll Radiol) 2005; 17:174-84. [PMID: 15901002 DOI: 10.1016/j.clon.2004.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aetiology and clinical management of primary cutaneous T-cell lymphoma (CTCL) and specifically of mycosis fungoides and Sezary syndrome are poorly defined. Interesting new insights into CTCL disease biology as well as a number of emerging of novel therapeutic interventions make this an increasingly interesting area for dermatologists and oncologists involved in the treatment of CTCL. This review article covers much of this new information including new drugs, such as denileukin diftitox (Ontak) a targeted cytotoxic biological agent, Bexarotene an RXR selective retinoid, anti-CD4 monoclonal antibodies (mAb), new cytotoxics agents and vaccines.
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Affiliation(s)
- V McFarlane
- Southampton Oncology Centre, Southampton University NHS Trust, Southampton S016 6YD, UK
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Abstract
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.
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Affiliation(s)
- Elizabeth Knobler
- Columbia University College of Physicians and Surgeons, New York, New York, USA.
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Gallardo F, Pujol RM. Diagnóstico y tratamiento de los linfomas cutáneos de células T primarios. ACTAS DERMO-SIFILIOGRAFICAS 2004. [DOI: 10.1016/s0001-7310(04)76864-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Girardi M, Knobler R, Edelson R. Selective immmunotherapy through extracorporeal photochemotherapy: yesterday, today, and tomorrow. Hematol Oncol Clin North Am 2003; 17:1391-403. [PMID: 14710891 DOI: 10.1016/s0889-8588(03)00106-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
ECP's extensive clinical record, as well as a considerable improvement in the understanding of the mechanism that underlies its efficacy, opens potential novel strategies for the treatment of cancer, GVHD, transplant rejection, and autoimmunity. The low side effect profile of this therapy has made it a more attractive treatment consideration than current conventional chemotherapeutic and immunosuppressive medications. As the mechanism of action of ECP is more fully elucidated and clinical studies are completed, the role of ECP in modern therapeutics of CTCL and other malignancies, as well as in the treatment of other T-cell mediated diseases, will be become clearer.
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Affiliation(s)
- Michael Girardi
- Department of Dermatology, Yale University, School of Medicine, Post Office Box 208059, New Haven, CT 06520-8059, USA.
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Duvic M, Apisarnthanarax N, Cohen DS, Smith TL, Ha CS, Kurzrock R. Analysis of long-term outcomes of combined modality therapy for cutaneous T-cell lymphoma. J Am Acad Dermatol 2003; 49:35-49. [PMID: 12833006 DOI: 10.1067/mjd.2003.449] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although cutaneous T-cell lymphoma (CTCL), including mycosis fungoides (MF) and Sézary syndrome, is often responsive to treatment, few current therapies increase survival or consistently induce durable remissions, especially in advanced disease. OBJECTIVE In an effort to improve treatment efficacy and outcome in CTCL, a combined modality protocol using 3 to 4 consecutive phases of therapy was initiated in 1987 at M.D. Anderson Cancer Center, Houston, Tex. METHODS During a period of 15 years between 1987 and 2001, 95 patients with early-stage (Ia-IIa, n = 50) and late-stage (IIb-IVb, n = 45) MF were treated with subcutaneous interferon-alpha and oral isotretinoin, followed by total-skin electron beam therapy, and long-term maintenance therapy with topical nitrogen mustard and interferon-alpha. Patients with late-stage (IIb-IVb) disease also received 6 cycles of combination chemotherapy before electron beam therapy. RESULTS Combined modality therapy yielded a response rate of 85% with a 60% complete response rate. Among 38 patients with early-stage disease and 18 patients with late-stage disease achieving complete response, 9 (24%) patients with early-stage MF and 3 (17%) patients with late-stage MF achieved sustained remissions lasting more than 5 years. The median disease-free survival (DFS) for early and late stages of disease was 62 and 7 months, with 5-year Kaplan-Meier estimated rates of 50% and 27%, respectively. Current median overall survival times on combined modality are 145 months for patients with early-stage disease and 36 months for those with late-stage disease. Death was attributable to CTCL disease in 17 (55%) of 31 cases. The Kaplan-Meier estimates for 5-year survival are 94% for early-stage and 35% for late-stage disease. Univariate survival analysis in this patient population reveals statistically significant associations of clinical stage with overall response rates (P =.02), DFS (P =.03), and overall survival (P <.0001); age with DFS (P =.001) and overall survival (P =.04); and T stage (P <.0001) and lactate dehydrogenase (P =.007) with overall survival. By multivariate analysis using a Cox proportional hazards model, only age was significantly associated with DFS (hazard ratio 2.9), and only stage with overall survival (hazard ratio 18.2). CONCLUSION This nonrandomized and uncontrolled CTCL study gives supportive evidence that this multiphased combined modality regimen is well tolerated and may yield higher response rates and DFS than total-skin electron beam therapy alone, but provides no evidence for a change in survival.
