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Suggested Guidelines for the Treatment of Mycosis Fungoides in Countries with Limited Resources. Dermatol Res Pract 2023; 2023:1360740. [PMID: 36762366 PMCID: PMC9904957 DOI: 10.1155/2023/1360740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 02/04/2023] Open
Abstract
The treatment options for mycosis fungoides (MF) have been expanding but unfortunately many of the currently used treatment modalities are unavailable in Egypt and other African/Arab countries. In addition, there is a lack of consensus on the treatment of hypopigmented MF (HMF), which is a frequently encountered variant in our population. We aimed to develop regional treatment guidelines based on the international guidelines but modified to encompass the restricted treatment availability and our institutional experience. Special attention was also given to studies conducted on patients with skin phototype (III-IV). Treatment algorithm was formulated at Ain-Shams cutaneous lymphoma clinic through the collaboration of dermatologists, haematologists, and oncologists. Level of evidence is specified for each treatment option. For HMF, phototherapy is recommended as a first line treatment, while low-dose methotrexate is considered a second line. For early classical MF, we recommend Psoralen-ultraviolet A (PUVA), which is a well-tolerated treatment option in dark phenotype. Addition of either retinoic acid receptor (RAR) agonist and/or methotrexate is recommended as a second line. Total skin electron beam (TSEB) is considered a third-line option. For advanced stage, PUVA plus RAR agonist and/or methotrexate is recommended as first line, TSEB or monochemotherapy is considered a second line option. Polychemotherapy is regarded as a final option. All patients with complete response (CR) enter a maintenance and follow-up schedule. We suggest a practical algorithm for the treatment of MF for patients with dark phenotype living in countries with limited resources.
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Shintani Y, Nishida E, Furuhashi T, Muramatsu S, Kubo R, Nakamura M, Watanabe S, Masuda H, Ikumi K, Matsumoto K, Yamazaki S, Morita A. Efficacy of bath-psoralen and ultraviolet A therapy for mycosis fungoides - retrospective analysis of 62 cases. J Dermatol 2021; 49:239-245. [PMID: 34309912 PMCID: PMC9292667 DOI: 10.1111/1346-8138.16077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 07/04/2021] [Accepted: 07/06/2021] [Indexed: 11/27/2022]
Abstract
Photochemotherapy with psoralen and ultraviolet A (PUVA) is widely used for refractory skin diseases. Bathwater delivery of 8‐methoxypsoralen (8‐MOPS) with subsequent UVA irradiation (bath‐PUVA) or oral administration of 8‐MOPS with UVA is used to treat mycosis fungoides. We retrospectively analyzed 62 patients with mycosis fungoides (8 stage IA, 30 stage IB, 5 stage IIB, 18 stage IIIA, and 1 stage IVA2) treated with bath‐PUVA at the Dermatology Clinic of Nagoya City University Hospital from November 2004 to December 2013. A complete response was achieved in 37 (59.7%) patients, a partial response was achieved in 16 (25.8%), and stable disease was achieved in 6 (9.7%). Progressive disease was observed in 3 (4.8%) patients. Almost all patients in stage IA/IB achieved a complete response. Of the 5 stage IIB patients, 2 achieved a partial response, 1 achieved stable disease, and 2 had progressive disease. The serum concentrations of soluble interleukin‐2 receptor and lactate dehydrogenase decreased significantly following treatment with bath‐PUVA (p < 0.001). We examined the risk factors of patients whose stage progressed despite PUVA treatment. A multivariate Cox regression analysis of risk factors associated with stage progression yielded a hazard ratio of 28.5 for stage IIb. Treatment with bath‐PUVA is highly effective in the early stages of mycosis fungoides, and partially effective in advanced stages.
