Cutaneous T-cell Lymphoma

Biomarkers of alopecia areata disease activity and response to corticosteroid treatment

Alopecia areata (AA) is a common inflammatory disease targeting the anagen-stage hair follicle. Different cytokines have been implicated in the disease profile, but their pathogenic role is not yet fully determined. We studied biopsies of pretreatment lesional and non-lesional (NL) scalp and post-treatment (intra-lesional steroid injection) lesional scalp of 6 patchy patients with AA using immunohistochemistry and gene expression analysis. Immunohistochemistry showed increases in CD3(+) , CD8(+) T cells, CD11c(+) dendritic cells and CD1a(+) Langerhans cells within and around hair follicles of pretreatment lesional scalp, which decreased upon treatment. qRT-PCR showed in pretreatment lesional scalp (compared to NL) significant increases (P < 0.05) in expression of inflammatory markers (IL-2, IL-2RA, JAK3, IL-15), Th1 (CXCL10 and CXCL9), Th2 (IL-13, CCL17 and CCL18), IL-12/IL-23p40 and IL-32. Among these, we observed significant downregulation with treatment in IL-12/IL-23p40, CCL18 and IL-32. We also observed significant downregulation of several hair keratins in lesional scalp, with significant upregulation of KRT35, KRT75 and KRT86 in post-treatment lesional scalp. This study shows concurrent activation of Th1 and Th2 immune axes as well as IL-23 and IL-32 cytokine pathways in lesional AA scalp and defined a series of response biomarkers to corticosteroid injection. Clinical trials with selective antagonists coupled with cytokine-pathway biomarkers will be necessary to further dissect pathogenic immunity.

In vivo reflectance confocal microscopy of mycosis fungoides: A preliminary study

BACKGROUND

Mycosis fungoides (MF) is a diagnostic challenge, frequently needing multiple and sequential biopsies to establish the diagnosis.

OBJECTIVE

Our aim was to evaluate lesions suggestive of MF using in vivo reflectance confocal microscopy (RCM) and to correlate confocal features with histopathologic findings.

METHODS

A total of 8 lesions from 7 patients either with a history of biopsy-proven MF or with lesions clinically suggestive of MF were imaged with RCM followed by a skin punch biopsy. These 8 lesions were confirmed to be MF by histopathology: patch type (n = 3), plaque type (n = 4), and tumor type (n = 1).

RESULTS

Under RCM, epidermal findings in patch lesions were subtle, as on histopathology, while the most prominent changes were observed in plaque type MF. At the level of the epidermis, weakly refractile oval to round structures within the spinous layer were observed in all MF lesions, but were difficult to distinguish from surrounding keratinocytes; these structures corresponded to epidermotropic lymphocytes on histopathology. In plaque-type lesions, vesicle-like dark spaces filled with collections of monomorphous weakly refractile oval to round cells were clearly elucidated by RCM; these structures corresponded to Pautrier's microabscesses on histopathology. RCM was also able to demonstrate spongiosis in the MF lesions, with findings of epidermal architectural disarray, areas with thickened and blurred intercellular demarcations, and epidermal cells with elongated nuclei. At the dermoepidermal junction, the basal cells surrounding the dermal papillae appeared as only faintly refractile rings on RCM. This feature corresponded with histopathologic findings of basal layer infiltration by tumor cells with permeation of rete ridges, thus, obscuring the dermoepidermal interface. Examination of the dermis under RCM for all the MF lesions showed weakly refractile structures, but was limited by loss of detail and contrast below the dermoepidermal junction.

LIMITATIONS

Because of limited imaging depth, RCM did not visualize dermal infiltration by tumor cells in tumor-type MF. Epidermotropic lymphocytes appeared weakly refractile under RCM and were difficult to distinguish from surrounding keratinocytes as a result of minimal difference in contrast. Other limitations on RCM include some similarity in findings with spongiotic and lichenoid dermatitides, and an inability to distinguish specific cell types. Moreover, this study did not address the inherent heterogeneity of MF lesions, but was primarily focused on correlating RCM and hematoxylin-eosin histopathology of the included cases.

CONCLUSION

Features correlating well to histopathology are observed on RCM of MF lesions; however, the specificity of these findings needs to be assessed.

T-cell prolymphocytic leukemia: update and focus on alemtuzumab (Campath-1H)

T-cell prolymphocytic leukemia (T-PLL) is a rare mature T-cell lymphoproliferative disorder. While the etiology of T-PLL is unknown, recent progress in unraveling the molecular basis of leukemogenesis has been substantial and may yield novel therapeutic targets. T-PLL is a distinct disease entity and the diagnosis can be readily made based on characteristic clinical features and laboratory findings. Prior to the appearance of pentostatin and alemtuzumab in clinical protocols, outcome for T-PLL patients was exceedingly poor with median survival measured in months. While the use of alemtuzumab in particular has improved remissions, the disease remains incurable. Future collaborative efforts investigating novel treatment approaches will be crucial to improving survival for patients with this disease.