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Affiliation(s)
- Madeleine Duvic
- Division of Internal Medicine, Department of Dermatology, University of Texas M. D. Anderson Cancer Center, Houston 77030-4095, USA
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Abstract
Extracorporeal photochemotherapy was originally conceived for the treatment of cutaneous T-cell lymphoma (CTCL) and as well as other T-cell mediated diseases. Evidence collected in the past 17 years has demonstrated that this treatment modality can have a very significant effect on the course of a subset of CTCL patients. The evidence available is positive but for a variety of reasons has been controversial within the medical community. A number of very well-designed multi-center trials which have been lacking since the first publication by Edelson et al. are being carried out so that hopefully a number of open questions will be resolved with greater clarity in the coming years. The fact remains that this innovative approach for the treatment of CTCL and T-cell mediated diseases has certainly opened new avenues of therapy and thought in photoimmunology and photomedicine. Clearly the very low side effect profile of this therapy has made it more attractive than the chemotherapeutic and immunosuppressive substances that are presently available or in experimental protocols. If and when the mechanisms of action are fully understood and appropriate studies investigating different treatment schedules and different combination therapies and modifications of its present form are performed the place of photopheresis in the therapeutics of CTCL as well as other T-cell mediated diseases and oncology will be better placed.
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Affiliation(s)
- R Knobler
- Division of Special and Environmental Dermatology, Department of Dermatology, Vienna Medical School, University of Vienna, Währinger Gürtel 18-20, Vienna A 1090, Austria.
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A prospective study on the evolution of the T-cell repertoire in patients with Sézary syndrome treated by extracorporeal photopheresis. Blood 2002. [DOI: 10.1182/blood.v100.6.2168] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Sézary syndrome is a leukemic form of epidermotropic cutaneous T-cell lymphoma related to the malignant proliferation of clonal CD4+ T cells. Extracorporeal photochemotherapy may induce a transient improvement of the clinical signs, but its efficiency is discussed. To investigate the frequency of the T-cell clone in the peripheral blood of patients with Sézary syndrome and to monitor its evolution in patients treated using extracorporeal photopheresis or chemotherapy, we used the immunoscope technique. In one patient, we observed a decrease of the relative frequency of the clone from 15.6% to 0%, paralleling a complete remission of the clinical disease and a disappearance of the circulating Sézary cells. In the other cases, the evolution of the relative frequency paralleled the initial improvement of the clinical status and the absence of long-term efficiency in patients treated with extracorporeal photopheresis or chemotherapy. We observed a quick-acting direct cytotoxicity of the association 8MOP + UVA on the T-cell clone. The immunoscope technique appears to be an efficient tool to appreciate the amount of tumoral cells and to monitor the evolution of the clonal component in the Sézary syndrome.
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A prospective study on the evolution of the T-cell repertoire in patients with Sézary syndrome treated by extracorporeal photopheresis. Blood 2002. [DOI: 10.1182/blood.v100.6.2168.h81802002168_2168_2174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Sézary syndrome is a leukemic form of epidermotropic cutaneous T-cell lymphoma related to the malignant proliferation of clonal CD4+ T cells. Extracorporeal photochemotherapy may induce a transient improvement of the clinical signs, but its efficiency is discussed. To investigate the frequency of the T-cell clone in the peripheral blood of patients with Sézary syndrome and to monitor its evolution in patients treated using extracorporeal photopheresis or chemotherapy, we used the immunoscope technique. In one patient, we observed a decrease of the relative frequency of the clone from 15.6% to 0%, paralleling a complete remission of the clinical disease and a disappearance of the circulating Sézary cells. In the other cases, the evolution of the relative frequency paralleled the initial improvement of the clinical status and the absence of long-term efficiency in patients treated with extracorporeal photopheresis or chemotherapy. We observed a quick-acting direct cytotoxicity of the association 8MOP + UVA on the T-cell clone. The immunoscope technique appears to be an efficient tool to appreciate the amount of tumoral cells and to monitor the evolution of the clonal component in the Sézary syndrome.
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