Primary cutaneous CD4+ small/medium pleomorphic T-cell lymphoproliferative disorder: Where do we stand? A systematic review

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.

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.

Care structure of patients with mycosis fungoides and Sézary syndrome in Germany - Care research based on SHI claims data

BACKGROUND

Cutaneous T-cell lymphomas (CTCLs) are rare forms of non-Hodgkin's lymphoma of T-cell origin that occur mainly in the skin. The most common form is mycosis fungoides (MF), but Sézary syndrome (SS), a more aggressive form of CTCL, is another relevant subgroup. Due to the rare nature of the disease, population-based studies of the epidemiology and disease burden and insights into care delivery are limited.

PATIENTS AND METHODS

Based on an anonymized, age and sex-adjusted routine dataset comprising approximately five million people with statutory health insurance, a retrospective, longitudinal healthcare research study was conducted over a six-year period (2012-2017).

RESULTS

In 55 % of patients with MF and SS, the initial diagnosis was documented in an outpatient setting; in 59 % of cases by a dermatologist. Immunophenotyping by flow cytometry is considered an important investigative tool for the detection and follow-up surveillance of blood involvement of cutaneous lymphomas, as the disease stage is the most important prognostic factor in MF and SS; this was performed in only 10 % of patients. The first-line treatment was topical (76 %), in particular with corticosteroids (66 %).

CONCLUSIONS

The findings from this healthcare research point to the need for increased guideline-based care.

Primary cutaneous CD4+ small/medium T-cell lymphoma: a case report

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder is a rare disease characterized by a single mass on the face or upper part of the trunk. It usually presents an asymptomatic and favorable progression, and its histopathologic findings include small and medium-sized lymphoid cells. The authors report a case of primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder on the forehead. A 51-year-old man presented with a protruding mass on his forehead that the patient had noted 1 month previously. Surgical excision and a permanent biopsy were performed under local anesthesia. Based on the biopsy results, the mass was diagnosed as a primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder. There was no evidence of recurrence at a 15-month follow-up visit.

The Clinical Spectrum of Primary Cutaneous CD4+ Small/Medium-Sized Pleomorphic T-Cell Lymphoproliferative Disorder: An Updated Systematic Literature Review and Case Series

BACKGROUND

Primary cutaneous CD4+ small/medium pleomorphic T-cell lymphoproliferative disorder (SMPLPD) is a provisional entity within the 2016 World Health Organization classification of primary cutaneous lymphomas. The condition is currently classified as a lymphoproliferative disorder to emphasize its benign course and discourage aggressive, systemic treatment modalities.

OBJECTIVE

To provide a relevant synthesis for the dermatological practitioner on the prevalence, presentation, and treatment of SMPLPD.

METHODS

We conducted an updated systematic literature review and a retrospective chart review of diagnosed cases of SMPLPD from 2 Canadian academic cutaneous lymphoma centers.

RESULTS

A total of 23 studies with 136 cases were extracted from the systematic review and 24 patients from our retrospective chart review. SMPLPD proved relatively common accounting for 12.5% of all cutaneous T-cell lymphomas encountered in our cutaneous lymphoma clinics, second in frequency only to mycosis fungoides. The typical clinical presentation was that of an older individual (median age 59 years) with an asymptomatic solitary lesion on their upper extremity. The most common clinical differentials were cutaneous lymphoid hyperplasia, basal cell carcinoma, and lymphoma unspecified. T follicular helper markers were reliably detected. The main treatment modalities were surgical excision, local radiation therapy, and topical or intralesional steroids. Cure was achieved in the vast majority of cases.

CONCLUSIONS

SMPLPD is an underdiagnosed T-cell lymphoma with an overtly benign clinical course. The condition has an excellent prognosis and responds well to skin-directed therapies. Practitioners should be aware of this condition to avoid aggressive systemic treatments.

Epidemiological changes in cutaneous lymphomas: an analysis of 8593 patients from the French Cutaneous Lymphoma Registry

BACKGROUND

Primary cutaneous lymphomas (PCLs) are a heterogeneous group of T-cell (CTCL) and B-cell (CBCL) malignancies. Little is known about their epidemiology at initial presentation in Europe and about potential changes over time.

OBJECTIVES

The aim of this retrospective study was to analyse the frequency of PCLs in the French Cutaneous Lymphoma Registry (GFELC) and to describe the demography of patients.

METHODS

Patients with a centrally validated diagnosis of primary PCL, diagnosed between 2005 and 2019, were included.

RESULTS

The calculated incidence was unprecedently high at 1·06 per 100 000 person-years. The number of included patients increased yearly. Most PCL subtypes were more frequent in male patients, diagnosed at a median age of 60 years. The relative frequency of rare CTCL remained stable, the proportion of classical mycosis fungoides (MF) decreased, and the frequency of its variants (e.g. folliculotropic MF) increased. Similar patterns were observed for CBCL; for example, the proportion of marginal-zone CBCL increased over time.

CONCLUSIONS

Changes in PCL frequencies may be explained by the emergence of new diagnostic criteria and better description of the entities in the most recent PCL classification. Moreover, we propose that an algorithm should be developed to confirm the diagnosis of PCL by central validation of the cases.

How do we treat cutaneous T-cell lymphoma?

Cutaneous T-cell lymphomas are a heterogeneous group of non-Hodgkin lymphomas which are based on the malignant proliferation of skin-related T lymphocytes. The clinical appearance, as well as the course and the associated therapeutic approach, are sometimes very different between the different subtypes. Since allogeneic stem cell transplantation is currently the only curative option, and the morbidity and mortality are not insignificant, a therapy concept should be developed that considers its often rather indolent but chronic course. This concept should enable a good disease control with as few side effects as possible and preserve or improve the quality of life. In the early stages of the disease, skin-oriented therapies are generally used first before systemic and increasingly aggressive therapeutic agents are used as the disease progresses. Considering the current guidelines, literature and subjective experience, we summarize in this review how we treat cutaneous T-cell lymphomas.

Multifocal CD4+ Primary Cutaneous Small/Medium Lymphoproliferative Disorder Successfully Treated With Low-Dose Oral Methotrexate: A Case Report

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (PCSM-LPD) is a rare indolent disorder often associated with a favourable prognosis. It typically presents as a solitary skin lesion, mainly in the head, neck, or upper trunk region. Multifocal PCSM-LPD is a rare entity, with no standard treatment approaches available. In this article, we present the case of a 56-year-old male patient with multifocal biopsy-proven PCSM-LPD that was treated with methotrexate orally at 10 mg/m² body surface area weekly and successfully achieved full clinical resolution by the 10th week of therapy. A review of the literature indicates the efficacy of combination chemotherapy. However, due to the indolent nature of this disorder and the undesired side effects from combination chemotherapy, our treatment method involved oral methotrexate alone, and it was successful. Oral methotrexate is a potential therapeutic option in the management of multifocal PCSM-LPD and it warrants further investigations.

Primary cutaneous CD4-positive small/medium T-cell lymphoproliferative disorder: The first-reported Latin-American case with response to doxycycline

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder is a provisional entity according to the last WHO-EORTC classification. The treatment of choice has not yet been defined. Local therapies have been used with variable response. Doxycycline as a main treatment option is a potential low-cost and effective alternative for this disorder.