The PROCLIPI international registry of early-stage mycosis fungoides identifies substantial diagnostic delay in most patients

Cutaneous T Cell Lymphoma Following Dupilumab Therapy in Patients with Atopic Dermatitis: Clinical Review and Recommendations

The complex interplay between atopic dermatitis (AD) and cutaneous T cell lymphomas (CTCL) has been known as a matter of clinical concern. With the widespread use of dupilumab, a monoclonal antibody inhibiting interleukin-4 receptor alpha (IL-4Ra) and interleukin-13 receptor (IL-13R), potential association between dupilumab and developing CTCL has been reported in patients with AD. Disease progression has also been described in patients with known CTCL who were treated with dupilumab. Although population-based and pharmacovigilance data support an increased risk of CTCL with dupilumab use in patients with AD, it is a rare association, most likely occurring in predisposed patients. No evidence is available to support a direct oncogenic risk of transforming AD into lymphoma by the treatment, and current literature suggests the role of IL-4Ra/IL-13R inhibition in unmasking pre-existing malignant T cell clones through increased IL-13 availability. On the basis of a comprehensive literature review and our experience in a cutaneous lymphoma clinic at a tertiary cancer center, we provide practical clinical care recommendations for the use of dupilumab in patients with AD, CTCL, and non-skin lymphomas. We also highlight the need for further researching alternative diagnostic approaches to differentiate CTCL from AD and other inflammatory skin disorders and studying the roles of IL-13 and its receptors in CTCL and the effect of the newly available IL-13-inhibiting therapies.

Geospatial analyses demonstrate variation of cutaneous T-cell lymphomas across Australia, providing insights into possible causes

BACKGROUND

Cutaneous T-cell lymphomas (CTCLs) are rare with distinct diagnostic challenges. Equitable access to cancer care is a recognized priority, internationally. To date, the geospatial distribution of CTCL has not been definitively studied. Understanding the incidence and geographical distribution of patients with CTCL are critical first steps towards the ultimate goal of equity of care. Geospatial analyses also allow the opportunity to explore environmental causative factors: for CTCL, the contribution of solar ultraviolet (UV) radiation on causation remains unclear.

OBJECTIVES

We investigate geospatial patterns of CTCL incidence across Australia, compare with all rare cancers, and consider solar UV exposure on causality and diagnosis rates.

METHODS

All CTCL diagnoses (1 January 2000 to 31 December 2019) were obtained from the nationwide dataset. Areas of residence were collected according to nationally approved definitions. Bayesian spatial incidence models were applied. Geospatial distributions were visually analysed.

RESULTS

The CTCL age-standardised incidence rate was 7.7 (95% confidence interval 7.4-7.9) per million people per year in Australia. Diagnostic disparity was seen between Australian states/territories, with lower diagnosis rates in rural/remote and socioeconomically disadvantaged areas. Incidence exceeded the national average within more densely populated capital cities. Visual comparisons of the geospatial distribution of CTCL revealed marked discordances with the geospatial patterns of all rare cancers and solar UV in Australia.

CONCLUSIONS

Geographical heterogeneity in CTCL exists across Australia. Incidence reflects population density. Geospatial patterns of CTCL differ substantially from all rare cancers, with implications for the unique diagnostic challenges and unmet needs of this patient population. The distribution of CTCL across Australia does not support a causative link with UV exposure. Further global evaluation of geospatial patterns is warranted.

Clinical Characteristics, Management and Long-Term Outcomes of 180 Patients With Early-Stage Mycosis Fungoides at a Tertiary Centre-A 34-Year Retrospective Study

BACKGROUND

Mycosis fungoides (MF) is the commonest form of primary cutaneous T-cell lymphoma. Progression is slow, with frequent relapses. Data for predicting early-stage MF progression and recurrence are inadequate.

METHODS

The clinical profile, treatment response, relapse, progression to advanced stage and final status of 180 patients diagnosed with early MF between January 1987 and September 2021 were investigated retrospectively.

RESULTS

Ninety-four (52.2%) patients were female and 86 (47.8%) male. Stage at diagnosis was IA in 74 (41.1%) patients, IB in 72 (40%) and IIA in 34 (18.9%). Initial treatment was PUVA in 76 (42.2%) patients and NB-UVB in 59 (32.7%). Complete response occurred in 109 (60.5%) patients, and 73 (51.5%) patients experienced recurrence. Stage IA/IB at diagnosis, normal B-2-microglobulin levels and low CLIPI score were associated with complete response. Progression to advanced stage occurred in 27 (%15) patients. Age 60 and over at diagnosis, stage at diagnosis, pruritus, LDH, CLIPI score between 3 and 5, and folliculotropism in pathology were found to be negative prognostic factors in progression to advanced stage. Classical pathology, PUVA treatment and complete response to initial treatment were found to be positive prognostic factors. In multivariate analysis, LDH and complete responsiveness to initial treatment were independently associated with progression to advanced stage.

CONCLUSION

Advanced age at diagnosis, a high CLIPI score and folliculotropism affect both progression to advanced stage and the final status of the disease. LDH level is a crucial indicator of progression to an advanced stage. Early diagnosis affects the treatment response, with a complete response to the initial treatment mitigating the risk of advanced-stage progression.

RN7SL1 overexpression promotes cell proliferation in cutaneous T-cell lymphoma via miR-34a-5p/MYCN axis

BACKGROUND

Cutaneous T-cell lymphoma (CTCL) is a type of lymphoma that presents in skin tissue without evidence of extracutaneous disease. Emerging evidence indicates that long noncoding RNA-RN7SL1 serves as crucial effectors in modulating progression of different malignancies, including breast cancer, liver cancer, and other neoplasms.

OBJECTIVE

To figure out the role of RN7SL1 in the pathogenesis of CTCL.

METHODS

We detected RN7SL1 expression of CTCL patients by quantitative real-time polymerase chain reaction and fluorescent in situ hybridization. CTCL cell lines were transfected with lentiviral-based RN7SL1 gene knockdown vectors. Whole transcriptome sequencing was conducted to investigate differentially expressed miRNA and mRNA in CTCL, and we used qRT-PCR, RNA immunoprecipitation, dual-luciferase assay, RNA pull down and Western Blotting to further detect the relation of miRNA and mRNA. Also, we have verified above results in mice and clinical samples.

RESULTS

LncRNA-RN7SL1 was overexpressed in CTCL compared with benign inflammatory dermatosis and was related to the TNMB stage of mycosis fungoides and Sézary syndrome (higher expression in IIB-IVB stage than IA-IIA stage). Additionally, the proliferation of CTCL cell lines HH and Hut78 was weakened, but apoptosis was facilitated by RN7SL1 downregulation, resulting in a reduced tumorigenic capacity in vivo. Subsequently, Whole transcriptome sequencing and target validation indicated that the RN7SL1/miR-34a-5p/MYCN axis may promoted malignant behavior in CTCL.

CONCLUSION

Our study suggested that RN7SL1 promoted malignant behavior by targeting miR-34a-5p/MYCN signaling. This finding might facilitate the discovery of novel biomarkers for CTCL diagnosis and treatment.

Mycosis fungoides: differentiation from inflammation and detection of circulating tumour cells with the EuroClonality next-generation sequencing assay

BACKGROUND

Mycosis fungoides (MF) is a rare malignancy that is characterized by the presence of circulating tumour cells (CTCs) in a subgroup of patients. Reliably distinguishing MF from inflammatory skin conditions is challenging.

OBJECTIVES

To evaluate the potential benefits of next-generation sequencing (NGS)-based T-cell receptor rearrangement repertoire analysis in detecting clonal rearrangements in MF and inflammatory skin conditions.

METHODS

Skin biopsies and blood samples from 33 patients with MF and 10 patients with inflammatory skin conditions were analysed using TRB and TRG NGS. Twenty-seven patients had early-stage IA (n = 19) and IB (n = 8) MF, and six had advanced-stage disease (IIB, n = 5; IIIA, n = 1).

RESULTS

Analysis applying standard abundance thresholds identified at least one clonal rearrangement in the skin DNA of 97% (n = 32/33) of patients with MF and in 90% (n = 9/10) of those with inflammatory skin conditions. To enhance specificity, an abundance and distribution-based approach was applied, which considered only rearrangements that significantly stood out from the physiological background as clonal (MF, n = 29/33; inflammatory skin conditions, n = 1/10), allowing for highly sensitive (88%) and specific (90%) discrimination between MF and other inflammatory skin conditions. CTCs were detected in 46% (n = 11/24) of patients with early-stage MF and in 60% (n = 3/5) of those with late-stage MF.

