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Christensen E, Foss OA, Holien T, Juzenas P, Peng Q. Application of Photodynamic Therapy with 5-Aminolevulinic Acid to Extracorporeal Photopheresis in the Treatment of Cutaneous T-Cell Lymphoma: A First-in-Human Phase I/II Study. Pharmaceutics 2024; 16:815. [PMID: 38931936 PMCID: PMC11207254 DOI: 10.3390/pharmaceutics16060815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/08/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Extracorporeal photopheresis (ECP) is a therapeutic modality used for T-cell-mediated disorders. This approach involves exposing isolated white blood cells to photoactivatable 8-methoxypsoralen (8-MOP) and UVA light, aiming to induce apoptosis in T-cells and thereby modulate immune responses. However, conventional 8-MOP-ECP lacks cell selectivity, killing both healthy and diseased cells, and has shown limited treatment efficacy. An alternative approach under investigation involves the use of 5-aminolevulinic acid (ALA) in conjunction with light, referred to as ALA-based photodynamic therapy. Our previous ex vivo studies suggest that ALA-ECP exhibits greater selectivity and efficiency in killing T-cells derived from patients with T-cell-mediated disorders compared to those treated with 8-MOP-ECP. We have conducted a clinical phase I-(II) study evaluating ALA-ECP safety and tolerability in cutaneous T-cell lymphoma (CTCL). Here, 20 ALA-ECP treatments were administered to one CTCL patient, revealing no significant changes in vital signs. Two adverse events were reported; both evaluated by the Internal Safety Review Committee as non-serious. In addition, five conceivable events with mainly mild symptoms took place. During the study period, a 53% reduction in skin involvement and a 50% reduction in pruritus was observed. In conclusion, the results indicate that ALA-ECP treatment is safe and well tolerated.
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Affiliation(s)
- Eidi Christensen
- Department of Dermatology, St. Olav’s Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 7030 Trondheim, Norway
- Department of Pathology, The Norwegian Radium Hospital, Oslo University Hospital, 0310 Oslo, Norway; (P.J.); (Q.P.)
| | - Olav Andreas Foss
- Department of Orthopaedic Surgery, Clinic of Orthopaedic, Rheumatology and Dermatology, St. Olav’s Hospital, Trondheim University Hospital, 7030 Trondheim, Norway;
| | - Toril Holien
- Department of Biomedical Laboratory Science, Norwegian University of Science and Technology (NTNU), 7030 Trondheim, Norway;
- Department of Immunology and Transfusion Medicine, St. Olav’s Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
| | - Petras Juzenas
- Department of Pathology, The Norwegian Radium Hospital, Oslo University Hospital, 0310 Oslo, Norway; (P.J.); (Q.P.)
| | - Qian Peng
- Department of Pathology, The Norwegian Radium Hospital, Oslo University Hospital, 0310 Oslo, Norway; (P.J.); (Q.P.)
- Department of Optical Science and Engineering, School of Information Science and Technology, Fudan University, Shanghai 200433, China
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Ninosu N, Melchers S, Kappenstein M, Booken N, Hansen I, Blanchard M, Guenova E, Assaf C, Goerdt S, Nicolay JP. Mogamulizumab Combined with Extracorporeal Photopheresis as a Novel Therapy in Erythrodermic Cutaneous T-cell Lymphoma. Cancers (Basel) 2023; 16:141. [PMID: 38201568 PMCID: PMC10778082 DOI: 10.3390/cancers16010141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Primary cutaneous T-cell lymphomas (CTCLs) are rare lymphoproliferative malignancies characterized by significant morbidity and mortality in advanced disease stages. As curative approaches apart from allogeneic stem cell transplantation are lacking, establishing new treatment options, especially combination therapies, is crucial. METHODS This retrospective study included 11 patients with SS or MF receiving therapy with mogamulizumab in combination with ECP from four European expert centers. The response rates in the skin and blood as well as treatment use and adverse events (AE) were described. RESULTS 8/11 patients (73%) showed an overall response (OR) in the skin. The mean mSWAT decreased from 98.2 ± 40.8 to 34.6 ± 23.8. The overall response rate (ORR) in the blood was 64% with two complete responses. During combination therapy, the mean number of Sézary cells decreased from 3365.3 × 106/L before treatment to 1268.6 × 106/L. The mean minimum known period without progress was 7.2 months in the skin and 7.6 months in the blood. The most common AEs were mogamulizumab-associated rash (MAR) (45.5%), anemia (27.3%), lymphocytopenia (27.8%), and infusion related reaction (16.7%). No AE led to treatment discontinuation. CONCLUSIONS Our study presents the combination of mogamulizumab and ECP as an effective therapy in the blood and skin in CTCL with good tolerability, similar to mogamulizumab monotherapy.
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Affiliation(s)
- Nadia Ninosu
- Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (N.N.); (S.M.); (S.G.)
| | - Susanne Melchers
- Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (N.N.); (S.M.); (S.G.)
- Skin Cancer Unit, German Cancer Research Center, 69120 Heidelberg, Germany
- Section of Clinical and Experimental Dermatology, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Max Kappenstein
- Department of Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Lübeck, 23538 Lübeck, Germany;
| | - Nina Booken
- Department of Dermatology and Venereology, University Skin Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (N.B.); (I.H.)
| | - Inga Hansen
- Department of Dermatology and Venereology, University Skin Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (N.B.); (I.H.)
| | - Maël Blanchard
- Department of Dermatology, Lausanne University Hospital (CHUV) and Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland; (M.B.); (E.G.)
| | - Emmanuella Guenova
- Department of Dermatology, Lausanne University Hospital (CHUV) and Faculty of Biology and Medicine, University of Lausanne, 1007 Lausanne, Switzerland; (M.B.); (E.G.)
| | - Chalid Assaf
- Department of Dermatology, Helios Hospital Krefeld, 47805 Krefeld, Germany;
- Institute for Molecular Medicine, Medical School Hamburg, 20457 Hamburg, Germany
| | - Sergij Goerdt
- Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (N.N.); (S.M.); (S.G.)
| | - Jan P. Nicolay
- Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, University of Heidelberg, 68167 Mannheim, Germany; (N.N.); (S.M.); (S.G.)
- Skin Cancer Unit, German Cancer Research Center, 69120 Heidelberg, Germany
- Section of Clinical and Experimental Dermatology, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
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Cho A, Paulitschke V, Knobler R. Mode of action, indications and recommendations on extracorporeal photopheresis (ECP). J Dtsch Dermatol Ges 2023; 21:1369-1380. [PMID: 37723908 DOI: 10.1111/ddg.15167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/02/2023] [Indexed: 09/20/2023]
Abstract
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.
