Does adjuvant alpha-interferon improve outcome when combined with total skin irradiation for mycosis fungoides?

Maintenance therapy in patients with mycosis fungoides or Sézary syndrome: A neglected topic

In advanced-stage cutaneous T-cell lymphoma (CTCL), the current therapeutic options rarely provide long-lasting responses, leaving allogenic stem-cell transplantation the only potentially curative option for highly selected patients. Until today, there are no standardised strategies for maintenance therapy in patients with CTCL who achieved disease control. Moreover, evidence-based treatment options or drugs that are approved for maintenance treatment in advanced stages after remission induction are still lacking. Patients require maintenance options that provide a good safety profile, are convenient to apply and do not negatively affect their health-related quality of life. However, carrying out large-scale, controlled studies is challenging in CTCL. In addition to information on the concept of maintenance therapy, this review provides an update on current and emerging approaches that target maintenance treatment in advanced-stage CTCL. After all, the group of potentially interesting maintenance therapy candidates, especially for patients in advanced stage, includes not only immunomodulating and phototherapeutic modalities that have been used already for many decades but also newer systemic therapies, including epigenetic modifiers.

Maintenance Therapy for Cutaneous T-cell Lymphoma After Total Skin Electron Irradiation: Evidence for Improved Overall Survival With Ultraviolet Therapy

BACKGROUND

Treatment of cutaneous T-cell lymphoma (CTCL) with total skin electron beam (TSEB) therapy has been associated with deep responses but short progression-free intervals. Maintenance therapy might prolong the response duration; however, limited data assessing the outcomes with maintenance therapy after TSEB are available. We evaluated the effect of maintenance therapy on the outcomes for patients with CTCL receiving TSEB therapy.

MATERIALS AND METHODS

We conducted a single-center retrospective analysis of 101 patients with CTCL who had received TSEB therapy from 1998 to 2018 at the Winship Cancer Institute of Emory University and compared the overall survival (OS) and progression-free survival (PFS) for patients had received maintenance therapy, including retinoids, interferon, ultraviolet therapy, nitrogen mustard, and extracorporeal photopheresis compared with those who had not.

RESULTS

We found that pooled maintenance therapies improved PFS (hazard ratio [HR], 0.60; P = .026) but not OS (median HR, 0.73; P = .264). The median PFS and OS was 7.2 months versus 9.6 months and 2.4 years versus 4.2 years for the no maintenance and maintenance groups, respectively. On exploratory analysis of the individual regimens, ultraviolet therapy was associated with improved OS (HR, 0.21; P = .034) and PFS (HR, 0.26; P = .002) compared with no maintenance.

CONCLUSION

Among the patients with CTCL who had received TSEB therapy, maintenance therapy improved PFS for all patients, and ultraviolet-based maintenance improved both PFS and OS in a subset of patients.

Low dose total skin electron beam therapy for the management of T cell cutaneous lymphomas

Mycosis fungoides (MF) represent the most common type of primary cutaneous lymphomas. Total skin electron beam (TSEB) therapy to a total skin administered dose of 36 Gy represents a very effective treatment regimen and its role in the management of MF is well established. Unfortunately, the issue in MF is that despite the proved effectiveness of radiation therapy, disease regress, and the main goal of TSEB treatment seems to be the prolongation of the overall response duration time. Taking into consideration the high radio-sensitivity of the disease, lower radiation doses have been tested with acceptable and comparable results. We prospectively analyzed low dose TSEB in 14 patients treated at ATTIKON University Hospital from 2011 to 2017. After a median duration of follow up time of 39 months we found that low dose TSEB is an effective treatment option, since therapeutic results are more than acceptable, with minimal toxicity. The fact that it can be repeated safely in the natural course of a "regressive" disease makes it more attractive than the standard full dose scheme of 36 Gy.

Clinical application of Total Skin Electron Beam (TSEB) therapy for the management of T cell cutaneous lymphomas. The evolving role of low dose (12 Gy) treatment schedule

BACKGROUND & PURPOSE

Although rare, cutaneous lymphomas represent a separate entity in hematologic oncology. T cell origin lymphomas are most common, with Mycosis Fungoides (MF) accounting for about 50-70% of cases. Sezary Syndrome (SS), which represents the leukemic varian of MF, accounts for 3% of Cutaneous T Cell Lymphomas (CTCL). Total Skin Electron Beam Therapy (TSEB) is included at the mainstream of treatment choices for CTCL. The scope of this study is to evaluate the effectiveness and toxicity of two treatment schedules of TSEB.