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Affiliation(s)
- Yoichi Shintani
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Emi Nishida
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takuya Furuhashi
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shinnosuke Muramatsu
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ryoji Kubo
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Motoki Nakamura
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shoichi Watanabe
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hideyuki Masuda
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kyoko Ikumi
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazuhiko Matsumoto
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Sayuri Yamazaki
- Department of Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Akimichi Morita
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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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: 16] [Impact Index Per Article: 4.0] [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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Abstract
Cutaneous T-cell lymphomas (CTCL) are a heterogenous group of non-Hodgkin lymphomas arising in the skin. Mycosis fungoides (MF), the most common variant, is characterised by clonal proliferation of skin residing malignant T-cells. Initially appearing with erythematous patches and plaques it follows a chronic course with progression to cutaneous tumours and extracutaneous involvement in some patients. Phototherapy with ultraviolet A radiation combined with 8-methoxypsoralen (PUVA) and with narrow-band ultraviolet B radiation (NB-UVB) are among the first line options for the treatment of MF and can induce remission in most patients. Sézary syndrome (SS) is a rare and more aggressive CTCL variant with generalized skin involvement. Patients with SS and with erythroderma from MF can benefit from treatment with extracorporeal photochemotherapy (ECP) where peripheral blood is exposed to PUVA. Phototherapy can be safely combined with systemic agents, most notably interferon-alpha and retinoids. Another photoresponsive CTCL variant is lymphomatoid papulosis (LP), a CD30+ lymphoproliferative disease characterised by chronically recurring papules. The disease responds favourably to PUVA but low dose methotrexate might be preferred for long term disease control. Recently updated treatment guidelines have been published to provide evidence-based algorithms for the stage-oriented treatment of MF, SS and LP. Areas of uncertainty are treatment schedules that are currently not optimised for CTCL, the use of phototherapy for maintenance, and the value of ultraviolet A1 radiation, excimer lasers, and photodynamic therapy.
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Affiliation(s)
- Franz Trautinger
- Department of Dermatology and Venereology, Karl Landsteiner University of Health Sciences, University Hospital of St. Pölten, Austria.
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Almohideb M, Walsh S, Walsh S, Shear N, Alhusayen R. Bath Psoralen-ultraviolet A and Narrowband Ultraviolet B Phototherapy as Initial Therapy for Early-stage Mycosis Fungoides: A Retrospective Cohort of 267 Cases at the University of Toronto. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:604-612. [DOI: 10.1016/j.clml.2017.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/04/2017] [Accepted: 06/08/2017] [Indexed: 10/19/2022]
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European Organisation for Research and Treatment of Cancer consensus recommendations for the treatment of mycosis fungoides/Sézary syndrome – Update 2017. Eur J Cancer 2017; 77:57-74. [DOI: 10.1016/j.ejca.2017.02.027] [Citation(s) in RCA: 202] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 02/19/2017] [Accepted: 02/24/2017] [Indexed: 01/03/2023]
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Olsen EA, Hodak E, Anderson T, Carter JB, Henderson M, Cooper K, Lim HW. Guidelines for phototherapy of mycosis fungoides and Sézary syndrome: A consensus statement of the United States Cutaneous Lymphoma Consortium. J Am Acad Dermatol 2015; 74:27-58. [PMID: 26547257 DOI: 10.1016/j.jaad.2015.09.033] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ultraviolet light (UVL) is a long established treatment for mycosis fungoides (MF) and Sézary syndrome (SS), subtypes of cutaneous T-cell lymphoma (CTCL). Treatments have traditionally included broadband, narrowband ultraviolet B light (UVB) and psoralen plus ultraviolet A light photochemotherapy (PUVA), but more recently, treatment options have expanded to include UVA1 and excimer laser. UVL is used either as monotherapy or as an adjuvant to systemic therapy, demonstrating efficacy in many cases that equal or surpass systemic medications. Despite its utility and duration of use, the current practice of using UVL guidelines for psoriasis to treat patients with MF/SS is problematic because the goals of prolonging survival and preventing disease progression are unique to CTCL compared to psoriasis. OBJECTIVES We sought to develop separate guidelines for phototherapy for MF/SS for both clinical practice and for clinical trials. METHODS Literature review and cutaneous lymphoma expert consensus group recommendations. RESULTS This paper reviews the published literature for UVB and UVA/PUVA in MF/SS and suggests practical standardized guidelines for their use. LIMITATIONS New standardization of phototherapy. CONCLUSIONS These guidelines should allow the comparison of results with phototherapy in MF/SS across different stages of patients, centers, and in combination with other agents in practice and in clinical trials.