CONCLUSIONS

NGS-based T-cell receptor repertoire analysis is a highly sensitive and specific method for the differential diagnosis of early-stage MF vs. inflammatory skin conditions, and for the sensitive molecular detection of CTCs.

Haematogenous seeding in mycosis fungoides and Sézary syndrome: current evidence and clinical implications

Cutaneous T-cell lymphomas (CTCLs) are a heterogeneous group of diseases characterized by abnormal neoplastic T-cell growth in the skin. Mycosis fungoides (MF), the most common CTCL, manifests as erythematous skin patches and/or plaques, tumours or erythroderma. The disease may involve blood, lymph nodes and rarely viscera. Sézary syndrome (SS) is a unique leukaemia/lymphoma syndrome related to MF, which presents with blood and skin involvement at diagnosis. The pathogenesis of MF/SS is not fully elucidated. The presence of skin lesions at distant sites underpins a hypothesis that MF/SS lesions may develop through haematogenous seeding. Phenotypic similarities between malignant and normal T cells led to the notion that disease-initiating mutations occur in specific subtypes of mature T cells, which are responsible for most CTCLs. However, this mature T-cell precursor model is not always consistent with clinical observations and research on MF/SS pathogenesis. Here, we review evidence supporting an alternative model of pathogenesis for MF/SS involving haematogenous seeding as a key process responsible for the initiation and progression of the disease. According to this hypothesis, malignant transformation occurs at an early stage of T-cell development (probably in bone marrow or thymus), yielding circulating neoplastic T cells which colonize the skin where the microenvironment is most permissive for proliferation and evolution. These mutated precursor cells seed the skin where they find a suitable niche to develop into clinically perceptible disease. Subsequently, malignant T cells can re-enter the bloodstream, re-seed pre-existing lesions and seed new areas of the skin, causing synchronous and convergent changes in the transcriptomic profile of lesions and tumours, and clinical disease progression - 'consecutive haematogenous seeding' captures this temporal phenomenon. This model radically changes the current understanding of CTCL pathogenesis, transforming it from a primarily cutaneous disease with secondary involvement of blood, to a systemic disease, where the spread of malignant cells through the blood to the skin is not a phenomenon of advanced disease but is an essential component of pathogenesis. This understanding of MF/SS could have several clinical implications, including standardizing our approach to assessing blood tumour burden, potential advances in prognosis and monitoring, and investigating combination treatments to improve patient outcomes.

T-Cell Receptor Rearrangements in Early Stages of Mycosis Fungoides May Be Associated with Pronounced Copy Number Variations: A Prognostic Factor?

Mycosis fungoides (MF), the most common form of cutaneous T-cell lymphoma, poses significant diagnostic challenges due to its overlap with benign inflammatory skin diseases and the absence of specific symptoms. Accurate early diagnosis and stratification of patients by progression risk are essential for effective treatment. This study proposes a proof-of-concept for integrating T-cell receptor (TCR) clonality analysis with somatic mutation profiling to enhance diagnostic confidence and prognostic accuracy in early-stage MF. This study's methodology comprised the analysis of nine patients with early MF (stages IA/IB) using whole-exome sequencing and TCR repertoire profiling. The analysis revealed the presence of clonal TCR rearrangements in seven patients, while somatic mutations were identified in two. A notable finding was a recurrent chromosome 7 trisomy in these two cases. The patients were stratified into three molecular profiles: (1) somatic mutations with clonal TCR rearrangement (n = 2), (2) clonal TCR rearrangement without somatic mutations (n = 4), and (3) neither somatic mutations nor clonal TCR rearrangement (n = 3). These findings emphasise the heterogeneity of MF and underscore the limitations of relying solely on TCR clonality or mutation burden for diagnosis. This study underscores the potential of somatic mutations as diagnostic markers to distinguish MF from benign conditions and as prognostic indicators for disease progression. A combined genetic approach may refine treatment decisions, particularly for patients with higher tumor cell fractions and pronounced genetic alterations. Despite the limited size of the cohort, the results advocate for larger, multi-center studies to validate these findings and integrate genetic analyses into routine MF management.

Differential Expression of p53 in Mycosis Fungoides, Sezary Syndromes, and Their Transformed Forms

ABSTRACT

Mycosis fungoides (MF) and Sezary syndrome (SS) are common entities among primary cutaneous lymphomas. Large cell transformation is challenging for diagnosis and therapy. Molecular mechanisms by which these lymphomas undergo this transformation are poorly defined. We studied the immunohistochemical status of p53 in these entities and assessed whether p53 expression could be a useful tool for diagnosis and assessment of transformation. We extracted patients with transformed and untransformed SS or MF from the French Study Group on Cutaneous Lymphoma database between 2014 and 2021, followed in the Rennes University Hospital. An immunohistochemical study of p53 expression was performed on the biopsies sampled as part of routine care. We compared p53 overexpression in the different groups. We included 25 patients with MF, 7 patients with transformed MF (T-MF), 11 patients with SS, and 5 patients with transformed SS (T-SS). Using a cut-off set at 30% expression of neoplastic cells, we noted an overexpression of p53 in T-MF and T-SS compared with nontransformed forms (47% vs. 12%, respectively, P < 0.01) and in MF compared with SS (23% vs. 7%, respectively, P < 0.01). Overexpression of p53 with a cut-off at 30% therefore seems to be a discriminating tool in the differential diagnosis of MF/SS versus their transformed forms as well as the differential diagnosis between MF and SS.

Single-cell sequencing delineates T-cell clonality and pathogenesis of the parapsoriasis disease group

BACKGROUND

Mycosis fungoides (MF), the most common cutaneous T-cell lymphoma, is often underdiagnosed in early stages because of similarities with benign dermatoses such as atopic dermatitis (AD). Furthermore, the delineation from what is called "parapsoriasis en plaque", a disease that can appear either in a small- or large-plaque form, is still controversial.

OBJECTIVE

We sought to characterize the parapsoriasis disease spectrum.

METHODS

We performed single-cell RNA sequencing of skin biopsies from patients within the parapsoriasis-to-early-stage MF spectrum, stratified for small and large plaques, and compared them to AD, psoriasis, and healthy control skin.

RESULTS

Six of 8 large-plaque lesions harbored either an expanded alpha/beta or gamma/delta T-cell clone with downregulation of CD7 expression, consistent with a diagnosis of early-stage MF. In contrast, 6 of 7 small-plaque lesions were polyclonal in nature, thereby lacking a lymphomatous phenotype, and also revealed a less inflammatory microenvironment than early-stage MF or AD. Of note, polyclonal small- and large-plaque lesions characteristically harbored a population of NPY+ innate lymphoid cells and displayed a stromal signature of complement upregulation and antimicrobial hyperresponsiveness in fibroblasts and sweat gland cells, respectively. These conditions were clearly distinct from AD or psoriasis, which uniquely harbored CD3+CRTH2+ IL-13 expressing "TH2A" cells, or strong type 17 inflammation, respectively.

CONCLUSION

These data position polyclonal small- and large-plaque parapsoriasis lesions as a separate disease entity that characteristically harbors a so far undescribed innate lymphoid cell population. We thus propose a new term, "polyclonal parapsoriasis en plaque", for this kind of lesion because they can be clearly differentiated from early- and advanced-stage MF, psoriasis, and AD on several cellular and molecular levels.

Mycosis fungoides and Sézary syndrome - Simplifying the approach for dermatologists. Part 1: Etiopathogenesis, clinical features and evaluation

Cutaneous T-cell lymphomas (CTCL) are a heterogeneous group of extranodal non-Hodgkin's lymphomas characterised by a cutaneous infiltration of malignant monoclonal T lymphocytes. While this broad spectrum of disease with its varied etiopathogenesis, clinical features and management options are well characterised, an approach from a dermatologist's perspective is lacking in the literature. We strive to elucidate the approach from a clinician's point of view, especially in respect of clinical examination, investigations, staging and management options that are available in the realm of the dermatologists. This review article is the first part out of the two, covering the etiopathogenesis, clinical features and evaluation.

