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

Mogamulizumab efficacy is underscored by its associated rash that mimics cutaneous T-cell lymphoma: a retrospective single-centre case series

BACKGROUND

Mogamulizumab is a humanized antibody against chemokine receptor type 4. It was recently approved by the US Food and Drug Administration for relapsed or refractory mycosis fungoides (MF) and Sézary syndrome (SS). The most commonly reported adverse event in the phase III licensing trial was drug eruption (28%), now termed mogamulizumab-associated rash (MAR). Clinical recommendations about MAR and its treatment differ between the current package insert and postapproval insights reported from two single-centre studies that focused on its characterization, but less so on outcomes and clinicopathological differentiation from cutaneous T-cell lymphoma (CTCL).

OBJECTIVES

To describe our experience in the diagnosis of MAR and treatment of patients with CTCL with mogamulizumab.

METHODS

This is a single-centre retrospective case series study.

RESULTS

We found a higher incidence of MAR in patients with CTCL (17 of 24, 68%) than previously reported. MAR development is associated with complete (11 of 17) or partial (four of 17) responses, with an overall response rate of 88%, compared with 29% (two of seven) in patients without MAR. Diagnosis of MAR may be obscured by its ability to mimic key CTCL features both clinically and histologically, but an absence of T-cell-receptor clonality and relatively decreased CD4 : CD8 ratio compared with baseline lesions strongly favour MAR over recurrent disease.

CONCLUSIONS

MAR has the potential to create a significant management problem for patients on mogamulizumab. Misidentification of MAR as recurrent CTCL may detrimentally result in the premature discontinuation of mogamulizumab in patients whose disease is historically hard to treat. Thorough clinicopathological investigation of new lesions during treatment with mogamulizumab is required to inform ideal treatment decisions and achieve better outcomes.

Wasik M, B. Koralov S, Geisler C, Kilian M, Iversen L, Woetmann A, Odum N. Bacterial toxins fuel disease progression in cutaneous T-cell lymphoma

In patients with cutaneous T-cell lymphoma (CTCL) bacterial infections constitute a major clinical problem caused by compromised skin barrier and a progressive immunodeficiency. Indeed, the majority of patients with advanced disease die from infections with bacteria, e.g., Staphylococcus aureus. Bacterial toxins such as staphylococcal enterotoxins (SE) have long been suspected to be involved in the pathogenesis in CTCL. Here, we review links between bacterial infections and CTCL with focus on earlier studies addressing a direct role of SE on malignant T cells and recent data indicating novel indirect mechanisms involving SE- and cytokine-driven cross-talk between malignant- and non-malignant T cells.

A systematic review of the safety of topical therapies for atopic dermatitis

BACKGROUND

The safety of topical therapies for atopic dermatitis (AD), a common and morbid disease, has recently been the focus of increased scrutiny, adding confusion as how best to manage these patients.

OBJECTIVES

The objective of these systematic reviews was to determine the safety of topical therapies for AD.

METHODS

Databases searched included: OVID Medline, Medline In-Process and Other Non-Indexed Citations, Embase, and the Cochrane Central Register of Controlled Trials. In addition to the articles identified by this search, investigators were also referred to a list of links (most recently updated 25 September 2005) to recent Food and Drug Administration (FDA) studies, reports and meetings regarding the topical calcineurin inhibitors for further potential references. Only fully published papers available in English and data obtained from FDA sites were included. Furthermore, the criteria for inclusion and exclusion for each systematic review were further evaluated at a meeting of all of the content and evidence-based medicine experts participating in this process and alteration of the inclusion criteria was done at that time when it was felt necessary to avoid inclusion of lower-quality data in the review. Qualitative review of the abstracted data was performed and reviewed at a meeting of all of the content and evidence-based medicine experts.

RESULTS

While systemic exposure to these topical agents does occur, physiological changes appear to be uncommon and systemic complications rare and have only been found with use of topical corticosteroids.

CONCLUSIONS

Based on the data that are available the overall safety of AD therapies appears to be good with the only documented systemic side-effects of therapy those occasionally seen with use of topical corticosteroids.