METHODS AND MATERIALS

We report our experience with TSEB in the management of MF and SS, as of 14 patients treated in our institution from 2011 to 2015. 8 patients received the 12 Gy (low dose) scheme while 6 patients were managed with 36 Gy (standard or full dose scheme) according to six dual field Stanford technique. The endpoints were overall response rate, duration of response and toxicity of treatment.

RESULTS

After a median follow up of 2.5 years we noted excellent treatment outcome, with both schemes being well tolerated and resulting in comparable response rates. The overall response rate for both treatment regimens was over 87.5%. Treatment was well tolerated with mild toxicity.

CONCLUSION

The role of TSEB in the management of MF and SS is well established. The low dose TSEB schedule of 12 Gy is an effective treatment option, since therapeutic results are more than acceptable, compliance is excellent and toxicity is minimal. Moreover, the evidence that it can be repeated safely makes it more attractive than the standard 36 Gy scheme, when a patient is referred to radiation treatment according to treatment guidelines.

Total Skin Electron Beam Therapy for Mycosis Fungoides Revisited With Adjuvant Systemic Therapy

BACKGROUND

Although standard-dose total skin electron beam therapy (TSEBT) has been thought to provide the greatest clinical benefit for mycosis fungoides, recent studies have shown that low-dose TSEBT may also provide high rates of disease control.

MATERIALS AND METHODS

A retrospective chart review was conducted for patients receiving TSEBT for mycosis fungoides at a single institution from 2009 to 2017. Patients were evaluated for overall survival, progression-free survival, and duration of clinical benefit. Partial response was defined as any documented clinical regression of lesions, whereas complete response was defined as complete resolution of lesions.

RESULTS

Twenty patients were included in the study. Twelve patients received low-dose radiation (≤ 12 Gy), and 8 received standard-dose radiation (> 12 Gy). Response rate was 100% in both groups. The rate of complete response was 38% in the standard-dose group and 25% in the low-dose group. There was no difference in overall survival between the 2 groups (P = .84). There was also no difference in median progression-free survival (P = .95) or duration of clinical benefit (P = .95) between the 2 groups. Of low-dose patients, 33% received immediate systemic therapy, whereas 92% received adjuvant topical or systemic therapy. In the standard-dose group, only 25% received systemic adjuvant therapy, and 63% received adjuvant topical or systemic therapy.

CONCLUSION

Low-dose TSEBT with adjuvant therapy results in adequate symptom palliation, comparable to standard-dose TSEBT. Low-dose TSEBT should be considered a standard treatment option in this population.

Total Skin Electron Beam Therapy with Rotary Dual Technique as Palliative Treatment for Mycosis Fungoides

BACKGROUND/AIM

The aim of the study was to retrospectively assess the efficacy and toxicity of total skin electron beam therapy (TSEBT) in patients with primary cutaneous T-cell lymphoma (MF, mycosis fungoides) at various stages of development.

PATIENTS AND METHODS

Treatment results of 40 patients with MF stage IB-III, treated between 2001 and 2015, were reviewed. Median total dose was 32 Gy, delivered to the entire skin surface. Median follow-up was 60 months.

RESULTS

Clinical complete response was documented in 29 and partial response in 11 patients. The clinical response significantly influenced overall survival (OS) (p=0.002) and progression-free survival (PFS) (p<0.001). Mean OS was 76 months. Mean PFS was 48.9 months and current one- and two-year PFS were 67.5% and 55%, respectively. A statistically significant correlation was found between partial and total remission time and stages of the lymphoma (p=0.015).

CONCLUSION

TSEBT is an efficient and well-tolerated palliative treatment for symptomatic primary cutaneous T-cell lymphoma.

The Use of Interferons in the Treatment of Cutaneous T-Cell Lymphoma

Interferons are polypeptides that naturally occur in the human body as a part of the innate immune response. By harnessing these immunomodulatory functions, synthetic interferons have shown efficacy in combating various diseases including cutaneous T-cell lymphoma. This article closely examines the qualities of interferon alfa and interferon gamma and the evidence behind their use in the 2 most common types of cutaneous T-cell lymphomas, namely, mycosis fungoides and Sézary syndrome.