Breaking Down the Barriers for Patients With Cutaneous T-Cell Lymphoma: Current Controversies and Challenges for Radiation Oncologists in 2024

Cutaneous T-cell lymphomas (CTCL) are a rare collection of diseases, frequently associated with diagnostic challenges and complex management dilemmas. The multidisciplinary team is vital for accurate clinico-pathological diagnoses and for collaborative therapeutic decisions throughout the management journey, which frequently involves multiple lines of therapy. Radiotherapy (RT) is a highly effective skin-directed therapy for CTCL, commonly delivered as localised fields or as total skin electron beam therapy (TSEBT). Mycosis fungoides (MF) is the most common of the CTCL, and patients typically experience high rates of morbidity and long natural histories of relapse and progression. Patients with MF typically present with incurable disease; in these patients, RT has an established role in symptom- and disease-control, achieving excellent response rates and proven therapeutic benefits. The role of RT continues to evolve, with modern practices favouring lower doses to reduce toxicity risks and allow for re-irradiation. Less commonly, there are situations where RT has an integral role in the potential cure of patients with MF: firstly, in the setting of unilesional MF where localised RT alone may be curative, and secondly, in the setting of preconditioning prior to curative-intent allogeneic hematopoietic stem cell transplant for patients with advanced MF/Sezary syndrome, where conventional-dose TSEBT is indicated as the most effective single agent for maximal debulking of skin disease. Radiotherapy also has an important role in the management of the less common CTCL, including the curative treatment of localised primary cutaneous anaplastic large cell lymphoma. Despite proven efficacy and quality of life benefits, disparity exists in access to RT and TSEBT. World-wide, stronger multidisciplinary collaborations and greater patient advocacy are required to increase access to RT and improve equity of care for our patients with CTCL.

Perspectives on the Mature T-Cell Lymphomas in the Middle East: A Comprehensive Review of the Present Status

Background: T-cell lymphomas (TCLs) are rare and aggressive malignancies associated with poor outcomes, often because of the development of acquired drug resistance as well as intolerance to the established and often toxic chemotherapy regimens in elderly and frail patients. The many subtypes of TCL are well established to exhibit marked geographic variation. The epidemiology, clinical presentation, diagnosis, prognosis, and treatment of TCLs in the Middle East (ME) are yet to be explored; hence, limited data are available about these entities in this part of the world. Aim: Therefore, in this review article, we aim to discuss the available data regarding the T-cell neoplasms in the ME, including the incidence of specific subtypes of peripheral T-cell lymphoma (PTCL), as well as the trends in survival and treatment, all in an effort to understand the natural history of these complex entities across the ME.

Maintenance therapy for CTCL: importance for prevention of disease progression

There are no established maintenance protocols for cutaneous lymphomas. We aim to determine patient treatments and outcomes during the COVID-19 pandemic in order to uncover the most effective maintenance protocols for cutaneous lymphomas and impact of treatment interruption. Data was collected retrospectively from nine international institutions, including 149 patients. Younger patients had earlier stages of disease and were most frequently treated with skin-directed therapies including topical steroids, mechlorethamine gel, and phototherapy. Treatment interruption varied by treatment type and stage, with patients on topical therapies and earlier stages of disease being least likely to experience interruption. Treatment interruption was significantly associated with progression of disease and worse outcomes, with twice as many patients progressing who had interruption compared to those without interruption. This study may demonstrate the significance of continuous maintenance therapies, even in younger patients with early stages of disease.

Real-world Use of Mogamulizumab Among Patients With Mycosis Fungoides and Sézary Syndrome Before and During COVID-19 in the United States

PURPOSE

During the coronavirus disease 2019 (COVID-19) pandemic, professional organizations suggested extending dosing intervals for systemic cancer therapies to limit in-person visits. Mogamulizumab, indicated for adults with relapsed or refractory mycosis fungoides (MF) or Sézary syndrome (SS) after ≥1 prior systemic therapy, should be administered every 7 days of the first 28-day cycle (loading) and every 14 days of each subsequent cycle (maintenance) according to the approved prescribing information in the United States (US). This study examined the real-world use of mogamulizumab before and during the COVID-19 pandemic in the US.

METHODS

Using Symphony Health's Integrated Dataverse (IDV) database, adults with ≥1 diagnosis of MF or SS and ≥1 mogamulizumab claim between October 1, 2018 and December 22-, 2022 were identified. Patients in MF and SS cohorts were divided into 3 subgroups based on the date they initiated mogamulizumab treatment: pre-COVID-19 (October 1, 2018-March 31, 2020), COVID-19 Phase 1 (April 1, 2020-July 31, 2021), and COVID- 19 Phase 2 (August 1, 2021-December 22, 2022).

FINDINGS

During the study, 270 patients with MF and 337 patients with SS initiated mogamulizumab. The pre-COVID-19, COVID-19 Phase 1, and COVID-19 Phase 2 subgroups included 95, 81, and 94 patients with MF and 124, 119, and 94 patients with SS, respectively. In the MF cohort, mean loading dosing intervals were 13, 12, and 9 days for the pre-COVID-19, COVID-19 Phase 1, and COVID-19 Phase 2 subgroups, respectively, and mean maintenance dosing intervals were 16, 16, and 16 days, respectively. In the SS cohort, mean loading dosing intervals were 16, 11, and 11 days, and mean maintenance dosing intervals were 19, 18, and 16 days, respectively. For both cohorts, more patients in the COVID-19 Phase 1 and Phase 2 subgroups than in the pre-COVID-19 subgroup had gaps of ≤10 days between loading doses and ≤21 days between maintenance doses.

IMPLICATIONS

In patients with MF and SS, loading dosing intervals in the pre-COVID-19 period were longer than the loading schedule per the approved prescribing information, but there was a trend towards closer concordance in the COVID-19 periods. Maintenance dosing intervals in patients with MF were consistently similar to the approved schedule across treatment periods, and in patients with SS became more closely aligned over time. Thus, dosing intervals for mogamulizumab in both loading and maintenance cycles do not appear to have been extended during the COVID-19 Phase 1 and Phase 2 periods compared with the pre-COVID-19 period, despite recommendations to extend dosing intervals for systemic cancer therapies during COVID-19.

Demonstration of T-Cell Monotypia Using Anti-TCRbeta1/2 (TRBC1/2) Immunostaining as a Rapid and Cost-Effective Alternative to PCR-Based Clonality Studies for the Diagnosis of T-Cell Lymphoma

BACKGROUND/OBJECTIVES

T-cell lymphomas are often histologically indistinguishable from benign T-cell infiltrates, and diagnosis typically relies on slow, complex, and expensive multiplexed PCR reactions, requiring significant training and experience to interpret them. We aimed to raise highly specific antibodies against the two alternatively used and very similar T-cell receptor beta constant regions, TCRbeta1 and TCRbeta2, encoded by the TRBC1 and TRBC2 gene segments, respectively. We sought to demonstrate the feasibility of detecting TCRbeta1 and TCRbeta2 immunohistochemically in routine clinical (formalin-fixed, paraffin-embedded (FFPE)) tissue sections as a novel diagnostic strategy for T-cell lymphomas.

METHODS

Recombinant rabbit antibodies were validated using Western blotting and FFPE immunostaining of T-cell leukemia lines. The immunostaining of FFPE tissue containing benign and lymphomatous T-cell populations was undertaken, with corroboration by BaseScopeTM high-sensitivity in situ hybridization and quantitative real-time PCR (Q-PCR). An additional Q-PCR literature review and analysis of publicly available RNAseq data was used to determine the TCRbeta2/TCRbeta1 ratio cut-off to separate benign and malignant T-cell populations.

RESULTS

Our TCRbeta1/TCRbeta2 antibody pair gave highly specific FFPE tissue staining. All benign samples analyzed (immunohistochemically, by BaseScopeTM, by Q-PCR, and by RNAseq data analysis) had TCRbeta1/TCRbeta2 or TRBC1/TRBC2 ranges well within the previously published flow cytometric benign range (TCRbeta2/TCRbeta1 = 0.18:1-5.7:1), while samples of T-cell lymphoma did not. One out of thirteen (7.7%) lymphoma samples showed some detectable TCRbeta1/TCRbeta2 protein co-expression, and 4 out of 13 (30.8%) T-cell lymphomas showed a TRBC1/TRBC2 transcript co-expression using BaseScopeTM.