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Affiliation(s)
- Ara Cho
- University Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Verena Paulitschke
- University Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Robert Knobler
- University Department of Dermatology, Medical University of Vienna, Vienna, Austria
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Moreno-Vílchez C, Muniesa C, González-Barca E, García-Muñoz N, Ortega-Sánchez S, Servitje O. Efficacy and safety of offline extracorporeal photopheresis in cutaneous T-cell lymphomas: A retrospective study. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2023; 39:667-669. [PMID: 37465951 DOI: 10.1111/phpp.12901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/24/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023]
Affiliation(s)
- Carlos Moreno-Vílchez
- Department of Dermatology, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Cristina Muniesa
- Department of Dermatology, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Eva González-Barca
- Department of Hematology, Institut Catalá d'Oncologia, Hospital Duran i Reynals, Institut d'Investigacio Biomedica de Bellvitge, Barcelona, Spain
| | - Nadia García-Muñoz
- Banc de Sang i Teixits, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Sandra Ortega-Sánchez
- Banc de Sang i Teixits, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Octavio Servitje
- Department of Dermatology, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Spain
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5
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Cho A, Paulitschke V, Knobler R. Wirkweise, Indikationen und Therapieempfehlungen der extrakorporalen Photopherese (ECP). J Dtsch Dermatol Ges 2023; 21:1369-1381. [PMID: 37946642 DOI: 10.1111/ddg.15167_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/02/2023] [Indexed: 11/12/2023]
Abstract
ZusammenfassungDie 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.
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Affiliation(s)
- Ara Cho
- Universitätsklinik für Dermatologie, Medizinische Universität Wien, Wien, Österreich
| | - Verena Paulitschke
- Universitätsklinik für Dermatologie, Medizinische Universität Wien, Wien, Österreich
| | - Robert Knobler
- Universitätsklinik für Dermatologie, Medizinische Universität Wien, Wien, Österreich
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Brazel D, Pinter-Brown L. SOHO State of the Art Updates and Next Questions | A Modern Approach to the Systemic Treatment of Advanced CTCL. CLINICAL LYMPHOMA MYELOMA AND LEUKEMIA 2023; 23:401-409. [PMID: 37061415 DOI: 10.1016/j.clml.2023.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/02/2023] [Accepted: 03/11/2023] [Indexed: 03/18/2023]
Abstract
The term cutaneous T-cell lymphoma (CTCL) is a general term for T-cell lymphomas that are found primarily in skin. The most common CTCL entities, mycosis fungoides and Sezary syndrome are incurable diseases with a plethora of conventional treatment options. In the past treatment options have been selected primarily according to stage. Given newer targeted therapies with varied response in different body compartments, we suggest a compartment-guided algorithm that may enhance response rates directing the selection of the most efficacious treatment options.
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Affiliation(s)
- Danielle Brazel
- Department of Medicine, University of California Irvine Medical Center, Orange, CA.
| | - Lauren Pinter-Brown
- Department of Medicine, University of California Irvine Medical Center, Orange, CA; Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
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Hristov AC, Tejasvi T, Wilcox RA. Cutaneous T-cell lymphomas: 2023 update on diagnosis, risk-stratification, and management. Am J Hematol 2023; 98:193-209. [PMID: 36226409 PMCID: PMC9772153 DOI: 10.1002/ajh.26760] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 02/04/2023]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell neoplasms involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or the blood involvement are generally approached with systemic therapies, including biologic-response modifiers, histone deacetylase inhibitors, or antibody-based strategies, in an escalating fashion. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Alexandra C. Hristov
- Departments of Pathology and Dermatology, 2800 Plymouth Road, Building 35, Ann Arbor, MI 48109-2800
| | - Trilokraj Tejasvi
- Department of Dermatology, 1910 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Ryan A. Wilcox
- Correspondence to: Ryan Wilcox, MD, PhD, Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, 1500 E. Medical Center Drive, Room 4310 CC, Ann Arbor, MI 48109-5948, Phone: (734) 615-9799, Fax: (734) 936-7376,
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8
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Sun LD, Polly S, Ko JS, Ricci K, Hsi ED, Cooper KD, Fernandez AP. Analysis of clinical and serologic predictors of response to extracorporeal photopheresis therapy in cutaneous T-cell lymphoma patients. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2022; 38:600-603. [PMID: 35132696 DOI: 10.1111/phpp.12780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 01/08/2022] [Accepted: 01/30/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Lillian D Sun
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Samantha Polly
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer S Ko
- Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Immunology, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Kristin Ricci
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Eric D Hsi
- Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kevin D Cooper
- Department of Dermatology at Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Anthony P Fernandez
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Kim YH. What factors guide treatment selection in mycosis fungoides and Sezary syndrome? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:303-312. [PMID: 34889422 PMCID: PMC8791145 DOI: 10.1182/hematology.2021000263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Cutaneous T-cell lymphoma (CTCL) comprises a spectrum of T-cell lymphomas with primary skin involvement. Mycosis fungoides (MF) and Sezary syndrome (SS) are the common subtypes of CTCL in which patients present with widely diverse profiles of skin involvement and varying extents of extracutaneous disease. Patients with early-stage disease have an excellent prognosis and are managed primarily with skin-directed therapies; however, those with advanced-stage MF or SS often require multiple lines and recurrent courses of systemic therapies. Many options are available when considering systemic agents, and it is often challenging to know how to prioritize therapies to address a patient's objective disease and quality of life issues. Appreciating the disease heterogeneity and understanding the patient's overall disease profile (eg, skin, lymph nodes, blood, large cell transformation) serve as a useful framework in aligning therapies that can optimally treat active sites of disease. Tissue or blood biomarkers can be integrated into our process of prioritizing therapies and personalizing management in MF or SS. Multidisciplinary management and optimizing supportive care are additional key elements for a favorable outcome. Appropriate patients with high-risk disease should be considered for allogeneic hematopoietic stem cell transplant.