Radiation Therapy for Cutaneous T-Cell Lymphomas

Radiation therapy is an extraordinarily effective skin-directed therapy for cutaneous T-cell lymphomas. Lymphocytes are extremely sensitive to radiation and a complete response is generally achieved even with low doses. Radiation therapy has several important roles in the management of mycosis fungoides. For the rare patient with unilesional disease, radiation therapy alone is potentially curative. For patients with more advanced cutaneous disease, radiation therapy to local lesions or to the entire skin can effectively palliate symptomatic disease and provide local disease control. Compared with other skin-directed therapies, radiation therapy is particularly advantageous because it can effectively penetrate and treat thicker plaques and tumors.

Total skin electron therapy for cutaneous T-cell lymphoma using a modern dual-field rotational technique

PURPOSE

To report our experience with rotational total skin electron irradiation (RTSEI) in cutaneous T-cell lymphoma (CTCL), and to examine response by disease stage and race.

METHODS AND MATERIALS

We reviewed our outcomes for 68 CTCL patients who received RTSEI (≥ 30 Gy) from 2000 to 2013. Primary outcomes were complete clinical response (CCR), recurrence-free survival (RFS), and overall survival (OS). Using log-rank tests and Cox proportional hazards, OS and RFS were compared across tumor stages at time of RTSEI with further racial subgroup analysis.

RESULTS

Median age at diagnosis and at time of radiation was 52 and 56 years, respectively. Median follow-up was 5.1 years, 49% were African American, and 49% were female. At time of treatment, 18, 37, and 13 patients were T stage 2, 3, and 4, respectively. At 6 weeks after RTSEI, overall CCR was 82% (88%, 83%, and 69% for T2, T3, and T4, respectively). Median RFS was 11 months for all patients and 14, 10, and 12 months for stage T2, T3, and T4, respectively. Tumor stage was not associated with RFS or CCR. Maintenance therapy after RTSEI was associated with improved RFS in both crude and multivariable analysis, controlling for T stage. Median OS was 76 months (91 and 59 months for T3 and T4, respectively). With the exception of improved OS in African Americans compared with whites at stage T2, race was not associated with CCR, RFS, or OS.

CONCLUSIONS

These results represent the largest RTSEI clinical outcomes study in the modern era using a dual-field rotational technique. Our observed response rates match or improve upon the standard set by previous outcome studies using conventional TSEI techniques, despite a large percentage of advanced CTCL lesions in our cohort. We found that clinical response after RTSEI did not seem to be affected by T stage or race.

Primary cutaneous T-cell lymphoma (mycosis fungoides and Sézary syndrome): part II. Prognosis, management, and future directions

Both mycosis fungoides (MF) and Sézary syndrome (SS) have a chronic, relapsing course, with patients frequently undergoing multiple, consecutive therapies. Treatment is aimed at the clearance of skin disease, the minimization of recurrence, the prevention of disease progression, and the preservation of quality of life. Other important considerations are symptom severity, including pruritus and patient age/comorbidities. In general, for limited patch and plaque disease, patients have excellent prognosis on ≥1 topical formulations, including topical corticosteroids and nitrogen mustard, with widespread patch/plaque disease often requiring phototherapy. In refractory early stage MF, transformed MF, and folliculotropic MF, a combination of skin-directed therapy plus low-dose immunomodulators (eg, interferon or bexarotene) may be effective. Patients with advanced and erythrodermic MF/SS can have profound immunosuppression, with treatments targeting tumor cells aimed for immune reconstitution. Biologic agents or targeted therapies either alone or in combination--including immunomodulators and histone-deacetylase inhibitors--are tried first, with more immunosuppressive therapies, such as alemtuzumab or chemotherapy, being generally reserved for refractory or rapidly progressive disease or extensive lymph node and metastatic involvement. Recently, an increased understanding of the pathogenesis of MF and SS with identification of important molecular markers has led to the development of new targeted therapies that are currently being explored in clinical trials in advanced MF and SS.

Institutional experience with a rotational total skin electron irradiation (RTSEI) technique-A three decade review (1981-2012)

Total skin electron irradiation (TSEI) for patients with cutaneous lymphomas is technically challenging, and numerous approaches have been developed to overcome the many field matching problems associated with such a large and complex treatment volume. Since 1981 we have delivered TSEI using a rotational total skin electron irradiation (RTSEI) technique in conjunction with patch, treat and boost fields in order to provide complete skin and dose coverage. Initially we used a 6 MeV electron beam at an extended source-skin distance (SSD) on a modified linear accelerator. More recently we began using a high dose rate electron mode on a commercially available linear accelerator. The RTSEI technique allows the delivery of a seamless surface dose to the majority of the patient's skin surface in a single treatment. In this review paper we present our three-decade experience with the technical development, dosimetry, treatment delivery and clinical outcomes of our RTSEI technique.