CONCLUSIONS

Analyzing T-cell monotypia immunohistochemically, analogous to B-cell monotypia (kappa: lambda ratio for B-cell and plasma cell neoplasms), could make the diagnosis of T-cell lymphomas cheaper, quicker, and more accurate. Larger studies are needed to validate our antibodies for clinical use.

Cutaneous T-cell lymphoma: Consensus on diagnosis and management in Taiwan

Cutaneous T cell lymphomas (CTCLs), with mycosis fungoides (MF) and Sézary syndrome (SS) as the classic types, are the commonest group of primary cutaneous lymphomas. The diverse clinical manifestation and non-specific histologic findings of early lesions in CTCLs render diagnosis challenging. Treatment modalities also vary and include topical and oral medications, chemotherapy, phototherapy, and radiation therapies. Local dermatological, hemato-oncologic and radiotherapeutical experts in Taiwan convened meetings in 2023 to review and discuss the latest evidence and updates regarding diagnosis and management of CTCLs. A consensus was developed with the aim to raise awareness and understanding, provide practical guidance for early diagnosis and appropriate management, and ultimately optimize care to maximize benefits of patients.

Nanopore Sequencing for T-Cell Receptor Rearrangement Analysis in Cutaneous T-Cell Lymphoma

Background: Analysis of T-cell receptor (TCR) clonality is a major diagnostic tool for lymphomas, particularly for cutaneous T-cell lymphomas (CTCL) like Mycosis fungoides and Sézary syndrome. However, a fast and cost-effective workflow is needed to enable widespread use of this method. Methods: We established a procedure for TCR rearrangement analysis via Oxford Nanopore Technology (ONT) sequencing. TCR receptor rearrangements (TCR-gamma and TCR-beta chains) were analyzed in samples from 45 patients with various diagnoses: Mycosis fungoides (37/45), Sézary Syndrome (2/45), folliculotropic CTCL (1/45), and non-CTCL diagnoses as polyclonal controls (5/45). Sample types included formalin-fixed paraffin-embedded (FFPE) samples (27/45), fresh frozen samples (9/45), and CD3-isolated cells (9/45). In addition, DNA of a Jurkat cell line was used as a monoclonal control. TCR amplicons were generated employing an optimized version of the protocol from the Euro Clonality consortium. Sequencing was conducted on the ONT GridION and Illumina MiSeq platforms, followed by similar bioinformatic analysis protocols. The tumor clone frequency (TCF), a crucial prognostic factor for CTCL patients, was used for method comparison. Results: The use of an optimized amplicon protocol and adapted bioinformatic tools demonstrated a strong correlation in TCF values between both sequencing methods across all sample types (range R: 0.992-0.996; range r2: 0.984-0.991). Conclusions: In summary, ONT sequencing was able to detect TCR clonality comparable to NGS, indicating its potential as a faster and more cost-effective option for routine diagnostic use.

Non-Invasive Imaging Including Line-Field Confocal Optical Coherence Tomography (LC-OCT) for Diagnosis of Cutaneous Lymphomas

Background/Objectives: Primary cutaneous lymphomas (PCL) are a heterogeneous group of non-Hodgkin lymphomas arising from malignant T (CTCL) or B (CBCL) cells, often mimicking other skin conditions. Recently, non-invasive diagnostic imaging modalities, including dermoscopy, Reflectance Confocal Microscopy (RCM), and Line-field Optical Coherence Tomography (LC-OCT), have become increasingly important, supporting clinicians in clinical practice. Hence, our study aimed to describe dermoscopic, RCM, and LC-OCT features of PCL and to explore their role in PCL management. Methods: Between December 2022 and January 2024, 40 lesions of 25 patients with PCL were retrospectively analyzed at the Dermatologic Unit of the University of Siena, Italy. Predefined dermoscopic, LC-OCT, and RCM criteria were assessed and their frequencies were calculated. Results: At dermoscopy, CTCL lesions were characterized by pinkish structureless areas (58,6%) and homogeneous distributed dotted vessels (35,7%), whereas 57.1% of CBCL presented with orange-yellow structureless areas. Considering CTCL, lymphocytes in the epidermis, dermal-epidermal junction, and dermis were detected by LC-OCT in 73.1%, 66.7%, and 51.9% and by RCM in 72.2%, 55.6%, and 61.1% of cases, respectively. The detection of lymphocytes was more precise using RCM than LC-OCT in CTCL (p < 0.001). Dermal infiltration of medium-reflective cells was visible in 80% and 40% of CBCL cases by LC-OCT and RCM, respectively. Conclusions: Non-invasive imaging techniques may support clinicians in managing PCL; however, further studies are mandatory in this field.

Detecting T-cell receptor clonality in patients with severe atopic dermatitis refractory to dupilumab

BACKGROUND

Trials and real-life studies demonstrated clinically meaningful improvements of disease activity in the majority of patients with moderate to severe atopic dermatitis (AD) treated with the anti-IL-4RA-antibody dupilumab. However, misdiagnosis or confounding skin diseases in particular cutaneous T-cell lymphoma (CTCL) may lead to inadequate response.

OBJECTIVE

To investigate the clinical and pathological features of patients with AD who showed insufficient response to dupilumab.

METHODS

We reviewed the medical records of 371 patients treated with dupilumab for severe AD. Insufficient response was defined as failure to achieve an improvement of the eczema area severity index (EASI) of at least 50% (EASI-50) at Week 16 and of 75% (EASI-75) at Week 52. Among 46 patients with insufficient response, 35 patients consented to a re-evaluation including a full physical exam, biopsies and laboratory assessments including immunohistochemistry and T-cell receptor gene rearrangement analysis to differentiate CTCL.

RESULTS

Of the 371 patients treated with dupilumab, 46 (12.3%) patients showed insufficient response to dupilumab. Of these, 35 underwent further evaluation, and 19 (54.2% of inadequate responders) were finally diagnosed with mycosis fungoides (MF). In these patients, transition to or addition of conventional MF treatment led to clinical improvements.

CONCLUSIONS

Insufficient response to dupilumab treatment may help uncover early MF on an existing AD background.

Urticarial mycosis fungoides: A distinctive presentation with blood involvement and a peculiar immunophenotype

Mycosis fungoides (MF) has been widely reported to mimick a considerable number of different dermatoses, including scarring alopecia, bullous dermatoses or cysts, and comedones. In atypical presentations, histopathology is essential for the diagnosis. We present two cases of MF with clinical urticarial lesions and a striking blood involvement that responded to mogamulizumab treatment. Histopathologically, both cases had classic MF features and shared a peculiar immunophenotype, with positivity for CD25 and FOXP3. Differential diagnoses included urticarial lymphomatoid drug reactions and other lymphomas, like T-cell prolymphocytic leukemia, atypical Sézary syndrome, or adult T-cell lymphocytic leukemia. A low suspicion threshold is necessary for the diagnosis of atypical presentations of MF.

Survival Analysis and Prognostic Factors in a Case Series of 148 Cutaneous T-Cell Lymphomas

BACKGROUND AND OBJECTIVE

Cutaneous T-cell lymphomas (CTCL) such as mycosis fungoides (MF) and Sézary syndrome (SS) are rare lymphomas with varying prognoses. The aim of the study was to describe the survival of a cohort of patients with MF/SS and evaluate the prognostic factors impacting disease survival.

MATERIALS AND METHODS

All cases of MF/SS diagnosed from 2008 through 2022 were retrospectively analyzed. The demographic variables, histological parameters, and analytical data were analyzed too. Progression-free survival (PFS) and disease-specific survival (DSS) were calculated.

RESULTS

A total of 148 cases were included. A total of 121 (82%) and 27 cases were diagnosed with MF, and SS, respectively. A total of 37 patients (25%) experienced progression at some point disease progression. The median PFS and median DSS were 127 and 135 months, respectively. Age >60 years, diagnosis of SS, the presence of large cell transformation (LCT) at diagnosis, folliculotropism in early stages, high Ki-67 expression, the presence of the clonal T-cell receptor (TCR) in blood, elevated LDH and B2M levels, and advanced stages (IIB, IVA, T3, T4, N3/Nx) were associated with worse prognosis across the entire cohort.

CONCLUSIONS

Stage IVA and the presence of LCT at diagnosis stood out as independent factors of unfavorable prognosis. LCT was the variable that most significantly impacted the patients' survival and was closely associated with tumor skin involvement and stage IIB.