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Affiliation(s)
- Youn H. Kim
- Correspondence Youn H. Kim, Stanford University School of Medicine, 780 Welch Rd, CJ220D, C. J. Huang Bldg, Palo Alto, CA 94304; e-mail:
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10
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Hristov AC, Tejasvi T, Wilcox RA. Cutaneous T-cell lymphomas: 2021 update on diagnosis, risk-stratification, and management. Am J Hematol 2021; 96:1313-1328. [PMID: 34297414 PMCID: PMC8486344 DOI: 10.1002/ajh.26299] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 11/08/2022]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell neoplasms involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multi-disciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or blood involvement are generally approached with systemic therapies, including biologic-response modifiers, histone deacetylase inhibitors, or antibody-based strategies, in an escalating fashion. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Alexandra C. Hristov
- Departments of Pathology and Dermatology, North Campus Research Complex, Ann Arbor, Michigan, USA
| | - Trilokraj Tejasvi
- Director Cutaneous Lymphoma program, Department of Dermatology, A. Alfred Taubman Health Care Center, Ann Arbor, Michigan, USA
| | - Ryan A. Wilcox
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, USA
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Baquero Rey JA, Zambrano Franco EA, Andrade Miranda A, Marciano S, Mazzuoccolo LD, Enz PA. Extracorporeal photopheresis and multimodality therapy in patients with T-cell cutaneous lymphomas: Real-life experience in Argentina. J Clin Apher 2021; 36:815-822. [PMID: 34478581 DOI: 10.1002/jca.21933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/22/2021] [Accepted: 08/17/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) as a part of multimodality therapy, is one of the treatments for Sézary syndrome (SS) and advanced stage mycosis fungoides (MF). This study aims to describe cutaneous and peripheral blood responses of patients with MF and SS who received multimodality therapy. METHODS In this cross-sectional retrospective study, patients with MF or SS who received ECP treatment in combination with at least one additional systemic treatment between 2011 and 2018 were included. ECP consisted of a two-session cycle every 2 to 4 weeks. Cutaneous and blood responses were evaluated with updated criteria. RESULTS Twenty-eight patients (11 (39%) with MF and 17 (51%) with SS) were included. Their median age at diagnosis was 63 (57-67) years. The median number of treatments before ECP was 2 (1-3). Seven out of 11 patients with MF (63%) underwent an assessment of cutaneous response. Five patients (70%) presented a partial response; 1 (15%), stable disease, and 1 (15%) progressive disease. Thirteen of the 17 patients with SS (76%) underwent evaluation. One patient (8%) presented a complete cutaneous response; 6 (46%), a partial response; 5 (38%), stable disease; and 1 (8%), progressive disease. None of them relapsed during the study period in both groups. No ECP-related adverse effects occurred during the study. CONCLUSION Most patients with SS and MF who underwent multimodality therapy with ECP had favorable cutaneous and blood response. It is safe to combine ECP with other treatments. Studies with large numbers of patients are necessary to assess the effects of ECP on patient survival.
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Affiliation(s)
- Jenny Andrea Baquero Rey
- Division of Dermatology, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Andrea Andrade Miranda
- Division of Dermatology, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sebastián Marciano
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Luis Daniel Mazzuoccolo
- Division of Dermatology, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Paula Andrea Enz
- Division of Dermatology, Department of Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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12
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Mehta-Shah N, Horwitz SM, Ansell S, Ai WZ, Barnes J, Barta SK, Clemens MW, Dogan A, Fisher K, Goodman AM, Goyal G, Guitart J, Halwani A, Haverkos BM, Hoppe RT, Jacobsen E, Jagadeesh D, Lunning MA, Mehta A, Olsen EA, Pro B, Rajguru SA, Shanbhag S, Shaver A, Shustov A, Sokol L, Torka P, Torres-Cabala C, Wilcox R, William BM, Zain J, Dwyer MA, Sundar H, Kim YH. NCCN Guidelines Insights: Primary Cutaneous Lymphomas, Version 2.2020. J Natl Compr Canc Netw 2021; 18:522-536. [PMID: 32380458 DOI: 10.6004/jnccn.2020.0022] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mycosis fungoides (MF) is the most common subtype of cutaneous T-cell lymphoma (CTCL), and Sézary syndrome (SS) is a rare erythrodermic and leukemic subtype of CTCL characterized by significant blood involvement. Although early-stage disease can be effectively treated predominantly with skin-directed therapies, systemic therapy is often necessary for the treatment of advanced-stage disease. Systemic therapy options have evolved in recent years with the approval of novel agents such as romidepsin, brentuximab vedotin, and mogamulizumab. These NCCN Guidelines Insights discuss the diagnosis and management of MF and SS (with a focus on systemic therapy).
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Affiliation(s)
- Neha Mehta-Shah
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Weiyun Z Ai
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | - Stefan K Barta
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | - Kristopher Fisher
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | - Joan Guitart
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | | | - Deepa Jagadeesh
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | - Barbara Pro
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Satish Shanbhag
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | - Andrei Shustov
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | | | - Basem M William
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
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13
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Grandi V, Baldo A, Berti E, Quaglino P, Rupoli S, Alaibac M, Alberti-Violetti S, Amerio P, Brazzelli V, Bruni PL, Calzavara-Pinton P, Parodi A, Cozzani E, Burlando M, Fargnoli MC, Gambini D, Iacovelli P, Pacifico A, Longo C, Monfrecola G, Motolese A, Mozzicafreddo G, Cota C, Pigatto P, Pileri A, Savoia P, Simonacci M, Venturini M, Offidani A, Molinelli E, Pellegrino M, Trovato E, Piccinno R, Lawrence K, Pimpinelli N. Italian expert-based recommendations on the use of photo(chemo)therapy in the management of mycosis fungoides: Results of an e-Delphi consensus. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2021; 37:334-342. [PMID: 33458864 DOI: 10.1111/phpp.12658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/26/2020] [Accepted: 01/12/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Phototherapy is a mainstay for the treatment of MF. However, there is scarce evidence for its use, mostly due to the lack of a unified schedule. AIMS The primary aim of this study was to establish the first structured, expert-based consensus regarding the indications and technical schedules of NB-UVB and PUVA for MF. The secondary aim was to determine the consensus level for each specific item. MATERIALS & METHODS E-delphi study. Item-specific expert consensus was defined as the number of "Totally Agree" results to ≥80% of the panelists. Cronbach alpha index ≥0.7 was used as a measure of homogeneity in the responses among questions related to the same topic. RESULTS Overall, there was a high homogeneity among responders (0.78). On specific topics, the highest grade was observed for technical items (0.8) followed by indications for early (0.73) and advanced stages (0.7). CONCLUSIONS Items related to the most canonical indications of phototherapy and to treatment schedules showed the highest agreements rates. There is consensus about the use of standardized treatment schedules for the induction and consolidation phases for NB-UVB and PUVA in MF.
