Systemic therapy for cutaneous T-cell lymphoma: who, when, what, and why?

Harnessing the Potential of Chimeric Antigen Receptor T-Cell Therapy for the Treatment of T-Cell Malignancies: A Dare or Double Dare?

Historical standard of care treatments of T-cell malignancies generally entailed the use of cytotoxic and depleting approaches. These strategies are, however, poorly validated and record dismal long-term outcomes. More recently, the introduction and approval of chimeric antigen receptor (CAR)-T cell therapy has revolutionized the therapy of B-cell malignancies. Translating this success to the T-cell compartment has so far proven hazardous, entangled by risks of fratricide, T-cell aplasia, and product contamination by malignant cells. Several strategies have been utilized to overcome these challenges. These include the targeting of a selective cognate antigen exclusive to T-cells or a subset of T-cells, disruption of target antigen expression on CAR-T constructs, use of safety switches, non-viral transduction, and the introduction of allogeneic compounds and gene editing technologies. We herein overview these historical challenges and revisit the opportunities provided as potential solutions. An in-depth understanding of the tumor microenvironment is required to optimally harness the potential of the immune system to treat T-cell malignancies.

Non-Hodgkin Lymphoma: Examining Mycosis Fungoides and Sézary Syndrome in the Context of Oncology Nursing

BACKGROUND

Mycosis fungoides and Sézary syndrome are the most common non-Hodgkin lymphomas that manifest primarily in the skin. Although early-stage disease has an excellent long-term survival rate, advanced disease carries a poor survival rate. Given the lengthy and complex clinical course, nurses are at the forefront of education and supportive care management for patients and caregivers.

OBJECTIVES

This article aims to provide an overview of mycosis fungoides and Sézary syndrome and to highlight practice considerations for optimal nursing care.

METHODS

Clinical presentation, diagnosis, management, and nursing consideration are discussed.

FINDINGS

Oncology nurses have a vital role in educating patients and their caregivers about the side effects of cancer treatment, appropriate skin care, and infection risk.

Enhancing antitumor immunity through checkpoint blockade as a therapeutic strategy in T-cell lymphomas

The majority of historical therapies for managing T-cell lymphomas (TCLs) have consisted of T-cell-depleting strategies. Unfortunately, these forms of therapies can hamper the ability to mount effective antitumor immune responses. Recently, the use of checkpoint inhibitors has revolutionized the therapy of solid and hematologic malignancies. The development of immunotherapies for the management of TCL has lagged behind other malignancies given 2 central reasons: (1) the competing balance of depleting malignant T cells while simultaneously enhancing an antitumor T-cell response and (2) concern for tumor hyperprogression by blocking inhibitory signals on the surface of the malignant T cell, thereby leading to further proliferation of the malignant cells. These challenges were highlighted with the discovery that programmed cell death protein 1 (PD-1) functions paradoxically as a haploinsufficient tumor suppressor in preclinical TCL models. In contrast, some preclinical and clinical evidence suggests that PD-1/programmed death ligand 1 may become an important therapeutic tool in the management of patients with TCL. Improved understanding of the immune landscape of TCL is necessary in order to identify subsets of patients most likely to benefit from checkpoint-inhibitor therapy. With increased preclinical research focus on the tumor microenvironment, substantial strides are being made in understanding how to harness the power of the immune system to treat TCLs. In this review, designed to be a "call to action," we discuss the challenges and opportunities of using immune-modulating therapies, with a focus on checkpoint inhibitors, for the treatment of patients with TCL.

Monotherapy and combination therapy with acitretin for mycosis fungoides: results of a retrospective, multicentre study

BACKGROUND

Retinoids have long been used in the treatment of cutaneous T-cell lymphomas. However, data on acitretin use for mycosis fungoides (MF) are very limited.

OBJECTIVES

To evaluate treatment outcomes of acitretin in patients with MF attending three academic referral centres in different regions of Greece.

METHODS

Data on effectiveness, safety and drug survival of acitretin as monotherapy or as adjuvant regimen were collected in a multicentre, register-based, retrospective study.

RESULTS

Overall, 128 patients (64.8% male; mean age at MF diagnosis 59.7 years) were included. Folliculotropic MF was present in 24 (18.8%) cases. Most patients (n = 118; 92.2%) had early-stage disease (≤IIA) at acitretin initiation. In all, 28 (21.9%) patients received acitretin monotherapy, while 100 (78.1%) subjects on acitretin concomitantly received phototherapy (n = 65; 50.8%) or topical steroids (n = 27; 21.1%). Acitretin was given as a first-line agent in 73 (57%) cases. A 77.3% overall response rate was noted: 44.5% and 32.8% for complete and partial responses, respectively. Acitretin was more effective as first-line than as a subsequent agent (P = 0.008). A trend towards better response was observed in the combination arm compared to patients receiving acitretin alone (P = 0.056). Median time to best response was 6.9 months (IQR 4.4-9.4); median duration of response was 23.7 months (IQR 11.9-35.4). Overall, the mean length of all treatment patterns was 569 days (SD 718.8). Therapy was discontinued in 5 (3.9%) cases due to drug intolerance. Adverse effects were recorded in 62 (48.4%) cases with dyslipidaemia (n = 31; 24.2%), xerosis (n = 24; 18.6%) and hair loss (n = 10; 7.8%) being the most commonly recorded.

CONCLUSIONS

Acitretin, either alone or as adjuvant, showed a stable long-term effectiveness in this cohort, especially when used in the first-line setting. This RAR-selective agonist may serve as an attractive option for treatment of MF and should be further evaluated.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.

Durable Control of Mycosis Fungoides after Sepsis: "Coley's Toxin?" Case Report and Review of the Literature

Mycosis fungoides, along with Sezary syndrome, is the most common subtype of cutaneous T-cell lymphoma. In this report, we present a patient with advanced-stage mycosis fungoides, who after successful treatment of methicillin-resistant Staphylococcus aureus bacteremia had prolonged disease control off systemic therapy. While this may have been due to single-agent gemcitabine, which can result in long remission, we hypothesize that our patient's durable response was in part due to the immune response elicited after treatment of her severe infection.

Highly cytotoxic natural killer cells are associated with poor prognosis in patients with cutaneous T-cell lymphoma

Paradoxically higher NK-cell activity in CTCL patients is associated with increased expression of phosphorylated STAT5. These highly effective NK cells are associated with poor prognosis in patients with leukemic CTCL.

MicroRNAs in Cutaneous T-Cell Lymphoma: The Future of Therapy

MicroRNAs (miRs) are small, noncoding RNAs with numerous cellular functions. With advancing knowledge of the many functions of miRs in cancer pathogenesis, there is emerging interest in miRs as therapeutic targets in cancers. One disease that poses an intriguing model for miR therapy is cutaneous T-cell lymphoma, a rare disease featuring malignant CD4⁺ T cells that proliferate in the skin. The hallmark of cutaneous T-cell lymphoma progression is epigenetic dysregulation, with aberrant miR levels being a common feature. This review aims to summarize the rapidly emerging advances in the development of miR-based therapies in cancers, with a special emphasis on CTCL.