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Affiliation(s)
- Elise A Olsen
- Departments of Dermatology and Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Emilia Hodak
- Department of Dermatology, Rabin Medical Center, Beilinson Hospital, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Thomas Anderson
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan
| | - Joi B Carter
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Marsha Henderson
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | - Kevin Cooper
- Department of Dermatology, Case Western Reserve University, Cleveland, Ohio
| | - Henry W Lim
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
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Pavlotsky F, Hodak E, Ben Amitay D, Barzilai A. Role of bath psoralen plus ultraviolet A in early-stage mycosis fungoides. J Am Acad Dermatol 2014; 71:536-41. [DOI: 10.1016/j.jaad.2014.04.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 04/04/2014] [Accepted: 04/08/2014] [Indexed: 11/17/2022]
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Kato H, Saito C, Ito E, Furuhashi T, Nishida E, Ishida T, Ueda R, Inagaki H, Morita A. Bath-PUVA therapy decreases infiltrating CCR4-expressing tumor cells and regulatory T cells in patients with mycosis Fungoides. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 13:273-80. [PMID: 23332394 DOI: 10.1016/j.clml.2012.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 11/29/2012] [Accepted: 12/08/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mycosis fungoides (MF) is a malignant lymphoma characterized by expansion of CD4(+) memory T-cell clones. Infiltrating cells express CCR4, which is attracted to CC chemokine ligands 17 and 22 (thymus and activation-regulated chemokine [TARC]/CCL17 and TARC/CCL22). Bath-psoralen plus ultraviolet A (PUVA) is effective against MF. In patients with psoriasis, bath-PUVA induces circulating regulatory T cells (Tregs), which suppress effector T cells. To understand the mechanisms in MF, we analyzed lesion-infiltrating cells before and after bath-PUVA therapy. PATIENTS AND METHODS Thirteen patients with MF (12 stage IB, 1 stage III; mean age 69.2 years, range 35-87 years; 6 men, 7 women) were recruited. RESULTS Immunohistochemical analysis revealed that lesion CCR4-positive (CCR4(+)) cells and Tregs significantly decreased from 105.1 ± 164.8 cells/10(-2) mm(2) to 31.4 ± 39.0 cells/10(-2) mm(2) and from 78.1 ± 67.8 cells/10(-2) mm(2) to 24.7 ± 25.0 cells/10(-2) mm(2), respectively. Serum TARC levels significantly correlated with infiltrating CD3(+) (r = 0.997), CCR4(+) (r = 0.991), and forkhead box P3-positive (Foxp3(+)) cells (r = 0.843). Circulating Tregs before bath-PUVA therapy were not significantly different from those in healthy volunteers. Bath-PUVA did not significantly change the percentage of circulating Tregs. CONCLUSIONS Bath-PUVA decreased CCR4(+) cells and Tregs in MF lesions but did not induce circulating Tregs, which might suppress effector T cells. Direct effects through skin lesions might eliminate both pathogenetically relevant cells and Tregs. Systemic immunosuppression was not induced.