[Translated article] Survival Analysis and Prognostic Factors in a Case Series of 148 Cutaneous T-Cell Lymphomas

BACKGROUND AND OBJECTIVE

Cutaneous T-cell lymphomas (CTCL) such as mycosis fungoides (MF) and Sézary syndrome (SS) are rare lymphomas with varying prognoses. The aim of the study was to describe the survival of a cohort of patients with MF/SS and evaluate the prognostic factors impacting disease survival.

MATERIALS AND METHODS

All cases of MF/SS diagnosed from 2008 through 2022 were retrospectively analyzed. The demographic variables, histological parameters, and analytical data were analyzed too. Progression-free survival (PFS) and disease-specific survival (DSS) were calculated.

RESULTS

A total of 148 cases were included. A total of 121 (82%) and 27 cases were diagnosed with MF, and SS, respectively. A total of 37 patients (25%) experienced progression at some point disease progression. The median PFS and median DSS were 127 and 135 months, respectively. Age >60 years, diagnosis of SS, the presence of large cell transformation (LCT) at diagnosis, folliculotropism in early stages, high Ki-67 expression, the presence of the clonal T-cell receptor (TCR) in blood, elevated LDH and B2M levels, and advanced stages (IIB, IVA, T3, T4, N3/Nx) were associated with worse prognosis across the entire cohort.

CONCLUSIONS

Stage IVA and the presence of LCT at diagnosis stood out as independent factors of unfavorable prognosis. LCT was the variable that most significantly impacted the patients' survival and was closely associated with tumor skin involvement and stage IIB.

Primary cutaneous, epidermotropic mycosis fungoides-like presentation: critical appraisal and description of two novel cases, broadening the spectrum of ALK+ T-cell lymphoma

Leading from a two-case series, including two patients receiving a diagnosis of epidermotropic T-cell lymphoma, featuring a mycosis fungoides (MF)-like clinical pattern and ALK expression and molecular alteration, we performed a critical appraisal of ALK+ primary cutaneous T-cell lymphomas (pcTCL). Considering our patients and the literature, 32 cases were retrieved, 7 of which featured an MF-like clinical picture over a 4-to-20-year period. MF-like cases show distinctive histology, comprising a predominantly epidermotropic infiltration of small-to-large, atypical-to-pleomorphic, with few anaplastic cells, negligible-to-intense CD30-expression, and a CD4+/cytotoxic granule+ phenotype. These features should prompt a search for ALK expression captured by the ALK D5F3 clone. Bona fide ALK+ pcTCL is very rare, and existent data suggest the presence of a broader pattern of disease, including instances mimicking MF and/or primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma. The major challenges in dealing with this subset include prodromal phases, misinterpreted as inflammatory dermatosis or parapsoriasis/early phase MF both clinically and histologically, while recognition of its ALK-driven biology is hampered both by the unusual clinic-pathologic pattern of the disease, which stands apart from the classical (i.e., nodal) picture of ALK+ anaplastic large cell lymphoma and by the low sensitivity of ALK1 clone. Data on its optimal management are far from being conclusive: An MF-like approach is currently chosen, but depending on CD30 and, most notably, ALK expression, a targeted therapy could be envisaged in advanced stages, as clinical response to ALK inhibition was documented in one patient.

The skin microbiome stratifies patients with cutaneous T cell lymphoma and determines event-free survival

Mycosis fungoides (MF) is the most common entity of Cutaneous T cell lymphomas (CTCL) and is characterized by the presence of clonal malignant T cells in the skin. The role of the skin microbiome for MF development and progression are currently poorly understood. Using shotgun metagenomic profiling, real-time qPCR, and T cell receptor sequencing, we compared lesional and nonlesional skin of 20 MF patients with early and advanced MF. Additionally, we isolated Staphylococcus aureus and other bacteria from MF skin for functional profiling and to study the S. aureus virulence factor spa. We identified a subgroup of MF patients with substantial dysbiosis on MF lesions and concomitant outgrowth of S. aureus on plaque-staged lesions, while the other MF patients had a balanced microbiome on lesional skin. Dysbiosis and S. aureus outgrowth were accompanied by ectopic levels of cutaneous antimicrobial peptides (AMPs), including adaptation of the plaque-derived S. aureus strain. Furthermore, the plaque-derived S. aureus strain showed a reduced susceptibility towards antibiotics and an upregulation of the virulence factor spa, which may activate the NF-κB pathway. Remarkably, patients with dysbiosis on MF lesions had a restricted T cell receptor repertoire and significantly lower event-free survival. Our study highlights the potential for microbiome-modulating treatments targeting S. aureus to prevent MF progression.

Immunobiology and treatment of cutaneous T-cell lymphoma

INTRODUCTION

Primary cutaneous T cell lymphomas (CTCL) are a heterogenous group of non-Hodgkin lymphomas derived from skin-homing T cells. These include mycosis fungoides and its leukemic variant Sezary syndrome, as well as the CD30+ lymphoproliferative disorders.

AREAS COVERED

In this review, we provide a summary of the current literature on CTCL, with a focus on the immunopathogenesis and treatment of mycosis fungoides and Sezary syndrome.

EXPERT OPINION

Recent advances in immunology have provided new insights into the biology of malignant T cells. This in turn has led to the development of new therapies that modulate the immune system to facilitate tumor clearance or target specific aspects of tumor biology.

Cutaneous T-cell lymphoma care across Europe: insights from the HORIZON programme

In this perspective we provide BJD readers with an overview of the HORIZON programme. It illuminates the diverse perspectives of specialists across five prominent European centres of excellence in the field of CTCL.

Update on T-Cell Lymphoma Epidemiology

PURPOSE OF REVIEW

T-cell lymphomas (TCLs) are a group of rare subtypes of non-Hodgkin lymphoma derived from mature T-lymphocytes. Recent updates in lymphoma classification based on the cell-of-origin pathogenesis have shed new light on TCL epidemiology and outcomes. Contemporary regional consortia and international studies, including those conducted recently in Asia and South America, have provided an updated delineation of the major subtypes across various global regions.

RECENT FINDINGS

Peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), remains the most common subtype globally except in Asia, where extra-nodal NK-T cell lymphoma (ENKTL) has emerged as the most prevalent. Angioimmunoblastic T-cell lymphoma (AITL) is the second most common subtype globally except in South America where its incidence falls behind adult T-cell leukemia/lymphoma (ATLL) and ENKTL. ALK-negative anaplastic large cell lymphoma (ALCL) has been recognized as the second most common subtype in some parts of South America. Studies on the newly classified breast implant-associated ALCL (BIA-ALCL) are beginning to reveal its distribution and risk factors. Deciphering the epidemiology of TCLs is a challenging endeavor due to the rarity of these entities and ongoing refinement in classification. Collaborative efforts on prospective registries based on the most current WHO classifications will help capture the true epidemiology of TCL subtypes to better focus resources for diagnostic, prognostic, and therapeutic efforts.

Systemic treatments with monoclonal antibodies in mycosis fungoides and Sézary syndrome

Mycosis fungoides (MF) and Sézary syndrome (SS) are the most prevalent non-Hodgkin lymphomas that comprise cutaneous T-cell lymphomas (CTCL), accounting for more than 70% of cases. Following the Tumor Lymph nodes Metastasis Blood system, disease staging is carried out, and within ten years, about thirty percent of patients in the early stages will have advanced disease. Plaques, folliculotropism, and age over 60 are risk factors for progression. A 5-year survival rate of less than 20% is associated with LCT in MF. Treatment requires an interdisciplinary approach; skin-directed therapies are available for early stages of the disease, but there are no curative options for advanced stages of the disease other than allogeneic stem cell transplantation. Because of their severe symptoms and poor treatment efficacy, patients in advanced stages have a lower quality of life and a lower chance of survival. In patients with CD30-expressing CTCL, Brentuximab Vedotin has demonstrated better response rates and progression-free survival (PFS); in advanced SS, mogamulizumab has significantly increased PFS. These findings emphasize the need to standardize prognostic factors and improve CTCL treatment.

Advances in the pharmacological management of cutaneous T-cell lymphoma

INTRODUCTION

Current treatment guidelines for cutaneous T cell lymphoma (CTCL) advocate a stage-driven approach, considering clinical presentation, symptom burden, and patient comorbidities. Therapy selection hinges on factors like disease subtype, severity, and treatment availability. The primary goal is to enhance the quality of life by mitigating symptoms, as achieving lasting complete remission is infrequent.