Investigation on the association between atopic dermatitis and the development of mycosis fungoides in dogs: a retrospective case-control study

In human medicine, the relationship between the immunodysregulation observed in atopic dermatitis (AD) and the development of mycosis fungoides (MF) has triggered considerable interest due to the increasing number of patients with MF who have a previous history of AD. The purpose of this retrospective case-control study was to investigate whether dogs diagnosed with MF were more likely to have AD. The records of 96 000 canine patients at the University of Florida were searched. Inclusion criteria were a clinical and histological diagnosis of MF. Dogs admitted to the University of Florida, Veterinary Medical Center during the same time period (1991-2004) without a diagnosis of MF were included as controls. Four controls for each study dog were randomly selected (matched by year of admission). Frequency of AD and other exposure variables were compared among case and control dogs by using conditional logistic regression. Records of 19 dogs with a diagnosis of MF were identified. Five of them (5/19, 26.3%) had previous diagnosis of AD. The odds of having MF was 12 times (OR = 12.54; 95% CI = 1.95-80.39; P < 0.01) higher in dogs with AD than in dogs without AD. In conclusion, this study suggests an association between AD and MF in dogs. Future studies are necessary to confirm this finding and to investigate the pathogenic mechanisms involved in this association.

CD30+ large cell transformation of mycosis fungoides after psoralen plus ultraviolet A photochemotherapy

Psoralen plus ultraviolet A (PUVA) photochemotherapy is widely used for the therapy of mycosis fungoides (MF). Clinical progression of MF is often associated with an increase in the size of tumour cells known as transformation. We report two patients with CD30+ large cell transformation that appeared after low-dose PUVA therapy for MF. Clinical data, histopathology, immunohistopathology and T-cell receptor gene rearrangement were studied. Nodules consisted of atypical large cells that expressed CD30. Monoclonal rearrangement of T-cell receptors was observed in one case. Low-dose PUVA therapy may be associated with CD30+ large cell transformation in patients with MF.

Primary CD30+ve Cutaneous T-cell Lymphoma Associated with Chronic Burn Injury in a Patient with Longstanding Psoriasis

An increased incidence of lymphoma has been reported in psoriatic patients, but most cases are nodal B-cell lymphoma. We report a unique case of CD30-expressing cutaneous T-cell lymphoma arising from underlying psoriatic plaque after intractable caustic burns and cellulitis in the palm of a patient with generalized chronic plaque psoriasis. Molecular studies confirmed a localized clonal T-cell expansion, and the lesion responded dramatically to multiagent chemotherapy. The case highlighted the possible role of chronic systemic and local T-cell activation in the pathogenesis of primary CD30+ve cutaneous T-cell lymphoma, and the importance of histologic assessment in chronic nonhealing skin lesions.

Clinical, morphological and immunohistochemical characterization of cutaneous lymphocytosis in 23 cats

Clinical, morphological and immunohistochemical features of cutaneous lymphocytosis, an uncommon disease histologically resembling well-differentiated malignant lymphoma, were characterized in 23 cats. Clinical outcome was correlated with histomorphology and immunophenotype in an attempt to predict benign vs. malignant behaviour. The disease mainly affected older cats. Lesions were solitary in 61% of cats and often characterized by alopecia (73.9%), as well as erythema, scaling and ulceration. The lateral thorax was most commonly affected (43.5%). Pruritus was frequent (65.2%). Systemic signs included anorexia and weight loss. Morphologically, lesions were characterized by dermal infiltrations of well-differentiated CD3+ T-cells (100%) and aggregates of CD79+ B-cells (64.3%). Cutaneous lymphocytosis is slowly progressive and relatively benign, although in some cats systemic signs led to euthanasia. Four of 12 euthanized cats and one live cat also had lymphoid infiltrates in internal organs. Unfortunately, we were unable to predict clinical outcome by histological and immunohistochemical evaluations of skin lesions.

Primary cutaneous CD30+ large T-cell lymphoma in a patient with psoriasis treated with cyclosporine

We report the case of a 61-year-old woman who developed an anaplastic CD30+ cutaneous T-cell lymphoma during oral cyclosporine (CsA) therapy for recalcitrant psoriasis. Two months after CsA discontinuation, clinical and histological resolution of the lymphoma was observed. However, 3 years later extracutaneous involvement of the lymphoma could be detected. The association between CsA administration and the occurrence of the lymphoma may be casual, but a relationship with immunosuppression may also be hypothesized. We have reviewed all relevant data in the literature. To our knowledge, this is the first case of primary cutaneous CD30+ anaplastic large T-cell lymphoma in a patient treated with CsA for psoriasis.