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Affiliation(s)
- Vieri Grandi
- Dip. Scienze della Salute, sezione Dermatologia, Universita' degli Studi di Firenze, Firenze, Italy.,St John's Institute of Dermatology, GSTT NHS Foundation Trust, London, UK
| | - Antonello Baldo
- Clinica Dermatologica Azienda Ospedaliera Universitaria Federico II, Napoli, Italy
| | - Emilio Berti
- Dipartimento di Medicina Interna, UOC Dermatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.,Dipartimento di Medicina, Fisiopatologia medico-chirurgica e dei trapianti, Università degli Studi di Milano, Milano, Italy
| | - Pietro Quaglino
- Clinica Dermatologica AOU Città della Salute e della Scienza, Università degli Studi di Torino, Torino, Italy
| | - Serena Rupoli
- SOD Clinica Ematologica, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Mauro Alaibac
- Clinica Dermatologica, Università degli Studi di Padova, Padova, Italy
| | - Silvia Alberti-Violetti
- Dipartimento di Medicina Interna, UOC Dermatologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.,Dipartimento di Medicina, Fisiopatologia medico-chirurgica e dei trapianti, Università degli Studi di Milano, Milano, Italy
| | - Paolo Amerio
- Clinica Dermatologica Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Valeria Brazzelli
- Clinica Dermatologica, Fondazione Policlinico San Matteo IRCCS, Pavia, Italy
| | - Pier Luigi Bruni
- Struttura Complessa di Clinica Dermatologica, Azienda Ospedaliera S. Maria, Terni, Italy
| | | | - Aurora Parodi
- Clinica Dermatologia, DISSAL, Ospedale Policlinico IRCSS San Martino, Genova, Italy
| | - Emanuele Cozzani
- Clinica Dermatologia, DISSAL, Ospedale Policlinico IRCSS San Martino, Genova, Italy
| | - Martina Burlando
- Clinica Dermatologia, DISSAL, Ospedale Policlinico IRCSS San Martino, Genova, Italy
| | - Maria Concetta Fargnoli
- UOSD di Dermatologia Generale ed Oncologica, Ospedale San Salvatore, e Dipartimento di Scienze Cliniche Applicate e Biotecnologiche, Università degli Studi dell'Aquila, L'Aquila, Italy
| | | | | | | | - Caterina Longo
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy.,Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Centro Oncologico ad Alta Tecnologia Diagnostica-Dermatologia, Reggio Emilia, Italy
| | | | - Alberico Motolese
- S.C. Dermatologia, Azienda USL di Reggio Emilia - IRCCS, Presidio Ospedaliero Provinciale Santa Maria Nuova, Reggio Emilia, Italy
| | | | - Carlo Cota
- UO Dermatologia, INRCA-IRCSS, Ancona, Italy
| | - Paolo Pigatto
- Dermatologia, IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | - Alessandro Pileri
- UO Dermatologia, Dipartimento di Medicina Specialistica Diagnostica e Sperimentale (DIMES), Università degli Studi di Bologna, Bologna, Italy
| | - Paola Savoia
- Dipartimento di Scienze della Salute, Università del Piemonte Orientale, Novara, Italy
| | - Marco Simonacci
- Unità Operativa Dermatologia, Ospedale di Macerata, Macerata, Italy
| | - Marina Venturini
- Clinica Dermatologica Università di Brescia e U.O. Dermatologia, ASST Spedali Civili, Brescia, Italy
| | - Annamaria Offidani
- SOD Clinica di Dermatologia, Azienza Ospedaliero Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - Elisa Molinelli
- SOD Clinica di Dermatologia, Azienza Ospedaliero Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | | | - Emanuele Trovato
- Dermatologia, Ospedale Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Roberta Piccinno
- Sezione Fotoradioterapia, UOC Dermatologia, Dipartimento di Medicina Interna e Specialità Mediche, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Karl Lawrence
- St John's Institute of Dermatology, Faculty of Life Sciences and Medicine, King's College of London, London, UK
| | - Nicola Pimpinelli
- Dip. Scienze della Salute, sezione Dermatologia, Universita' degli Studi di Firenze, Firenze, Italy
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14
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Knobler R, Arenberger P, Arun A, Assaf C, Bagot M, Berlin G, Bohbot A, Calzavara-Pinton P, Child F, Cho A, French LE, Gennery AR, Gniadecki R, Gollnick HPM, Guenova E, Jaksch P, Jantschitsch C, Klemke C, Ludvigsson J, Papadavid E, Scarisbrick J, Schwarz T, Stadler R, Wolf P, Zic J, Zouboulis C, Zuckermann A, Greinix H. European dermatology forum - updated guidelines on the use of extracorporeal photopheresis 2020 - part 1. J Eur Acad Dermatol Venereol 2020; 34:2693-2716. [PMID: 33025659 PMCID: PMC7820969 DOI: 10.1111/jdv.16890] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/06/2020] [Indexed: 01/01/2023]
Abstract
Background Following the first investigational study on the use of extracorporeal photopheresis for the treatment of cutaneous T‐cell lymphoma published in 1983, this technology has received continued use and further recognition for additional earlier as well as refractory forms. After the publication of the first guidelines for this technology in the JEADV in 2014, this technology has maintained additional promise in the treatment of other severe and refractory conditions in a multi‐disciplinary setting. It has confirmed recognition in well‐known documented conditions such as graft‐versus‐host disease after allogeneic bone marrow transplantation, systemic sclerosis, solid organ transplant rejection including lung, heart and liver and to a lesser extent inflammatory bowel disease. Materials and methods In order to further provide recognized expert practical guidelines for the use of this technology for all indications, the European Dermatology Forum (EDF) again proceeded to address these questions in the hands of the recognized experts within and outside the field of dermatology. This was done using the recognized and approved guidelines of EDF for this task. All authors had the opportunity to review each contribution as it was added. Results and conclusion These updated 2020 guidelines provide at present the most comprehensive available expert recommendations for the use of extracorporeal photopheresis based on the available published literature and expert consensus opinion. The guidelines are divided in two parts: PART I covers cutaneous T‐cell lymphoma, chronic graft‐versus‐host disease and acute graft‐versus‐host disease while PART II will cover scleroderma, solid organ transplantation, Crohn's disease, use of ECP in paediatrics practice, atopic dermatitis, type 1 diabetes, pemphigus, epidermolysis bullosa acquisita and erosive oral lichen planus.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - P Arenberger
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - A Arun
- FRCPath, The Rotherham NHA Foundation Trust, Rotherham, UK
| | - C Assaf
- Department of Dermatology and Venerology, Helios Klinikum Krefeld, Krefeld, Germany
| | - M Bagot
- Hospital Saint Louis, Université de Paris, Paris, France
| | - G Berlin
- Department of Clinical Immunology and Transfusion Medicine, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - A Bohbot
- Onco-Hematology Department, Hautepierre Hospital, Strasbourg, France
| | | | - F Child
- FRCP, St John's Institution of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Cho
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - L E French
