Utility of Low-Dose Duvelisib for Advanced Mycosis Fungoides: A Single-Institution Study

Duvelisib, a small-molecule phosphatidylinositol 3-kinase-δ,γ inhibitor, has shown efficacy for mycosis fungoides (MF) at dosage ranges of 25-100 mg twice daily (BID), but with significant toxicity. We conducted a retrospective cohort study of patients with advanced MF treated with low-dose duvelisib (15 mg every other day to BID), in an effort to minimize toxicity. A total of 7 patients were included. The overall response rate on duvelisib was 71%, with the remaining patients maintaining stable disease. Mean modified Severity Weighted Assessment Tool score improved by 57.4% and mean percent body surface area involved improved by 52%. Median progression-free survival was 10.3 months. Adverse events occurred in 4 of 7 patients, the most common being fatigue (2/7; grades 1-2), nausea (2/7; grades 1-2), and transaminitis (2/7; grade 3). Overall, low-dose duvelisib showed efficacy for advanced MF with less toxicity, providing a rationale for its use as monotherapy and potentially combinatorial therapy.

Clinical Response in Heavily Pretreated Mycosis Fungoides with Pembrolizumab: A Case Report

Mycosis fungoides (MF) is a disease almost impossible to cure. In the context of heavily pretreated patients, the anti-programmed cell death protein 1 (anti-PD-1) pembrolizumab is a valid therapeutic option. The alteration of the PD-1-PD ligand 1 (PD-L1) axis is often present in MF, and this aspect explains the feasibility of this therapy. We report the case of a 60-year-old woman diagnosed with MF in 2003, Olsen stage IA (T1M0NXBO). Since the moment of the diagnosis, she received 10 lines of therapy, with a short duration of response after each one of them. In April 2020, our patient started pembrolizumab 2 mg/kg every 3 weeks, and she achieved a partial response after the 4th cycle, consistent with the modified severity assessment tool (mSWAT) 1, which she is still maintaining after 10 cycles. No grade ≥3 adverse events were recorded. We conclude that pembrolizumab can induce extremely rapid responses in MF, with very low toxicity.

Evolution of Dupilumab-Associated Cutaneous Atypical Lymphoid Infiltrates

BACKGROUND

Observations highlighting the "unmasking" of cutaneous T-cell lymphoma after treatment with dupilumab for atopic dermatitis (AD) have been recently reported. However, there remains a paucity of literature describing the evolution of clinical and histopathological features that characterizes this phenomenon.

OBJECTIVE

To define the clinical and histopathologic evolution of atypical lymphoid infiltrates after the administration of dupilumab for AD.

METHODS

A cross-sectional study of clinical and histopathologic features in 7 consecutive patients with a diagnosis of "atypical lymphoid infiltrate" or mycosis fungoides (MF) on dupilumab for AD was performed.

RESULTS

Seven patients with atypical lymphoid infiltrates or MF in evolution after dupilumab therapy (age range 27-74 years) were reviewed. Average duration of AD before MF diagnosis was 5.7 years, and the average duration on dupilumab treatment was 9.8 months. Notable histopathologic features across predupilumab and postdupilumab biopsies included progressive increase in the densities of the atypical lymphoid infiltrates (7/7), presence of atypical epidermotropic lymphocytes (6/7), and papillary dermal fibrosis (6/7).

LIMITATIONS

Small retrospective cohort study.

CONCLUSION

These cases highlight the transformation of lymphoid infiltrates after dupilumab treatment for AD and emphasize the importance of clinical and histopathologic evaluation before and during treatment with dupilumab for treatment-refractory presumed AD.

Micosis fungoide e inhibidores del TNFα: ¿riesgo o beneficio?

The growing use of anti-TNF drugs during the last years has reopened the discussion about the possible increased risk of developing non-Hodgkin lymphoma in patients with such type of treatments. We present our clinical experience and critical opinion about the current situation of such issue regarding cutaneous T-cell lymphomas.El creciente uso de fármacos anti-TNF durante los últimos años ha reabierto el debate sobre el posible aumento de riesgo de linfomas no Hodgkin en los pacientes con este tipo de tratamientos. Presentamos nuestra experiencia clínica y opinión critica sobre la situación actual de este tema en relación a los linfomas cutáneos de células T.