AREAS COVERED

Over the past decade (2013-2023), the therapeutic landscape of CTCL has experienced substantial transformation with the introduction of innovative therapies. This review explores the main pivotal developments in traditional treatment schedules and recently introduced drugs, aiming to offer clinicians and researchers a thorough perspective on the decade's progress in the field.

EXPERT OPINION

Despite the progress made in CTCL therapeutics, ranging from topical chemotherapeutics to immunomodulatory agents, several unmet needs persist. Firstly, there is a pressing need for the incorporation of readily available predictors for treatment response, encompassing clinical, pathological, and molecular features. Secondly, a more profound comprehension of the tumor microenvironment is imperative to optimize the landscape of targetable molecules. Lastly, the undertaking of studies on combination regimens should be encouraged as it enhances therapy efficacies by synergistically combining agents with diverse modes of action.

Risk of progression of early-stage mycosis fungoides, 10-year experience

BACKGROUND

Mycosis fungoides is the most frequent form of cutaneous T-cell lymphoma. It is characterized by a chronic, slow, and progressive course, and is associated with mortality rates that depend on several factors, such as clinical staging. A median survival time of up to 13 months is found in patients with advanced stages that require more aggressive treatments, with greater toxicity and higher costs. In Latin America, few prognostic studies of the disease are available.

OBJECTIVE

To determine the rate of progression from early stages (IA, IB, IIA) to more advanced stages (> IIB) in patients older than 18 years with mycosis fungoides treated at two medical centers in Colombia between January 1, 2010, and December 31, 2019.

METHODS

Retrospective cohort study with a longitudinal design.

RESULTS

112 patients diagnosed with early mycosis fungoides were included. 56.2% were male (n = 63), with a median age of 53 years (IQR 43‒67). The most frequent clinical variant was classic (67.9%; n = 76), followed by folliculotropic (16%; n = 18), and hypopigmented (10.7%; n = 12). The most common first-line treatment was NB-UVB phototherapy (27.7%; n = 31), followed by PUVA phototherapy (25.8%; n = 29%), and topical corticosteroids (25%; n = 28). The global rate of disease progression was 8% (n = 9), with an overall mortality of 12.5% (n = 14).

STUDY LIMITATIONS

Its retrospective design and the lack of molecular studies for case characterization.

CONCLUSIONS

Early mycosis fungoides is a disease with a good prognosis in most patients, with a progression rate of 8% (n = 9).

Five paediatric patients with mycosis fungoides and our approach to provide age-appropriate information and psychological support

Cutaneous lymphoproliferative diseases in childhood are rare and they are clinically and pathologically heterogeneous, which makes their diagnosis challenging. Although there is limited long-term data and guidance on management, evidence suggests these to be different conditions from cutaneous lymphoma in adults, highlighting the need for age-appropriate patient information. We present clinical outcomes for our paediatric cohort of five patients with mycosis fungoides, emphasizing that despite diagnostic delays, mycosis fungoides in this age group tends to yield a good prognosis. It remains uncommon to provide clinical expertise together with psychological support in a dermatology paediatric service. Here, we provide our experience in offering this combined service. In conjunction with these patients, we have co-produced an accessible patient information leaflet targeted at a younger audience for support and to clarify potential misconceptions from a diagnosis of cutaneous lymphoma.

Predictive and Prognostic Biomarkers in Patients With Mycosis Fungoides and Sézary Syndrome (BIO-MUSE): Protocol for a Translational Study

BACKGROUND

Cutaneous T-cell lymphoma (CTCL) is a rare group of lymphomas that primarily affects the skin. Mycosis fungoides (MF) is the most common form of CTCL and Sézary syndrome (SS) is more infrequent. Early stages (IA-IIA) have a favorable prognosis, while advanced stages (IIB-IVB) have a worse prognosis. Around 25% of patients with early stages of the disease will progress to advanced stages. Malignant skin-infiltrating T-cells in CTCL are accompanied by infiltrates of nonmalignant T-cells and other immune cells that produce cytokines that modulate the inflammation. Skin infection, often with Staphylococcus aureus, is frequent in advanced stages and can lead to sepsis and death. S. aureus has also been reported to contribute to the progression of the disease. Previous reports indicate a shift from Th1 to Th2 cytokine production and dysfunction of the skin barrier in CTCL. Treatment response is highly variable and often unpredictable, and there is a need for new predictive and prognostic biomarkers.

OBJECTIVE

This prospective translational study aims to identify prognostic biomarkers in the blood and skin of patients with MF and SS.

METHODS

The Predictive and Prognostic Biomarkers in Patients With MF and SS (BIO-MUSE) study aims to recruit 120 adult patients with MF or SS and a control group of 20 healthy volunteers. The treatments will be given according to clinical routine. The sampling of each patient will be performed every 3 months for 3 years. The blood samples will be analyzed for lactate dehydrogenase, immunoglobulin E, interleukins, thymus and activation-regulated chemokine, and lymphocyte subpopulations. The lymphoma microenvironment will be investigated through digital spatial profiling and single-cell RNA sequencing. Microbiological sampling and analysis of skin barrier function will be performed. The life quality parameters will be evaluated. The results will be evaluated by the stage of the disease.

RESULTS

Patient inclusion started in 2021 and is still ongoing in 2023, with 18 patients and 20 healthy controls enrolled. The publication of selected translational findings before the publication of the main results of the trial is accepted.

CONCLUSIONS

This study aims to investigate blood and skin with a focus on immune cells and the microbiological environment to identify potential new prognostic biomarkers in MF and SS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04904146; https://www.clinicaltrials.gov/study/NCT04904146.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55723.

Mortalität, prognostische Parameter und Behandlungsstrategien bei Mycosis fungoides

Hintergrund und Ziele

Mycosis fungoides (MF), das häufigste primär kutane T‐ Zell‐Lymphom, ist durch einen variablen klinischen Verlauf charakterisiert. Dieser ist entweder indolent oder infaust bei Progression mit extrakutaner Beteiligung. Das Fehlen von Prognosemodellen bei überwiegend palliativen Therapiemodalitäten erschweren das Patientenmanagement. Ziel dieser Studie war es, Überlebensraten, Treffsicherheit von verfügbaren Prognosemodellen und den Therapieerfolg bei MF‐Patienten zu evaluieren.

Patienten und Methodik

Hundertvierzig MF‐Patienten wurden retrospektiv untersucht. Prognose, Krankheitsprogression beziehungsweise Überlebensraten wurden anhand univariater Cox‐ Regressionsmodellen und Kaplan‐Meier‐ Schätzungen analysiert.

Ergebnisse

Hauttumoren waren im Vergleich zu Erythrodermie mit einem kürzeren progressionsfreien Überleben und Gesamtüberleben sowie einem 3,48‐fach erhöhtem Risiko für Krankheitsprogression verbunden. Der Cutaneous Lymphoma International Prognostic Index identifizierte Risikopatienten lediglich im frühen Krankheitsstadium. Zudem waren die Expression von Ki‐67 > 20%, CD30 > 10%, CD20+ und CD7– unabhängig vom Krankheitsstadium mit einem signifikant schlechteren Outcome verbunden. Eine langfristige Krankheitskontrolle wurde lediglich mit Interferon‐α als Monotherapie oder durch Kombination von Phototherapie mit Interferon‐α oder Retinoiden/Bexaroten erreicht.

Schlussfolgerungen

Unsere Daten unterstützen die Vorhersagekraft von etablierten Prognoseparametern und ‐modellen bei MF. Zusätzlich wurden neue Parameter, die mit einer schlechten Prognose assoziiert sind, identifiziert. Prospektive Studien, die Prognoseindikatoren in Bezug auf Krankheitsstadium und Therapie synergistisch evaluieren sind erforderlich, um die Patientenbetreuung zu verbessern.

Evaluation of mortality, prognostic parameters, and treatment efficacy in mycosis fungoides

BACKGROUND AND OBJECTIVES

Mycosis fungoides (MF), the most common primary cutaneous T-cell lymphoma, is characterized by a variable clinical course, presenting either as indolent disease or showing fatal progression due to extracutaneous involvement. Importantly, the lack of prognostic models and predominantly palliative therapy settings hamper patient care. Here, we aimed to define survival rates, disease prediction accuracy, and treatment impact in MF.

