Prevention of acute graft-versus-host disease in adult T-cell leukemia-lymphoma patients who received mogamulizumab before allogeneic hematopoietic cell transplantation

Mogamulizumab (Mog) is effective against adult T-cell leukemia-lymphoma (ATL), but as we reported previously, Mog increases the incidence of severe acute GVHD when administered before allogeneic hematopoietic cell transplantation (allo-HCT). Here, we report the cases of two ATL patients who did not develop acute GVHD despite receiving Mog before allo-HCT. Case 1: a 63-year-old female who underwent allo-HCT from an HLA-matched donor 2 months after the last dose of Mog. Case 2: a 47-year-old male with ATL that relapsed 3 months after first allo-HCT. He received eight doses of Mog and underwent a second allo-HCT from a haploidentical donor 4 months after the last dose of Mog. Mog blood levels were measured and lymphocytes analyzed by mass cytometry. Mog blood levels measured before starting the conditioning regimens were low. A small proportion of regulatory T cells (Tregs) was detected before and shortly after allo-HCT. When using Mog before allo-HCT, it is important to consider the number of Mog doses and the interval from the last dose of Mog to allo-HCT. Analyzing Mog blood levels and Treg counts before and after allo-HCT should also be useful.

Clinical and histopathological significance of PD-1 expression in cutaneous lesions of adult T-cell leukemia-lymphoma

BACKGROUND

Adult T-cell leukemia-lymphoma (ATL) is a mature T-cell malignancy caused by human T-cell leukemia virus type I infection and is known to exhibit cutaneous involvement in 50% or more patients. Few studies have evaluated the clinicopathological significance of programmed death-1 (PD-1) expression in the cutaneous lesions of ATL.

METHODS

Skin biopsy specimens from 29 ATL patients with cutaneous lesions were evaluated regarding the clinicopathological feature, survival outcome, and PD-1 expression level on infilitrated CD3+CD4 + CD25+ cells. The optimal cut-off point of PD-1 expression for clinicopathological feature and outcome was determined as the value of the maximum Youden index by receiver operating characteristic (ROC) analysis.

RESULTS

PD-1 was expressed broadly from zero to 90% on the skin biopsy specimens of the 29 patints, with the median value of 50%. The PD-1-expression level was significantly higher in the poorer-prognosis eruption group (nodulotumoral, erythrodermic and purpuric types) (P = 0.003), in the poorer histopathological infiltration patterns (diffuse and nodular) (P = 0.007), and in the poorer infiltrating cell-size group (large-sized cells) (P = 0.017) than in the corresponding group. ROC curve analyses showed that the optimal cut-off value for PD-1-expression level to predict the poorer-prognosis eruption, the poorer- histopathological infiltration pattern, the poorer infiltration cell size, and the poorer outcome (death) was 60%, 50%, 50%, and 80%, respectively. Patients with high PD-1 expression had a shorter median survival time than those with low PD-1 expression (18.2 months vs. 26.0 months), but the difference was not statistically significant.

CONCLUSIONS

ATL patients with cutaneous lesions in which PD-1 were highly expressed have more advanced dermatological and histopathological patterns and possibly worse survival than those with low PD-1 expression on cutaneous lesions. Further large-scale studies are warranted to verify these findings.

A Review of New Findings in Adult T-cell Leukemia-Lymphoma: A Focus on Current and Emerging Treatment Strategies

Adult T-cell leukemia–lymphoma (ATL), a rare and aggressive T-cell malignancy caused by human T-cell lymphotropic virus type 1 (HTLV-1), is associated with a poor prognosis. Evidence-based standard treatment options are lacking and outcomes are generally unsatisfactory, particularly for patients with relapsed or refractory disease. Continued research is contributing to changing treatment landscape as a number of existing and investigational agents are evaluated. We describe the epidemiology of HTLV-1 and ATL, discuss the biology behind the disease, review current treatment practices and guidelines, and provide an overview of emerging therapies in ATL, with a focus on those for relapsed or refractory disease.

Adult T-cell leukemia cell-induced uveitis: rapid increase in adult T-cell leukemia cells disrupts the blood-ocular barrier

Adult T-cell leukemia-lymphoma (ATL), a rare lymphoid malignancy with a high mortality rate, is caused by the human T-cell leukemia virus type 1. Due to its rarity and poor prognosis, ocular manifestations have yet to be well documented. The mechanisms that underlie ocular involvement in ATL patients, thus, remain poorly understood. We report the first successfully tracked case of ocular inflammation (i.e., uveitis) that developed simultaneously in conjunction with a rapid increase in ATL cells. Our findings for this case suggest that a rapid increase in ATL cells contributed to the disruption of the blood-ocular barrier, which may, thus, represent one mechanism underlying the induction of uveitis in ATL patients. Furthermore, with the development of novel therapies, the longer survival times of ATL patients have raised new issues, such as quality of vision in ATL patients. Hematologists should be aware that a rapid increase in the number of ATL cells may cause adult T-cell leukemia cell-induced uveitis.

Fatal pneumonia and viremia due to human parainfluenza virus type 1 in a patient with adult T-cell leukemia-lymphoma treated with mogamulizumab

We report a case of fatal pneumonia and viremia due to human parainfluenza virus type 1 (HPIV-1) in a 65-year-old male patient with adult T-cell leukemia–lymphoma (ATL) treated with mogamulizumab, a brand-new therapeutic agent for ATL. To our knowledge, this is the first report describing viremia due to HPIV-1. After administering mogamulizumab, lymphocyte count in the blood was drastically decreased and the patient suffered from complicated infections including gram-negative bacterial sepsis, cytomegalovirus antigenemia and aspergillosis. Although these infections were successfully controlled by broad spectrum antimicrobial therapy, patchy ground-grass opacities in the both lungs were gradually worsened. He finally died due to acute respiratory failure. Since findings of the chest CT was consistent with typical patterns of viral pneumonia, we screened major respiratory viruses in the peripheral blood with multiplex PCR, and it turned out that RNA of HPIV-1 was positive. Although ATL cells were not detected in the autopsied lungs and a variety of other tissues, cytoplasmic inclusion bodies, which are commonly observed in RNA viral infection, were abundantly observed in the autopsied lung tissue. These findings suggest that mogamulizumab accomplished complete remission of ATL, while the chemotherapy-induced prolonged lymphopenia caused fatal pneumonia and viremia due to HPIV-1. As it has been well recognized that community respiratory viruses including HPIV-1 often cause fatal pneumonia in patients with leukemia, but also there is no specific treatment for HPIV-1, we have to enforce standard precautions especially when we treat leukemic patients with intensively immunosuppressive agents such as mogamulizumab.