Mechanism of action of chlormethine gel in mycosis fungoides

Case report: Canadian consensus on chlormethine gel use in mycosis fungoides-CTCL: literature review and real-world experience

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma (CTCL), representing the majority of all lymphomas arising in the skin. The disease treatment focuses on managing symptoms and preventing disease evolution. To date, there is no gold standard for MF-CTCL treatment. Chlormethine, a DNA alkylating agent, is a long-known treatment for CTCL. The new chlormethine 0.02% gel (CL-gel) formulation provides proven efficacy and ease of application, improving patient compliance and outcome. The current consensus paper and real-world experience with CL-gel in the treatment of early-stage MF-CTCL may help meet the unmet need for treatments in Canada. A modified Delphi process comprised a virtual meeting and an online follow-up. A panel of 9 board-certified dermatologists with expertise in cutaneous lymphoma and 1 radiation oncologist discussed the systematic literature review results, drew from clinical experience and the opinion of the panel to adopt and agree on five consensus statements. The panel shared real-world patient cases to illustrate the use of chlormethine gel in a variety of patients across Canada. Five real-world patient cases were provided to illustrate the panels' use of chlormethine gel.

Chlormethine Gel for Treatment of Patients with Mycosis Fungoides: Best Practices and Guidance to Clinicians

BACKGROUND

Mycosis fungoides (MF) is the most common form of cutaneous T cell lymphoma. While multiple guidelines provide treatment recommendations, there are currently no clear treatment algorithms for MF. Chlormethine gel is recommended by major treatment guidelines as a first-line option for stage IA-IIA disease, and, on the basis of these guidelines, used in combination with other therapies in patients with advanced-stage MF in clinical practice.

OBJECTIVES

To provide guidance regarding the use of chlormethine gel for patients with all stages of MF, based on clinical expertise.

METHODS

Opinions on best practices regarding the use of chlormethine gel were collected through discussions that involved eight clinicians with extensive experience in treating patients with MF.

RESULTS

Chlormethine gel can be used as monotherapy in first- or second-line treatment of early-stage MF. In first-line, chlormethine gel monotherapy is prescribed for stage IA MF, and is particularly convenient for patients unable/unwilling to travel for hospital-based phototherapy, patients with thick plaques or palmoplantar involvement, when ultraviolet treatment is contraindicated, and for sanctuary sites. Chlormethine gel is also an appropriate first-line monotherapy for patients with stage IB or IIA MF; it may be used as part of combination regimens in these patients as well. For patients with late-stage MF, skin-directed treatments such as chlormethine gel should be combined with systemic therapies.

CONCLUSIONS

Chlormethine gel is a safe and effective treatment option that can be used in all stages of MF, either as monotherapy or in combination, depending on disease stage and patient characteristics and needs.

Chlormethine gel in combination with other therapies for treatment of mycosis fungoides: a review with patient cases

Topical chlormethine gel has been approved as monotherapy for treatment of adult patients with mycosis fungoides (MF), the most common form of cutaneous T-cell lymphoma. In clinical practice, chlormethine gel is often combined with other skin-directed or systemic therapies to optimize response and target recalcitrant lesions. Positive outcomes with combination regimens using chlormethine gel and topical corticosteroids, phototherapy, retinoids, methotrexate, or interferon-α have been reported in literature. However, there are no treatment guidelines on the use of combination regimens with chlormethine gel. To provide real-world evidence and guidance on the use of chlormethine gel combination regimens, several cases of patients treated with chlormethine gel combined with phototherapy (n = 5), retinoids (n = 16), or mogamulizumab (n = 3) are presented. These different combination regimens showed promising results. Most patients had a complete or partial response following treatment and the combinations were well-tolerated over extended treatment periods. Patients receiving chlormethine gel with retinoids had long-term periods of remission, even after treatment discontinuation. Durations of response of up to 3 years were observed in these patients. This long-term disease control may be the result of disease-modifying effects of chlormethine. Previous studies have shown targeted reductions in malignant T-cell clones in patients treated with chlormethine gel as well as improved post-treatment responses. Further research is needed to determine the effectiveness and safety of combination treatment regimens with chlormethine gel and to assess the impact chlormethine gel has on disease control.

Advances in the treatment of mycoses fungoides and Sézary syndrome: a narrative update in skin-directed therapies and immune-based treatments

Mycoses fungoides (MF) and Sézary syndrome (SS) are cutaneous T-cell lymphomas that are often challenging to manage given the absence of reliably curative therapies, at times high symptom burden with significant detriment to quality of life, and need for ongoing treatment for disease and symptom control. Recent developments in skin-directed treatments include optimizing the use of existing topical therapies, the introduction of known dermatological agents and treatment modalities for the specific treatment of MF/SS (such as mechlorethamine gel, calcineurin inhibitor creams, and photodynamic therapy), and novel local and topical agents. For advanced disease, dedicated clinical trials have translated to exciting progress, leading to the approval of brentuximab vedotin (2017) and mogamulizumab (2018) for relapsed MF/SS. Additional studies of other active systemic agents, including various cellular therapies, represent further attempts to add to the therapeutic armamentarium in treating MF/SS. In this review, we highlight these recent advancements, ranging from optimization of skin-directed therapies to the introduction of novel systemic agents. We focus on therapies approved in the preceding five years or under investigation in advanced-phase clinical trials.