- Department of Dermatology, University Hospital, München, Germany
| | - A R Gennery
- Translational and Clinical Research Institute, Newcastle University Great North Children's Hospital Newcastle upon Tyne, Newcastle University, Newcastle upon Tyne, UK
| | - R Gniadecki
- Division of Dermatology, University of Alberta, Edmonton, AB, Canada
| | - H P M Gollnick
- Dept. Dermatology & Venereology, Otto-von-Guericke University, Magdeburg, Germany
| | - E Guenova
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Dermatology, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - P Jaksch
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
| | - C Jantschitsch
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - C Klemke
- Hautklinik Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - J Ludvigsson
- Crown Princess Victoria Children's Hospital and Division of Pediatrics, Department of Biomedical and Clinical Sciences, University Hospital, Linköping University, Linköping, Sweden
| | - E Papadavid
- National and Kapodistrian University of Athens, Athens, Greece
| | | | - T Schwarz
- Department of Dermatology, University Clinics Schleswig-Holstein, Kiel, Germany
| | - R Stadler
- University Clinic for Dermatology Johannes Wesling Medical Centre, UKRUB, University of Bochum, Minden, Germany
| | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - J Zic
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - A Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - H Greinix
- Division of Haematology, LKH-Univ. Klinikum Graz, Medical University of Graz, Graz, Austria
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15
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Kalay Yildizhan I, Sanli H, Akay BN, Uzundere C, Okcu Heper A. Folliculotropic mycosis fungoides: Clinical characteristics, treatments, and long-term outcomes of 53 patients in a tertiary hospital. Dermatol Ther 2020; 33:e13585. [PMID: 32410323 DOI: 10.1111/dth.13585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/02/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
Abstract
Folliculotropic mycosis fungoides (FMF) is characterized by a broad clinical spectrum and worse prognosis compared to classical MF. This study aimed to evaluate the clinical characteristics, treatment modalities and long-term outcome and risk factors for progression and survival of FMF patients. We conducted a single-center retrospective study and reviewed 53 patients diagnosed with FMF between 1990 to 2019 in a referral center at Ankara University, Turkey. Regarding to stage at diagnosis, 24 patients (45.3%) had advanced-stage disease (≥IIB). Follicular papules was observed in 66% and alopecia in 49.1% of the cases. Forty-three patients (81.1%) suffered from pruritus. The majority of the patients (92.4%) had at least one systemic therapy. Complete remission was achieved in 24.5% of the patients. The median time of overall survival (OS) was 50 months (range 9-324 months) and 5-year and 10-year OS was 83% and 69%, respectively. Twenty-eight (52.3%) patients progressed to more advanced stages and seven (13.2%) patients died due to MF during the follow-up period. FMF is associated with a progressive course and in most patients, skin-directed therapies were found to be inefficient to control the disease and multiple systemic therapeutic agents were required to control the disease.
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Affiliation(s)
| | - Hatice Sanli
- Faculty of Medicine, Department of Dermatology, Ankara University, Ankara, Turkey
| | - Bengu N Akay
- Faculty of Medicine, Department of Dermatology, Ankara University, Ankara, Turkey
| | - Ceren Uzundere
- Faculty of Medicine, Department of Dermatology, Ankara University, Ankara, Turkey
| | - Aylin Okcu Heper
- Faculty of Medicine, Department of Pathology, Ankara University, Ankara, Turkey
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16
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Hristov AC, Tejasvi T, Wilcox RA. Mycosis fungoides and Sézary syndrome: 2019 update on diagnosis, risk-stratification, and management. Am J Hematol 2019; 94:1027-1041. [PMID: 31313347 DOI: 10.1002/ajh.25577] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 01/04/2023]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas (CTCL) are a heterogenous group of T-cell neoplasms involving the skin, the majority of which may be classified as Mycosis fungoides (MF) or Sézary syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multi-disciplinary approach to treatment. For patients with disease limited to the skin, skin-directed therapies are preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or blood involvement are generally approached with systemic therapies. These include biologic-response modifiers, histone deacetylase (HDAC) inhibitors, or antibody-based strategies, in an escalating fashion. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Alexandra C. Hristov
- Departments of Pathology and DermatologyUniversity of Michigan Ann Arbor Michigan
| | | | - Ryan A. Wilcox
- Division of Hematology/Oncology, Department of Internal MedicineUniversity of Michigan Rogel Cancer Center Ann Arbor Michigan
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17
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Kuhn AK, Bartoo GT, Dierkhising RA, Mara KC, Winters JL, Patnaik MM, Gastineau DA, Adamski J, Merten JA. Iron deficiency anemia associated with extracorporeal photopheresis: A retrospective analysis. J Clin Apher 2019; 34:666-671. [PMID: 31436854 DOI: 10.1002/jca.21744] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/23/2019] [Accepted: 08/08/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is associated with few adverse effects. We have anecdotally noted patients treated with long-term ECP develop iron deficiency anemia (IDA). METHODS We performed a retrospective chart review of adult patients who received ECP for any indication at Mayo Clinic Rochester and Mayo Clinic Arizona. The primary objective was to describe the cumulative incidence of IDA at 1 year of ECP therapy. RESULTS A total of 123 patients were eligible for analysis. Graft-vs-host disease was the most common indication for ECP (n = 76, 61.8%). At 1 year of ECP therapy, the cumulative incidence of IDA was 24.1% (95% CI, 14.2%-32.9%). At 5 years, the cumulative incidence of IDA was 68.3% (95% CI, 38%-83.8%). Risk factors for the development of IDA included: cumulative number of ECP sessions (HR 1.34, 95% CI, 1.05-1.73 per 10 additional sessions, P = .022), an indication for ECP of solid organ transplant rejection (compared to cutaneous T-cell lymphoma, HR 5.46, 95% CI, 2.06-14.49, P < .001), and proton pump inhibitor use at baseline (HR 2.15, 95% CI, 1.1-4.21, P = .03). Iron supplementation was initiated in 29 of 37 evaluable patients who developed IDA, with a cumulative incidence of supplementation in 77.2% patients within 3 months of recognition of IDA (95% CI, 55.8%-88.3%). Hemoglobin normalized in 50.1% of patients started on iron supplementation for IDA within 7 months (95% CI, 25.2%-66.7%). CONCLUSIONS Iron deficiency anemia is common in patients receiving long-term ECP and occurs throughout ECP therapy. IDA resolved with iron supplementation in half of patients.