Methotrexate-induced necrolysis in tumoral-stage mycosis fungoides: a challenging diagnosis

Methotrexate-induced cutaneous ulceration is a rare but potentially serious drug adverse reaction. This adverse reaction of methotrexate therapy has been initially described in psoriasis patients and is unusual in patients with cutaneous T-cell lymphoma. In 1978, Mc Donald et al reported the first three cases of cutaneous ulcerations in patients treated for a mycosis fungoides with intravenous infusions of methotrexate. Since then, few cases of methotrexate-induced skin ulcers in patients with mycosis fungoides have been published. We report an additional patient with erythrodermic mycosis fungoides who developed cutaneous ulcerations as a sole manifestation of methotrexate toxicity.

Cutaneous lymphoproliferative disorders in organ transplant recipients: update 2014

Post-transplant lymphoproliferative disorders (PTLD) are lymphoid or plasmacytic proliferations that develop after solid organ, bone marrow or stem cell transplantation. PTLD are the leading cause of cancer-related mortality and graft loss in both pediatric and adult solid organ transplant recipients (ORT). These disorders comprise a spectrum ranging from usually EBV-driven, mostly B-cell polyclonal proliferations to B- and T-cell lymphomas indistinguishable from their counterparts occurring in immunocompetent individuals. PTLD usually present in extranodal sites; isolated skin involvement of PTLD is rare. A recent multicenter European case series showed that primary cutaneous T-cell PTLD are more common than primary cutaneous B-cell PTLD, and along with its folliculotropic variant, mycosis fungoides (MF) is the most frequent form of posttransplant primary cutaneous T-cell lymphoma (CTCL). This case series also disclosed that primary cutaneous CD30+ lymphoproliferative disorders is the second most common posttransplant CTCL subtype, indicating that the spectrum of primary CTCL in OTR is similar to that in the general population. However, in contrast with the immunocompetent individuals, the prognosis of primary cutaneous CD30+ anaplastic large T-cell lymphoma is worse than posttransplant MF and than its counterpart in the general population which has an excellent prognosis. The recent case series indicated that the spectrum of primary cutaneous B-cell PTLD differs significantly from cutaneous B-cell lymphoma in the general population, with a predominance of EBV-associated forms. Currently, the best therapeutic intervention(s) for primary cutaneous PTLD remains unknown.

Mycosis fungoides in a patient with ankylosing spondylitis during infliximab therapy

Immunosuppressive therapies, in particular cyclosporine, are known to induce the development of lymphoproliferative malignancies. In general, the lymphomas that occur in the setting of impaired immune function are B cell non-Hodgkin's lymphomas, often large cell lymphomas. Mycosis fungoides (MF) is the most common form of cutaneous T cell lymphomas, which can require persistent antigen and superantigen stimulation by way of chronic immunosuppression and HIV. Tumor necrosis factor antagonists, which are novel immunomodulatory agents, might produce significant adverse effects, including an increased risk of malignancy. Currently available data do not show whether these agents were the proximate cause of the reported lymphomas. We present a 32-year-old male with ankylosing spondylitis treated with infliximab who developed MF during the second year of therapy.

Mycosis fungoides Progression and Chronic Solvent Exposure

The effect of repeated exposure to specific chemicals on the initiation or progression of mycosis fungoides (MF) remains unsettled. A patient with low-grade patch stage MF progressively developed MF plaques restricted to his arms, and a tumour on his right thigh. These areas were subject to repeated exposure to solvents. His thigh was indeed in close contact with his trousers pocket where he used to store a wiping rag drenched into white spirit and cellulosic thinner. Immunophenotyping these lesions revealed a dense LCA+, CD2+, CD3+, CD4+, CD5+, CD7+, CD45+, CD45RO+ T-cell infiltrate admixed with many factor XIIIa+ dendrocytes. T-cell receptor rearrangement analysis identified a monoclonal T-cell infiltrate. An internal work-up remained negative. Stopping further solvent exposure failed to improve his condition. Oral corticotherapy combined with low-dose interferon-alpha2a halted disease progression. This observation suggests that long-term solvent exposure may trigger MF and hasten its progression from the patch stage to the plaque and tumour stages.