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Affiliation(s)
- Hiroshi Kato
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
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Walker D, Jacobe H. Phototherapy in the Age of Biologics. ACTA ACUST UNITED AC 2011; 30:190-8. [DOI: 10.1016/j.sder.2011.08.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 08/07/2011] [Indexed: 11/29/2022]
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Trautinger F. Phototherapy of mycosis fungoides. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2011; 27:68-74. [PMID: 21392108 DOI: 10.1111/j.1600-0781.2011.00559.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND/PURPOSE Among the primary cutaneous T-cell lymphomas, mycosis fungoides (MF) is the most common disease entity. Recently, an improved understanding of the pathology, clinical presentation, and prognosis of MF has lead to the development of new and practically useful classification and staging systems. In most patients, MF presents with patches and plaques and remains confined to the skin for years and decades, making it an ideal target for phototherapy. However, treatment schedules vary widely and this review describes the current knowledge about phototherapy of MF focusing mainly on narrow- and broadband UVB and 8-methoxypsoralen plus UVA, its indications, practical aspects, and clinical outcome. METHODS Review and summary of the pertinent literature. RESULTS AND CONCLUSIONS Since 1976, when the first report on phototherapy for MF was published, sufficient evidence has accumulated to make narrowband UVB and PUVA safe and effective treatment options for early stages of the disease. In refractory cases or more advanced stages, combination of phototherapy with systemic treatments including mainly interferons and retinoids might be valuable. Additional research is required to further define the optimal treatment schedules and the role of maintenance.
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Affiliation(s)
- Franz Trautinger
- Karl Landsteiner Institute for Dermatological Research, St. Pölten, Austria.
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Gomes AJ, Lunardi LO, Caetano FH, Machado AEH, Oliveira-Campos AMF, Bendhack LM, Lunardi CN. Biodegradable nanoparticles containing benzopsoralens: An attractive strategy for modifying vascular function in pathological skin disorders. J Appl Polym Sci 2011. [DOI: 10.1002/app.33427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Inaoki M, Kawabata C, Yagishita M, Nishijima C. Large plaque parapsoriasis with the "deck-chair" sign successfully treated with bath psoralen and ultraviolet A therapy. J Dermatol 2010; 37:570-2. [PMID: 20536677 DOI: 10.1111/j.1346-8138.2010.00832.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rodríguez-Granados MT, Carrascosa JM, Gárate T, Gómez-Díez S, Guimaraens-Juantorena D. Documento de consenso sobre la modalidad terapéutica del baño-PUVA. ACTAS DERMO-SIFILIOGRAFICAS 2007; 98:164-70. [PMID: 17504700 DOI: 10.1016/s0001-7310(07)70040-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Bath PUVA is a variant of phototherapy as efficacious as oral PUVA therapy that avoids many of the adverse effects associated to this treatment. Nevertheless, the special features and the specialized equipment required for its employment have limited its application in the dermatologic clinics of our country. Following the trend initiated after the publication of the consensus document on oral PUVA therapy and narrow band (NB) UVB therapy, the Spanish Photobiology Group from the Spanish Academy of Dermatology and Venereology has developed a therapeutic guideline for bath PUVA therapy based on the literature review and the experience of its members. The document aims to be a practical reference guide for those dermatological centres that include phototherapy among their services. It reviews the concept and indications of this type of treatment and proposes recommendations concerning therapeutic procedures, drug associations of interest and prophylaxis and management of adverse effects.
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Rodríguez-Granados M, Carrascosa J, Gárate T, Gómez-Díez S, Guimaraens-Juantorena D. Consensus Document on Therapy With Bath Psoralen-UV-A. ACTAS DERMO-SIFILIOGRAFICAS 2007. [DOI: 10.1016/s1578-2190(07)70420-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Ko CJ. The New World Health Organization–European Organization for Research and Treatment of Cancer Classification of Cutaneous Lymphomas. ACTA ACUST UNITED AC 2006; 22:259-77. [PMID: 17249305 DOI: 10.1016/j.yadr.2006.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The WHO-EORTC classification of cutaneous lymphomas is a good start to unifying nomenclature, a necessity before coherent consensus diagnoses can be made. There are three provisional diagnoses in this new classification that are not covered in detail in this review because they are rare diseases that still require further study for definitive classification. Much remains to be elucidated about cutaneous lymphomas, but understanding of the major entities within the new classification is an important first step in understanding these diverse diseases.
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Affiliation(s)
- Christine J Ko
- Yale University, 15 York Street, LMP 5031, New Haven, CT 06510, USA.
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