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Affiliation(s)
- Alexis K Kuhn
- Pharmacy Services, Mayo Clinic Rochester, Rochester, Minnesota
| | | | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic Rochester, Rochester, Minnesota
| | - Jeffrey L Winters
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Mrinal M Patnaik
- Division of Hematology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Dennis A Gastineau
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Jill Adamski
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona
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18
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Wain T, Venning VL, Consuegra G, Fernandez‐Peñas P, Wells J. Management of cutaneous T‐cell lymphomas: Established and emergent therapies. Australas J Dermatol 2019; 60:200-208. [DOI: 10.1111/ajd.13011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/28/2019] [Indexed: 01/04/2023]
Affiliation(s)
- Thevaki Wain
- Department of Dermatology Westmead Hospital SydneyNew South Wales Australia
| | - Victoria L Venning
- The Skin Hospital WestmeadNew South Wales Australia
- Faculty of Medicine University of Sydney Sydney New South Wales Australia
| | - Germana Consuegra
- Department of Dermatology Westmead Hospital SydneyNew South Wales Australia
- Faculty of Medicine University of Sydney Sydney New South Wales Australia
| | - Pablo Fernandez‐Peñas
- Department of Dermatology Westmead Hospital SydneyNew South Wales Australia
- The Skin Hospital WestmeadNew South Wales Australia
- Faculty of Medicine University of Sydney Sydney New South Wales Australia
| | - Jillian Wells
- Department of Dermatology Westmead Hospital SydneyNew South Wales Australia
- Faculty of Medicine University of Sydney Sydney New South Wales Australia
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19
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Cho A, Jantschitsch C, Knobler R. Extracorporeal Photopheresis-An Overview. Front Med (Lausanne) 2018; 5:236. [PMID: 30211164 PMCID: PMC6119964 DOI: 10.3389/fmed.2018.00236] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/03/2018] [Indexed: 12/23/2022] Open
Abstract
Extracorporeal photopheresis (ECP) has been in clinical use for over three decades after receiving FDA approval for the palliative treatment of the Sézary Syndrome variant of cutaneous T-cell lymphoma (CTCL) in 1988. After the first positive experiences with CTCL, additional indications have been successfully explored including areas such as graft-vs.-host disease (GVHD), scleroderma, and solid organ transplantation. The mechanism of action is still not fully resolved, but important steps in understanding ECP in recent years have been very informative. Originally, the primary hypothesis stated that psoralen and ultraviolet A (UVA) in combination induce apoptosis in the treated immune cells. This view shifted in favor of dendritic cell initiation, modification of the cytokine profile and stimulation of several T-cell lineages, in particular regulatory T-cells. A number of ECP guidelines have been produced to optimize treatment regimens in the clinical context. In CTCL, enough evidence is available for the use of ECP as a first line treatment for Sézary Syndrome (SS), but also as a second line or rescue treatment in therapy-refractory forms of mycosis fungoides (MF). ECP in the treatment of acute and chronic GVHD has shown promising results as second line therapy in steroid-refractory presentations. In solid organ transplantation, ECP has been used to increase tissue tolerance and decrease infections with opportunistic pathogens, attributed to the use of high doses of immunosuppressive medication. Infection with cytomegalovirus (CMV) remains a limiting factor affecting survival in solid organ transplantation and the role of ECP will be discussed in this review. A trend toward prophylactic use of ECP can be observed and may further contribute to improve the outcome in many patients. To further deepen our knowledge of ECP and thus facilitate its use in patients that potentially benefit most from it, future prospective randomized trials are urgently needed in this rapidly growing field. The aim of this review is to (1) introduce the method, (2) give an overview where ECP has shown promising effects and has become an essential part of treatment protocols, and (3) to give recommendations on how to proceed in numerous indications.
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Affiliation(s)
| | | | - Robert Knobler
- Department of Dermatology, Medizinische Universität Wien, Vienna, Austria
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20
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Janiga J, Kentley J, Nabhan C, Abdulla F. Current systemic therapeutic options for advanced mycosis fungoides and Sézary syndrome. Leuk Lymphoma 2018; 59:562-577. [PMID: 29308723 DOI: 10.1080/10428194.2017.1347650] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Mycosis fungoides (MF) and Sézary syndrome (SS) are the most common cutaneous T-cell lymphomas (CTCLs). Both lack curative options, and advanced-stage carries a poor prognosis. Whilst there are a number of treatments available, achieving and maintaining a durable remission remains challenging. We review current systemic treatment options as monotherapy for advanced-stage MF (IIB-IV), appraising their mechanism of action, analyzing their efficacy, and describing toxicities. Individually, reported overall response rates (ORR) vary widely in the literature and duration of responses are typically short, ranging from 7.5 to 22.4 months. Combined therapy is frequently used in an effort to boost responses, although prospective studies comparing combinations to single agent therapies are rarely conducted. While recent translational research has led to increased understanding of the immunopathogenesis of MF and SS and the development of new treatments, current standard of care therapies are not curative and have low ORR for advanced-stage disease.