Carbamazepine-Induced Pseudo Mycosis Fungoides

OBJECTIVE

To report a case of pseudo mycosis fungoides due to carbamazepine.

CASE SUMMARY

A 54-year-old man experienced a skin lesion resembling mycosis fungoides without any systemic symptoms or signs 2 months after he had begun carbamazepine treatment for his seizures. Skin-punch biopsy specimens revealed mycosis fungoides-like histopathologic appearance. After drug discontinuation, the patient experienced complete remission of the clinical and pathologic findings. This suggests a diagnosis of pseudo mycosis fungoides due to carbamazepine.

DISCUSSION

Mycosis fungoides is the cutaneous T-cell lymphoma of the skin that needs aggressive chemotherapy and radiation treatment. Pseudo mycosis fungoides is a condition caused by certain drugs that has a similar clinical and histopathologic appearance to mycosis fungoides. When the causative drug is discontinued, the lesions resolve completely.

CONCLUSIONS

An objective causality assessment revealed that carbamazepine was highly probable as the cause of the adverse reaction. Patients who are diagnosed with mycosis fungoides should be asked about any drug use, and clinicians should recognize signs of pseudo mycosis fungoides.

Atypical pigmentary purpura: a clinical, histopathologic, and genotypic study

BACKGROUND

The pigmentary purpuras (PPs) are a heterogeneous group of dermatoses defined by specific clinicopathologic features but sharing, at the light microscopic level, superficially disposed dermal lymphocytic infiltrates and hemorrhage. The term atypical pigmentary purpura (APP) is used by the authors in reference to cases of PP in which individual lesions, although clinically presenting as PP, show morphological features typically associated with mycosis fungoides (MF) including Sezary cells and epidermotropism. The integrated concept of lymphocyte atypia and PP is a confusing and enigmatic one to which reference in the literature has been previously made. Specifically, there are reports of PP presaging fully evolved MF, lymphoid atypia has been identified in lesions of routine PP and MF with purpuric features has been described. The clinical, light microscopic, and genomic features of biopsied lesions showing pathological features of APP and which clinically were consistent with PP is explored.

DESIGN

The light microscopy of skin biopsy specimens from 34 patients with a pathological diagnosis of APP was correlated to medical and drug histories. In 14 cases, adequate tissue was present in the paraffin blocks to allow DNA extraction. The polymerase chain reaction (PCR) was used in these 14 cases to explore for rearrangement of the T-cell receptor. Fisher's exact test and pair wise exact tests were used to assess the significance of histological differences between cases determined by dinical features to be of MF- or drug-related origin, or to be idiopathic in nature.

RESULTS

Of 34 patients, 7 were held to have MF related PP; specifically these patients had violaceous, infiltrative, variably purpuric plaques on trunk, buttocks, and thighs accompanied by typical PP lesions which occurred either concomitant to or preceded the MF lesions. In 10 cases, a diagnosis of idiopathic PP was made whereby the clinical presentation was characteristic of PP; there were no concomitant lesions suspicious for MF and a drug-based origin was excluded. A drug-based origin was established in 17 patients based on lesional onset related to initiation (5 patients) and/or resolution after discontinuation (12 patients) of drugs including calcium channel blockers, lipid-lowering agents, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, antihistamines, antidepressants, or analgesics. There was considerable overlap histologically between all 3 groups including the degree of lymphoid atypia in the dermis, the presence of dermal-based Sezary cells, the degree and pattern of epidermotropism, the paucity of other inflammatory cell elements, and the presence of laminated dermal sclerosis. Morphological features predictive of MF related APP over the other 2 groups were intraepidermal lymphocytes which were more atypical than the dermal-based infiltrate. Intraepidermal Sezary cells were less frequent in biopsies of drug-related APP relative to idiopathic PP (IPP) and MF related PP. PCR studies conducted in 14 cases (2 cases of MF, 6 cases of drug-related APP, and 6 cases of IPP) revealed clonality in 2 cases of drug-related APP and 2 cases of IPP; the 2 studied MF-related cases did nor show clonal restriction.