Giant condylomata (Buschke-Löwenstein tumours): our case load in surgical treatment and review of the current therapies

BACKGROUND

Buschke-Löwenstein tumour (BLT) or giant condyloma is a verrucous infiltrating lesion, due to a sexually transmitted virus infection, human papilloma virus subtypes 6 and 11. Poor hygiene, promiscuity, chronic irritation and cellular immunocompromised states are often implicated in its genesis. Typical treatment of giant condyloma includes imiquimod cream, podophillin resin, cryotherapy, laser surgery, tangential shave excision with electrocautery.

OBJECTIVE

The authors report their case load in the treatment of giant condyloma and the review of the modern therapies.

METHODS AND MATERIALS

27 consecutive patients (18 men, nine women) underwent surgery for giant condylomata of perianal region and externa genitalia at the Department of Plastic Surgery of the University of Palermo, from October 2006 to December 2009. All the patients had been treated before with conservative therapies without significant results. We performed the radical excision with split-thickness skin graft in all the patients.

RESULTS

No significant complications have occurred in all the cases. The functional and aesthetic outcome were satisfying. No recurrence of disease were noticed in the follow-up.

CONCLUSION

the radical excision with split-thickness skin graft appears to be a successful option of treatment for Buschke-Löwenstein tumours. Compared to other methods it does not necessitate several stages of treatment, moreover it has the advantage of a lower risk of recurrence, it allows a complete histologic examination, the healing process is rapid, the improvement of quality of patients's life is significant.

New targets of therapy in T-cell lymphomas

T-cell lymphomas (TCL) are characterized by poor response to chemotherapy and generally poor outcome. While molecular profiling has identified distinct biological subsets and therapeutic targets in B-cell lymphomas, the molecular characterization of TCL has been slower. Surface markers expressed on malignant T-cells, such as CD2, CD3, CD4, CD25, and CD52 were the first TCL-specific therapeutic targets to be discovered. However, the presence of these receptors on normal T-cells means that monoclonal antibody (mAb)- or immunotoxin (IT)-based therapy in TCL inevitably results in variable degrees of immunosuppression. Thus, although some mAbs/IT have significant activity in selected subsets of TCL, more specific agents that target signaling pathways preferentially activated in malignant T-cells are needed. One such novel class of agents is represented by the histone deacetylase (HDAC) inhibitors. These molecules selectively induce apoptosis in a variety of transformed cells, including malignant T-cells, both in vitro and in vivo. Several HDAC inhibitors have been studied in TCL with promising results, and have recently been approved for clinical use. Immunomodulatory drugs, such as interferons and Toll Receptor (TLR) agonists have significant clinical activity in TCL, and are particularly important in the treatment of primary cutaneous subtypes (CTCL). Although most classical cytotoxic drugs have limited efficacy against TCL, agents that inhibit purine and pyrimidine metabolism, known as nucleoside analogues, and novel antifolate drugs, such as pralatrexate, are highly active in TCL. With improved molecular profiling of TCL novel pharmacological agents with activity in TCL are now being discovered at an increasingly rapid pace. Clinical trials are in progress and these agents are being integrated in combination therapies for TCL, both in the relapsed/refractory setting as well as front line.

Maintenance therapy in cutaneous T-cell lymphoma: Who, when, what?

The aim of current therapy for cutaneous T-cell lymphoma (CTCL) is to induce clinically meaningful remission, provide symptom relief, improve patient quality of life (QoL) and prolong disease-free and overall survival. A key research question is whether such remissions or minimal disease status can be maintained in the long term. There have been few formal studies of maintenance therapy in CTCL. Some skin-directed therapies such as total-skin electron-beam therapy and high-dose psoralen plus ultraviolet A may not be considered suitable, because of the risk of long-term cumulative toxicities. Other therapies such as nitrogen mustard, interferon (IFN)-alpha and bexarotene have demonstrated positive effects in prolonging remissions in small numbers of patients. Large longitudinal studies are required to investigate the efficacy of maintenance treatments in CTCL and their impact on patients' QoL and overall survival. Of the systemic therapies currently approved for the treatment of CTCL, bexarotene and IFN-alpha are obvious candidates for testing, because they can be self-administered by the patient and provide good long-term tolerability.