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Affiliation(s)
- Jenna Janiga
- a Stritch School of Medicine , Loyola University , Chicago , IL , USA
| | - Jonathan Kentley
- b Department of Dermatology , Royal London Hospital, Barts Health NHS Trust , London , UK
| | - Chadi Nabhan
- c Cardinal Health Specialty Solutions , Waukegan , IL , USA
| | - Farah Abdulla
- d Department of Medicine, Section of Dermatology , University of Chicago Medicine and Biological Sciences , Chicago , IL , USA
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21
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Geskin L, Malone DC. An exploratory cost-effectiveness analysis of systemic treatments for cutaneous T-cell lymphoma. J DERMATOL TREAT 2017; 29:522-530. [DOI: 10.1080/09546634.2017.1412064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Larisa Geskin
- Department of Dermatology, Columbia University Medical Center, New York, NY, USA
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22
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Atilla E, Atilla P, Bozdag S, Yuksel M, Toprak S, Topcuoglu P, Akay B, Sanli H, Akan H, Demirer T, Beksac M, Arslan O, Ozcan M, Gurman G, Ilhan O. Extracorporeal photochemotherapy in mycosis fungoides. Transfus Clin Biol 2017; 24:454-457. [DOI: 10.1016/j.tracli.2017.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/02/2017] [Indexed: 01/27/2023]
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23
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Wilcox RA. Cutaneous T-cell lymphoma: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol 2017; 92:1085-1102. [PMID: 28872191 DOI: 10.1002/ajh.24876] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multi-disciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or blood involvement are generally approached with biologic-response modifiers or histone deacetylase inhibitors prior to escalating therapy to include systemic, single-agent chemotherapy. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Ryan A. Wilcox
- Division of Hematology/Oncology; University of Michigan Comprehensive Cancer Center; Ann Arbor Michigan 48109-5948
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24
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Alfred A, Taylor PC, Dignan F, El-Ghariani K, Griffin J, Gennery AR, Bonney D, Das-Gupta E, Lawson S, Malladi RK, Douglas KW, Maher T, Guest J, Hartlett L, Fisher AJ, Child F, Scarisbrick JJ. The role of extracorporeal photopheresis in the management of cutaneous T-cell lymphoma, graft-versus-host disease and organ transplant rejection: a consensus statement update from the UK Photopheresis Society. Br J Haematol 2017; 177:287-310. [PMID: 28220931 PMCID: PMC5412836 DOI: 10.1111/bjh.14537] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/23/2016] [Indexed: 12/17/2022]
Abstract
Extracorporeal photopheresis (ECP) has been used for over 35 years in the treatment of erythrodermic cutaneous T‐cell lymphoma (CTCL) and over 20 years for chronic and acute graft‐versus‐host disease (GvHD) and solid organ transplant rejection. ECP for CTCL and GvHD is available at specialised centres across the UK. The lack of prospective randomised trials in ECP led to the development of UK Consensus Statements for patient selection, treatment schedules, monitoring protocols and patient assessment criteria for ECP. The recent literature has been reviewed and considered when writing this update. Most notably, the national transition from the UVAR XTS® machine to the new CELLEX machine for ECP with dual access and a shorter treatment time has led to relevant changes in these schedules. This consensus statement updates the previous statement from 2007 on the treatment of CTCL and GvHD with ECP using evidence based medicine and best medical practise and includes guidelines for both children and adults.
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Affiliation(s)
- Arun Alfred
- Rotherham Foundation NHS Trust, Rotherham, UK
| | | | - Fiona Dignan
- Central Manchester NHS Foundation Trust, Manchester, UK
| | - Khaled El-Ghariani
- Therapeutics and Tissue Services, NHS Blood and Transplant, Sheffield, UK
| | - James Griffin
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew R Gennery
- Institute of Cellular Medicine, Newcastle University and Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | - Denise Bonney
- Royal Manchester Children's Hospital, Manchester, UK
| | - Emma Das-Gupta
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ram K Malladi
- University Hospitals Birmingham NHS Trust, Birmingham, UK
| | | | | | - Julie Guest
- Institute of Cellular Medicine, Newcastle University and Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | | | - Andrew J Fisher
- Institute of Transplantation, Newcastle University and Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Fiona Child
- St John's Institute of Dermatology, Guy's and St Thomas' Hospital, London, UK
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25
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McIver ZA, Kryman MW, Choi Y, Coe BN, Schamerhorn GA, Linder MK, Davies KS, Hill JE, Sawada GA, Grayson JM, Detty MR. Selective photodepletion of malignant T cells in extracorporeal photopheresis with selenorhodamine photosensitizers. Bioorg Med Chem 2016; 24:3918-3931. [PMID: 27301678 DOI: 10.1016/j.bmc.2016.05.071] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 05/29/2016] [Accepted: 05/30/2016] [Indexed: 01/07/2023]
Abstract
Extracorporeal photopheresis (ECP) has been used successfully in the treatment of erythrodermic cutaneous T cell lymphoma (CTCL), and other T cell-mediated disorders. Not all patients obtain a significant or durable response from ECP. The design of a selective photosensitizer that spares desirable lymphocytes while targeting malignant T cells may promote cytotoxic T cell responses and improve outcomes after ECP. A series of selenorhodamines built with variations of the Texas red core targeted the mitochondria of malignant T cells, were phototoxic to malignant T cells presumably via their ability to generate singlet oxygen, and were transported by P-glycoprotein (P-gp). To determine the selectivity of the photosensitizers in the ECP milieu, staphylococcal enterotoxin B (SEB)-stimulated and non-stimulated human lymphocytes were combined with HUT-78 cells (a CTCL) to simulate ECP. The amide-containing analogues of the selenorhodamines were transported more rapidly than the thioamide analogues in monolayers of MDCKII-MDR1 cells and, consequently, were extruded more rapidly from P-gp-expressing T cells than the corresponding thioamide analogues. Selenorhodamine 6 with the Texas red core and a piperidylamide functionality was phototoxic to >90% of malignant T cells while sparing >60% of both stimulated and non-stimulated T cells. In the resting T cells, (63±7)% of the CD4+ T cell compartment, and (78±2.5)% of the CD8+ cytotoxic T cell population were preserved, resulting in an enrichment of healthy and cytotoxic T cells after photodepletion.
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Affiliation(s)
- Zachariah A McIver
- Department of Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, United States.
| | - Mark W Kryman
- Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY 14260, United States.
| | - Young Choi
- Department of Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, United States.
| | - Benjamin N Coe
- Department of Hematology and Oncology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, United States.
| | - Gregory A Schamerhorn
- Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY 14260, United States.
| | - Michelle K Linder
- Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY 14260, United States.
| | - Kellie S Davies
- Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY 14260, United States.
| | - Jacqueline E Hill
- Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY 14260, United States.
| | - Geri A Sawada
- Drug Disposition, Eli Lilly and Company, Indianapolis, IN 46285, United States.
| | - Jason M Grayson
- Department of Microbiology and Immunology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, United States.
| | - Michael R Detty
- Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY 14260, United States.
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Wilcox RA. Cutaneous T-cell lymphoma: 2016 update on diagnosis, risk-stratification, and management. Am J Hematol 2016; 91:151-65. [PMID: 26607183 PMCID: PMC4715621 DOI: 10.1002/ajh.24233] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 11/03/2015] [Indexed: 12/11/2022]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral, or blood involvement are generally approached with biologic-response modifiers or histone deacetylase inhibitors before escalating therapy to include systemic, single-agent chemotherapy. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.