PATIENTS AND METHODS

Hundred-forty MF patients were assessed retrospectively. Prognosis and disease progression/survival were analyzed using univariate Cox proportional hazards regression model and Kaplan-Meier estimates.

RESULTS

Skin tumors were linked to shorter progression-free, overall survival and a 3.48 increased risk for disease progression when compared to erythroderma. The Cutaneous Lymphoma International Prognostic Index identified patients at risk in early-stage disease only. Moreover, expression of Ki-67 >20%, CD30 >10%, CD20+, and CD7- were associated with a significantly worse outcome independent of disease stage. Only single-agent interferon-α and phototherapy combined with interferon-α or retinoids/bexarotene achieved long-term disease control in MF.

CONCLUSIONS

Our data support predictive validity of prognostic factors and models in MF and identified further potential parameters associated with poor survival. Prospective studies on prognostic indices across disease stages and treatment modalities are needed to predict and improve survival.

TOX, TWIST1, STAT4, and SATB1 protein expressions in early-stage mycosis fungoides

BACKGROUND

Diagnosis of early mycosis fungoides (eMF) is challenging and often delayed as many of its clinical and histopathologic features may mimic various benign inflammatory dermatoses (BIDs). The products of the thymocyte selection-associated high mobility group box (TOX), twist family BHLH transcription factor 1 (TWIST1), signal transducer and activator of transcription 4 (STAT4), and special AT-rich sequence-binding protein 1 (SATB1) genes function as transcription factors and are involved in the pathogenesis of MF.

OBJECTIVES

We aim to determine the diagnostic value of TOX, TWIST1, STAT4, and SATB1 protein expressions in eMF.

METHODS

This non-randomized, controlled, prospective analytic study was conducted by performing immunohistochemistry staining with TOX, TWIST1, STAT4, and SATB1 polyclonal antibodies in lesional skin biopsies of eMF and BID patients. Nuclear staining of lymphocytes was compared between eMF and BIDs, and the capacity of these antibodies to predict eMF was determined.

RESULTS

Immunostainings with anti-TWIST1 showed an increase in protein expression (p = 0.003) and showed a decrease with anti-SATB1 antibodies in eMF compared to BIDs (p = 0.005) while anti-TOX and anti-STAT4 antibodies did not exhibit significant differences (p = 0.384; p = 0.150). Receiver operating characteristic analysis showed that immunohistochemical evaluations of TWIST1 and SATB1 protein expressions can differentiate eMF (area under the curve [AUC]: 0.728, 95% confidence interval [CI]: 0.605-0.851, p = 0.002; AUC: 0.686, 95% CI: 0.565-0.807, p = 0.013).

CONCLUSIONS

TWIST1 and SATB1 are potential diagnostic markers for the histologic diagnosis of eMF.

Allogeneic stem cell transplant for treatment of mycosis fungoides and Sezary syndrome: a systematic review and meta-analysis

Allogeneic hematopoietic stem cell transplant (allo-HSCT) has been noted to be a potential curative treatment in cases of advanced-stage mycosis fungoides (MF) or Sezary syndrome (SS). To assess outcomes of allo-HSCT for MF/SS we performed a systematic review and meta-analysis including 15 manuscripts and 557 patients, published from 2010-2023. Meta-analysis revealed 1-year and 3+year overall survival (OS) of 51% (95% CI 39-64%) and 40% (32-49%). Progression-free survival at 1 year and 3+years were 42% (31-53%) and 33% (25-42%). Non-relapse mortality was 18% (13-23%). Relapse occurred in of 47% (40-53%) with a median time to relapse of 7.9 months (range 1.6-24 months). Rates of acute and chronic graft-versus-host disease (GVHD) were 45% (35-55%) and 40% (33-48%). Reduced-intensity conditioning (RIC) was associated with superior OS compared to myeloablative conditioning (MAC) (58% vs. 30%, p < 0.001). Of patients with relapse after allo-HSCT, 46% treated with donor lymphocyte infusion (DLI) achieved complete remission. These data support use of allo-HSCT for treatment of advanced-stage MF/SS and suggest superiority of RIC over MAC. Rates of GVHD were comparable to allo-HSCT in general. The improved OS for RIC and high rate of CR with DLI underscore the importance of the graft-versus-lymphoma effect in allo-HSCT for MF/SS.

Allogeneic transplantation and cellular therapies in cutaneous T-cell lymphoma

INTRODUCTION

Mycosis fungoides (MF) and Sezary syndrome (SS) are the most common types of cutaneous T-cell lymphoma. Although many available treatments offer temporary disease control, allogeneic hematopoietic stem cell transplant (allo-HSCT) is the only curative treatment option for advanced stage MF and SS. CAR T-cell therapy is a promising new avenue for treatment.

AREAS COVERED

In this review, we discuss the evidence supporting the use of allo-HSCT for the treatment of MF/SS, including disease status at the time of transplant, conditioning regimen, total body irradiation (TBI), and donor lymphocyte infusion (DLI). We also address the potential role for CAR T-cell therapy in CTCL.

EXPERT OPINION

Allo-HSCT is an effective treatment for patients with advanced MF and SS. However, significant research is required to determine optimal treatment protocols. Data support the use of reduced-intensity conditioning regimens and suggests that the use of TBI for debulking of skin disease may result in more durable remissions. Donor lymphocyte infusions (DLI) appear to be particularly effective in inducing complete remission in MF/SS patients with relapsed or residual disease. Challenges with CAR-T therapies in T-cell lymphoma include T-cell fratricide due to shared antigens on malignant and nonmalignant T-cells, penetrance into the skin compartment, and CAR-T cell persistence.

Clusters, crop dusters, and myth busters: a scoping review of environmental exposures and cutaneous T-cell lymphoma

INTRODUCTION

Cutaneous T-cell lymphoma (CTCL) is a heterogenous group of non-Hodgkin lymphomas. Similar presentation to benign conditions, significant genetic variation, and lack of definitive biomarkers contributes to diagnostic delay. The etiology of CTCL is unknown, and environmental exposures, such as geographic, occupational, chemicals, sunlight, and insects have been investigated.

EVIDENCE ACQUISITION

Review of the literature for CTCL and exposures was performed in PubMed and Google Scholar in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews. This search yielded 193 total results, which were initially screened with defined inclusion and exclusion criteria. The 45 remaining articles were reviewed and classified by exposure type.

EVIDENCE SYNTHESIS

The most frequently investigated CTCL exposure type was geographic (13/45 articles, 29%). Chemical exposures were commonly discussed (10/45 articles, 22%), along with occupational (10/45 articles, 22%). Insect exposures (6/45, 13%) and sun exposure (3/45, 7%) were also reviewed, along with articles describing multiple exposure types (3/45, 7%). Article types ranged from cases to systematic reviews and case-control studies. Evidence linking CTCL and these exposures was mixed. Limitations of this investigation include reliance on patient reporting and frequent speculation on disease association versus causality.

CONCLUSIONS

This investigation synthesizes the current literature on exposures potentially implicated in the pathogenesis of CTCL, while offering guidance on patient history-taking to ensure potential exposures are captured. Awareness of these possible associations may improve understanding of disease pathogenesis and diagnosis. Moreover, these insights may help with public health decision-making and disease mitigation.

International study of treatment efficacy in SS shows superiority of combination therapy and heterogeneity of treatment strategies

Despite increasing availability of therapies, patients with Sezary syndrome (SS) commonly endure multi-line treatment journeys, mostly with partial responses of short duration. Measuring clinical benefit is challenging; time-to-next-treatment (TTNT) provides a robust, objective measurement of efficacy. This international observational study examines patterns of clinical care and therapeutic benefit as measured by TTNT. TTNT was calculated for monotherapies and combination therapies, with consideration to treatment line. 178 patients with SS (73% de novo, 27% secondary) were included, receiving 721 lines of systemic therapy, with median follow-up of 56.9 months. Across all lines, 58 different therapeutic regimens were prescribed (54 were systemic therapies) and classified into 17 treatment groups. The most common first-line treatments were extracorporeal photopheresis (ECP)-containing combination therapy (20%) and retinoid monotherapy (19%). Median TTNT for all first-line therapies was short (5.4 months). First-line, combination therapies had longer median TTNT than monotherapies, 10.0 vs 5.0 months (P = .004), respectively. Later delivery of combination therapies was associated with shorter clinical benefit, with median TTNT reduced to 6.2 and 2.2 months for mid-line (2nd-4th line) and late-line (≥5th line), respectively (P < .001). First-line ECP-containing treatments were associated with longer median TTNT than non-ECP-containing treatments, 9.0 vs 4.9 months (P = .007). For both ECP-monotherapy and ECP-containing combination therapy, significant reductions in TTNT were seen in later lines. These data suggest therapeutic benefit from first-line delivery of combination therapy for SS and favor early inclusion of ECP in the treatment algorithm for those who can access it.

