Proteomic Approaches to Biomarker Discovery in Cutaneous T-Cell Lymphoma

Cutaneous T-cell lymphoma (CTCL) is the most frequently encountered type of skin lymphoma in humans. CTCL encompasses multiple variants, but the most common types are mycosis fungoides (MF) and Sezary syndrome (SS). While most cases of MF run a mild course over a period of many years, other subtypes of CTCL are very aggressive. The rapidly expanding fields of proteomics and genomics have not only helped increase knowledge concerning the carcinogenesis and tumor biology of CTCL but also led to the discovery of novel markers for targeted therapy. Although multiple biomarkers linked to CTCL have been known for a relatively long time (e.g., CD25, CD45, CD45RA, and CD45R0), compared to other cancers (lymphoma, melanoma, colon carcinoma, head and neck cancer, renal cancer, and cutaneous B-cell lymphoma), information about the antigenicity of CTCL remains relatively limited and no dependable protein marker for CTCL has been discovered. Considering the aggressive nature of some types of CTCL, it is necessary to identify circulating molecules that can help in the early diagnosis, differentiation from inflammatory skin diseases (psoriasis, nummular eczema), and aid in predicting the prognosis and evolution of this pathology. This review aims to bring together some of the information concerning protein markers linked to CTCL, in an effort to further the understanding of the convolute processes involved in this complex pathology.

Primary Cutaneous T Cell Lymphoma (Gamma Delta subtype)

Primary cutaneous T-cell lymphoma gamma-delta subtype is an extremely rare entity of all the cutaneous T-cell lymphomas. Our case provides an insight on clinical behavior and treatment response with feasible effective combination chemotherapy. We believe this will be of great interest to clinicians when facing this difficult clinical entity. We present a case of a 66-year-old Malay man with a threeweek history of rapidly growing skin nodules and plaques which spread throughout his body. He was commenced on combination chemotherapy gemcitabine, etoposide, and carboplatin with near complete remission on completion of second cycle but he defaulted. He relapsed within a month and he progressed despite treatment with the same regime. He was salvaged with fludarabine, cytarabine, and vinblastine combination chemotherapy but progressed with brain metastasis and died. However, more investigations and studies need to be done in this relatively unknown rare entity. A rare lymphoma registry might be of help to better understand and treat similar conditions.

[CUTANEOUS T CELL LYMPHOMA: UNILESIONAL MYCOSIS FUNGOIDES]

Unilesional mycosis fungoides is a rare cutaneous T cell lymphoma that warrants either radiation therapy or surgical excision. Benign characteristics result in misdiagnosis, delayed tissue biopsy and subsequently delayed provision of adequate treatment. A young patient presented with a history of 18 months of eczematous benign - appearing single lesion restricted to her index finger. Local electron-beam radiation following tissue diagnosis resulted in full recovery.

75% Complete Response and 15% Partial Response to Extracorporeal Photopheresis Combined With Other Therapies in Resistant Early Stage Cutaneous T-Cell Lymphoma

INTRODUCTION

Extracorporeal photopheresis (ECP) has been used for the treatment of advanced stage or treatment refractory cutaneous T-cell lymphoma (CTCL) since 1987, and more recently has also been shown to be of benefit for earlier stage resistant CTCL. Complete response rates in prior studies of ECP in early CTCL have ranged from 0% to 40%.

METHODS

We reviewed electronic medical records of all CTCL patients seen in the University of Kansas Cancer Center between June 2007 and May 2011. International review board approval was obtained. Inclusion criteria were (1) early stage CTCL and (2) ECP treatment. Data included demographics, type of intravenous access employed, CTCL subtype, cytogenetic features, adverse events, adjuvant treatments, and survival time in years. Treatment response was assessed via a modified severity weighted assessment tool (mSWAT). Primary outcome measures were response rates to ECP at 6 months and 12 months after beginning treatment.

RESULTS

Of 20 patients (13 female; 7 male), 7 were Stage 1A, 11 were 1B, and 2 were 2A. Seven patients with stable disease and 2 patients with progression at 6 months received adjuvant therapy (PUVA/systemic retinoids/metotrexate/interferon) in addition to ECP. Twelve-month response to ECP was 90%: 15 patients (75%) had complete responses, 3 (15%) had partial responses, 1 had stable disease, and 1 progressed.

CONCLUSION

Used alone or in combination with adjuvant treatments, ECP can be an effective treatment method in early stage CTCL. <br /><br /> <em>J Drugs Dermatol.</em> 2016;15(10):1212-1216.