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Affiliation(s)
- Ryan A. Wilcox
- Division of Hematology/Oncology, University of Michigan Cancer Center, 1500 E. Medical Center Drive, Room 4310 CC, Ann Arbor, MI 48109-5948
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27
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Zic JA. Extracorporeal Photopheresis in the Treatment of Mycosis Fungoides and Sézary Syndrome. Dermatol Clin 2015; 33:765-76. [DOI: 10.1016/j.det.2015.05.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Atzmony L, Amitay-Laish I, Gurion R, Shahal-Zimra Y, Hodak E. Erythrodermic mycosis fungoides and Sézary syndrome treated with extracorporeal photopheresis as part of a multimodality regimen: A single-centre experience. J Eur Acad Dermatol Venereol 2015; 29:2382-9. [DOI: 10.1111/jdv.13243] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 05/07/2015] [Indexed: 11/29/2022]
Affiliation(s)
- L. Atzmony
- Department of Dermatology; Rabin Medical Center; Beilinson Hospital; Petach Tikva Israel
| | - I. Amitay-Laish
- Department of Dermatology; Rabin Medical Center; Beilinson Hospital; Petach Tikva Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - R. Gurion
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Hematology Institute; Davidoff Cancer Center; Rabin Medical Center; Beilinson Hospital; Petach Tikva Israel
| | - Y. Shahal-Zimra
- Hematology Laboratory; Rabin Medical Center; Beilinson Hospital; Petach Tikva Israel
| | - E. Hodak
- Department of Dermatology; Rabin Medical Center; Beilinson Hospital; Petach Tikva Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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29
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Yakut E, Jakobs C, Peric A, Michel G, Baal N, Bein G, Brüne B, Hornung V, Hackstein H. Extracorporeal photopheresis promotes IL-1β production. THE JOURNAL OF IMMUNOLOGY 2015; 194:2569-77. [PMID: 25681340 DOI: 10.4049/jimmunol.1400694] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Extracorporeal photopheresis (ECP) is a widely used clinical cell-based therapy exhibiting efficacy in heterogenous immune-mediated diseases such as cutaneous T cell lymphoma, graft-versus-host disease, and organ allograft rejection. Despite its documented efficacy in cancer immunotherapy, little is known regarding the induction of immunostimulatory mediators by ECP. In this article, we show that ECP promotes marked release of the prototypic immunostimulatory cytokine IL-1β. ECP primes IL-1β production and activates IL-1β maturation and release in the context of caspase-1 activation in monocytes and myeloid dendritic cells. Of interest, IL-1β maturation by ECP was fully intact in murine cells deficient in caspase-1, suggesting the predominance of an inflammasome-independent pathway for ECP-dependent IL-1β maturation. Clinically, patient analysis revealed significantly increased IL-1β production in stimulated leukapheresis concentrates and peripheral blood samples after ECP. Collectively, these results provide evidence for promotion of IL-1β production by ECP and offer new insight into the immunostimulatory capacity of ECP.
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Affiliation(s)
- Erhan Yakut
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University Giessen, D-35390 Giessen, Germany
| | - Christopher Jakobs
- Institute of Molecular Medicine, University Hospital, University of Bonn, 53127 Bonn, Germany; and
| | - Adriana Peric
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University Giessen, D-35390 Giessen, Germany
| | - Gabriela Michel
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University Giessen, D-35390 Giessen, Germany
| | - Nelli Baal
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University Giessen, D-35390 Giessen, Germany
| | - Gregor Bein
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University Giessen, D-35390 Giessen, Germany
| | - Bernhard Brüne
- Institute of Biochemistry I, Faculty of Medicine, Goethe-University Frankfurt, 60590 Frankfurt, Germany
| | - Veit Hornung
- Institute of Molecular Medicine, University Hospital, University of Bonn, 53127 Bonn, Germany; and
| | - Holger Hackstein
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig-University Giessen, D-35390 Giessen, Germany;
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30
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Knobler R, Berlin G, Calzavara-Pinton P, Greinix H, Jaksch P, Laroche L, Ludvigsson J, Quaglino P, Reinisch W, Scarisbrick J, Schwarz T, Wolf P, Arenberger P, Assaf C, Bagot M, Barr M, Bohbot A, Bruckner-Tuderman L, Dreno B, Enk A, French L, Gniadecki R, Gollnick H, Hertl M, Jantschitsch C, Jung A, Just U, Klemke CD, Lippert U, Luger T, Papadavid E, Pehamberger H, Ranki A, Stadler R, Sterry W, Wolf IH, Worm M, Zic J, Zouboulis CC, Hillen U. Guidelines on the use of extracorporeal photopheresis. J Eur Acad Dermatol Venereol 2014; 28 Suppl 1:1-37. [PMID: 24354653 PMCID: PMC4291097 DOI: 10.1111/jdv.12311] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND After the first investigational study on the use of extracorporeal photopheresis for the treatment of cutaneous T-cell lymphoma was published in 1983 with its subsequent recognition by the FDA for its refractory forms, the technology has shown significant promise in the treatment of other severe and refractory conditions in a multi-disciplinary setting. Among the major studied conditions are graft versus host disease after allogeneic bone marrow transplantation, systemic sclerosis, solid organ transplant rejection and inflammatory bowel disease. MATERIALS AND METHODS In order to provide recognized expert practical guidelines for the use of this technology for all indications the European Dermatology Forum (EDF) proceeded to address these questions in the hands of the recognized experts within and outside the field of dermatology. This was done using the recognized and approved guidelines of EDF for this task. RESULTS AND CONCLUSION These guidelines provide at present the most comprehensive available expert recommendations for the use of extracorporeal photopheresis based on the available published literature and expert consensus opinion.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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31
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Wilcox RA. Cutaneous T-cell lymphoma: 2014 update on diagnosis, risk-stratification, and management. Am J Hematol 2014; 89:837-51. [PMID: 25042790 DOI: 10.1002/ajh.23756] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS). DIAGNOSIS The diagnosis of MF or SS requires the integration of clinical and histopathologic data. RISK-ADAPTED THERAPY TNMB (tumor, node, metastasis, and blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral or blood involvement are generally approached with biologic-response modifiers or histone deacetylase inhibitors prior to escalating therapy to include systemic, single-agent chemotherapy. Multiagent chemotherapy (e.g., CHOP) may be employed for those patients with extensive visceral involvement requiring rapid disease control. In highly selected patients, allogeneic stem-cell transplantation may be considered.
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Affiliation(s)
- Ryan A. Wilcox
- Division of Hematology/Oncology; University of Michigan Cancer Center; Ann Arbor Michigan
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