Epidemiologie reifzelliger T- und NK-Zell-Lymphome in Deutschland - Eine repräsentative Querschnittanalyse von GKV-Routinedaten: Epidemiology of mature T/NK-cell lymphomas in Germany - A representative cross-sectional study based on SHI claims data

Hintergrund

Primäre kutane Lymphome sind seltene lymphoproliferative Neoplasien und gehören zur heterogenen Gruppe der Non‐Hodgkin‐Lymphome. Sie umfassen ein klinisch und histologisch breites Spektrum an Manifestationsformen, wobei kutane T‐Zell‐Lymphome (CTCL) mit 73% am häufigsten sind. Aufgrund der Seltenheit der Erkrankungen sind bevölkerungsbasierte Untersuchungen zur Versorgungssituation und Epidemiologie kaum vorhanden.

Patienten und Methodik

Auf Basis anonymisierter, alters‐ und geschlechtsadjustierter GKV‐Routinedaten von circa fünf Millionen gesetzlich Krankenversicherten wurde im Sechsjahreszeitraum (2012–2017) eine retrospektive Analyse zur Bestimmung von Prävalenz, Inzidenz und Letalität von Patienten mit reifzelligen T/NK‐Zell Lymphomen in Deutschland durchgeführt.

Ergebnisse

Insgesamt 1336 T‐Zell‐Lymphom‐Patienten konnten im Beobachtungszeitraum identifiziert werden. Die Sechsjahres‐Prävalenz liegt demnach zwischen 27,35 und 43,58 pro 100 000 Einwohner. Die Patienten waren zu 65% männlich mit einem durchschnittlichen Alter von 66 Jahren (SD 15). Es verstarben 246 Patienten (circa 20 %) innerhalb der 6 Jahre, pro Jahr bis zu 7 %. Die ermittelte Inzidenz bei 153 identifizierten Patienten im Jahr 2017 liegt bei 3,65 bis 3,92 pro 100 000 Einwohner.

Schlussfolgerungen

Erstmalig in Deutschland wurden mithilfe von Abrechnungsdaten der gesetzlichen Krankenversicherung (GKV‐Routinedaten), valide epidemiologische Erkenntnisse von Patienten mit reifzelligen T‐ und NK‐Zell Lymphomen gewonnen. Weitere Analysen für tiefergehende Einblicke in die Versorgung der Patienten mit dieser seltenen Erkrankung sind wünschenswert.

Mode of action, indications and recommendations on extracorporeal photopheresis (ECP)

Extracorporeal photopheresis (ECP) has gained importance in the treatment of several diseases. Initially introduced as a new therapeutic modality for the treatment of patients with cutaneous T-cell lymphoma, the indications for the use of ECP have expanded to include hematology and transplantation immunology. Extracorporeal photopheresis has found its place in the treatment plan of cutaneous T-cell lymphoma, systemic sclerosis, graft-versus-host disease, organ transplantation such as heart and lung, sometimes as first-line therapy and very often in combination with various systemic immunosuppressive therapies. The procedure basically consists of three steps: leukapheresis, photoactivation and reinfusion. The following article presents possible theories about the mechanism of action, which is not yet fully understood, and discusses the five most common indications for ECP treatment with corresponding therapy recommendations.

Typical and Atypical Imaging Features of Malignant Lymphoma in the Abdomen and Mimicking Diseases

Malignant lymphoma typically presents with homogeneous enhancement of enlarged lymph nodes without internal necrotic or cystic changes on multiphasic CT, which can be suspected without invasive diagnostic methods. However, some subtypes of malignant lymphoma show atypical imaging features, which makes diagnosis challenging for radiologists. Moreover, there are several lymphoma-mimicking diseases in current clinical practice, including leukemia, viral infections in immunocompromised patients, and primary or metastatic cancer. The ability of diagnostic processes to distinguish malignant lymphoma from mimicking diseases is necessary to establish effective management strategies for initial radiological examinations. Therefore, this study aimed to discuss the typical and atypical imaging features of malignant lymphoma as well as mimicking diseases and discuss important diagnostic clues that can help narrow down the differential diagnosis.

Epidemiology of mature T/NK-cell lymphomas in Germany - A representative cross-sectional study based on SHI claims data

BACKGROUND

Primary cutaneous lymphomas (PCL) are rare skin tumors of lymphoproliferative neoplasms and belong to the heterogeneous group of non-Hodgkin's lymphomas. PCL encompass a broad spectrum of clinical and histologic manifestations, with cutaneous T-cell lymphoma (CTCL) being the most common (73%). Due to the rarity of the diseases, population-based studies of care and epidemiology are limited.

PATIENTS AND METHODS

Based on anonymized, age- and sex-adjusted SHI (statutory health insurance) claims data of approximately five million SHI-insured patients, a retrospective analysis was conducted over a six-year period (2012-2017) to determine the prevalence, incidence, and lethality in patients with mature-cell T/NK-cell lymphoma in Germany.

RESULTS

A total of 1,336 patients with T-cell lymphoma were identified during the observation period. The six-year prevalence ranged from 27.35 to 43.58 per 100,000. Patients were 65% male with a mean age of 66 years (SD 15). There were 246 patients (approx. 20%) who died within the 6 years, up to 7% per year. The calculated incidence in 153 identified patients in 2017 is 3.65 to 3.92 per 100,000.

CONCLUSIONS

For the first time, valid epidemiologic findings of patients with mature T-cell and NK-cell lymphomas were obtained using SHI claims data in Germany. Further analyses are needed to gain a deeper insight into the healthcare reality of patients with this rare disease.

What Is New in Cutaneous T Cell Lymphoma?

PURPOSE OF REVIEW

This review focuses on updates in prognosis, pathogenesis, and treatment of cutaneous T cell lymphoma (CTCL).

RECENT FINDINGS

Cohort studies indicate imaging may be necessary in early-stage CTCL. Risk factors for progression of CTCL have been identified. Interactions between malignant cells and the tumor microenvironment (TME) and the skin microbiome advance the understanding of pathogenesis and tumor cell dissemination. Studies support a hypothesis of circulating malignant tumor cells. MicroRNA (miR) influence tumor progression and prognosis; the IL22-STAT3-CCL20 cascade may be a novel target. IL-4, IL-5, and IL-31 cytokines are relevant for pruritus and could be targets for therapeutic interventions. Systemic therapies, such as JAK inhibitors, targeted antibodies, and checkpoint inhibitors, show promise in advanced stages. Allogenic hematopoietic stem cell transplantation provides a potential curative option for patients. Further investigations of prognosis and translational research are necessary to improve stratification of patients for treatment.

Wirkweise, Indikationen und Therapieempfehlungen der extrakorporalen Photopherese (ECP)

Die extrakorporale Photopherese (ECP) hat in jüngster Zeit bei der Behandlung verschiedener Krankheiten an Bedeutung gewonnen. Ursprünglich als neue Therapie zur Behandlung von Patienten mit kutanem T‐Zell‐Lymphom vorgestellt, hat sich der Indikationsbereich für die ECP auf Hämatologie und Transplantationsimmunologie erweitert. Die ECP hat ihren festen Platz im Therapieplan bei kutanen T‐Zell‐Lymphomen, systemischer Sklerose, Graft‐versus‐Host‐Erkrankung, Organtransplantationen wie Herz und Lunge, teilweise als Erstlinientherapie und sehr häufig in Kombination mit verschiedenen systemischen immunsuppressiven Therapien. Das Verfahren besteht im Wesentlichen aus drei Schritten: Leukapherese, Photoaktivierung und Reinfusion. Im folgenden Artikel werden die noch nicht vollständig verstandenen Wirkmechanismen dargestellt, die fünf häufigsten Indikationen für die Behandlung mit ECP diskutiert und Therapieempfehlungen für die jeweilige Indikation gegeben.