CONCLUSION

APP should not be equated with purpuric MF; it is not necessarily a precursor lesion of MF, and may be of drug-based origin. Clinical features are critical to the final assessment because there is overlap pathologically in the 3 clinical subtypes of APP.

Generalized pustular eruption associated with converting enzyme inhibitor therapy

A 67-year-old man presented with a high fever and a generalized rash. His extended hospital stay was characterized by fever with repeated staphylococcal bacteremia and the appearance of axillary lymphadenopathy and splenomegaly. Skin lesions became hyperpigmented, dry, and atrophic with areas of exfoliation and uclers. Examination of skin and lymph node biopsy specimens showed findings consistent with mycosis fungoides. The patient unexpectedly recovered on discontinuation of captopril. A positive macrophage inhibiting factor response for both captopril and enalapril indicated that the non-sulfhydryl moiety was the antigenic stimulant for the lesion resembling mycosis fungoides.

Mycosis fungoides: carcinogens and cerebral involvement

Three patients with mycosis fungoides, who were long-term employees of a manufacturer of solid fuel propellants, were seen. Two of these patients had tumorous involvement of the central nervous system, which was successfully treated with radiation therapy. The potential relationship of carcinogens is discussed.

Mycosis fungoides-like lesions associated with phenytoin therapy

An 83-year-old woman developed generalized lymph node hyperplasia together with mycosis fungoides-like skin lesions 11 months after institution of anticonvulsant therapy with phenytoin. The clinicopathological changes disappeared completely three weeks after cessation of therapy. This circumstantial evidence together with the known data on the association of phenytoin with lymphoproliferative disorders suggest that it was the phenytoin that was responsible for the patient's condition. This case had features similar to those associated with the pseudo-mycosis fungoides syndrome except that the cutaneous lesions consisted of two localized erythematous plaques, with no generalized exfoliative erythrodermic dermatitis. Nonetheless, we believe that the use of the term pseudo-mycosis fungoides for this and similar cases would be appropriate.

Conjunctival involvement with mycosis fungoides in a patient receiving PUVA therapy

A 40-year-old woman had documented mycosis fungoides of the skin. Over a period of five years, she had undergone intermittent treatment with psoralen long-wave ultraviolet light (PUVA) therapy. Despite regression of the skin lesions, tumor plaques developed in her eyelid and conjunctiva within the area shielded by dark glasses. Light and electron microscopic examination of a biopsy from the conjunctival plaque confirmed that the lesion was a deposit of mycosis fungoides. Local radiotherapy resulted in complete regression of these ocular lesions. The conjunctiva may well be an iatrogenic "sanctuary site" when this disease is treated with PUVA therapy.

Pseudolymphoma with mycosis fungoides manifestations, hyperresponsiveness to diphenylhydantoin, and lymphocyte disregulation

Three patients receiving diphenylhydantoin (DPH) were seen with a reversible process suggesting mycosis fungoides. Clinical and laboratory manifestations included generalized pruritic exfoliative erythroderma, eosinophilia, lymphadenopathy, hepatosplenomegaly, circulating Sézary cells, epidermal Pautrier's microabscesses on skin biopsy, and moderate liver dysfunction. Studies of the distribution and function of the various lymphocyte subpopulations from these patients showed: (1) an increase in the relative and absolute number of T lymphocytes (85--92%); (2) significant stimulation of lymphocyte-blastic transformation by DPH and low response to pokeweed mitogen stimulation; (3) the impaired ability of T gamma lymphocytes to suppress B-cell differentiation and immunoglobulin production. With only one exception, 15 symptom-free patients on DPH showed none of these abnormalities. The clinical manifestations and immunologic abnormalities of patients with this pseudo mycosis fungoides syndrome remitted three to four weeks after DPH administration was discontinued. The proliferation of T lymphocytes and the inhibition of the function of T gamma-suppressor lymphocytes noted in these patients may be significant to the development of other types of pseudolymphoma and to that of true lymphoma.