Cutaneous Lymphoma in Korea: A Nationwide Retrospective Study

The epidemiological and clinicopathological features of cutaneous lymphoma may vary by geographical area. However, only a few large-scale epidemiological studies of cutaneous lymphoma have been performed, mainly in the USA and Europe. This aim of this study was to determine the recent characteristics of cutaneous lymphoma in Korea according to the WHO/EORTC classification. A total of 422 patients with newly diagnosed cutaneous lymphoma from January 2009 to December 2013 comprising 293 cases of mature T-cell and natural killer (NK)-cell lymphoma and 39 cases of mature B-cell lymphoma were retrospectively reviewed. The incidence of mature B-cell lymphoma was lower in Korea than in Europe and the USA. Diffuse large B-cell lymphoma was more prevalent in Korea than in Western countries. The incidence of extranodal NK/T-cell lymphoma, nasal-type was higher in Korea than in Western countries and Japan.

Illness Perception in Primary Cutaneous T-cell Lymphomas: What Patients Believe About Their Disease

There is currently no information available on illness perception in primary cutaneous T-cell lymphomas (CTCL). The aim of this study was therefore to gather initial information on disease understanding and interpretation in patients with CTCL. Consecutive patients from a hospital-based primary cutaneous lymphoma ward completed the Revised Illness Perception Questionnaire (IPQ-R) on 2 consecutive visits. A total of 24 patients with different variants of CTCL were included in the study. Patients experienced their condition as being long-lasting, but not fundamentally affecting their lives. Patients had poor belief in personal control, but strong belief in treatment control. They did not show a good understanding of their disease, and had a moderately negative emotional response to their illness. In conclusion, the IPQ-R provides a feasible and reproducible tool for measurement and better understanding of illness perception in patients with CTCL. Knowledge of patients' attitudes towards their disease should enable optimization of the patient-physician relationship and patient care.

Cutaneous T-cell lymphoma: 2016 update on diagnosis, risk-stratification, and management

DISEASE OVERVIEW

Cutaneous T-cell lymphomas are a heterogenous group of T-cell lymphoproliferative disorders involving the skin, the majority of which may be classified as Mycosis Fungoides (MF) or Sézary Syndrome (SS).

DIAGNOSIS

The diagnosis of MF or SS requires the integration of clinical and histopathologic data.

RISK-ADAPTED THERAPY

TNMB (tumor, node, metastasis, blood) staging remains the most important prognostic factor in MF/SS and forms the basis for a "risk-adapted," multidisciplinary approach to treatment. For patients with disease limited to the skin, expectant management or skin-directed therapies is preferred, as both disease-specific and overall survival for these patients is favorable. In contrast, patients with advanced-stage disease with significant nodal, visceral, or blood involvement are generally approached with biologic-response modifiers or histone deacetylase inhibitors before escalating therapy to include systemic, single-agent chemotherapy. In highly-selected patients, allogeneic stem-cell transplantation may be considered, as this may be curative in some patients.

Clinical Practice Guidelines for Cutaneous Lymphomas

Primary cutaneous lymphomas are non-Hodgkin lymphomas, which are broadly divided into cutaneous T-cell lymphomas and cutaneous B-cell lymphomas. These classifications include numerous distinct entities, all with varying clinical presentations and disease courses. Herein, we will review the cutaneous T-cell lymphomas, including Mycosis Fungoides, Sézary syndrome, CD30+ lymphoproliferative disorders, as well as other less common entities. Cutaneous B-cell lymphomas will also be discussed, including primary cutaneous marginal zoned lymphoma, cutaneous follicle-center lymphoma, diffuse large B-cell lymphoma, leg type, as well as other less common entities. Accurate and early diagnosis is key, as the treatment and prognosis varies significantly between conditions.

Primary Cutaneous T-cell Lymphoma With Aberrant CD-20 Expression

IMPORTANCE

Primary cutaneous T-cell lymphoma with aberrant expression of cluster of differentiation (CD) 20 is an exceedingly rare manifestation of cutaneous T-cell lymphoma that is easily misdiagnosed as B-cell lymphoma. The significance and prognostic implications of T-cell neoplasms demonstrating the classic CD20 B-cell marker have yet to be elucidated.

OBSERVATIONS

We present a case of primary cutaneous T-cell lymphoma with aberrant CD20 expression in a 97-year-old male who presented with a 2-year history of pruritic plaques and nodules covering his body. Nodule biopsy demonstrated a dense, atypical dermal T-lymphocytic infiltrate consisting of predominantly large cells exhibiting classic T-cell markers (CD4 and CD3) along with aberrant expression of the B-cell marker CD20 (expressed in late pro-B to mature B cells).

CONCLUSIONS

The patient was tentatively diagnosed with primary cutaneous CD30-negative large T-cell lymphoma with aberrant CD20 co-expression, pending workup to exclude systemic lymphoma with cutaneous involvement. He unfortunately passed away 4 days after the initial dermatologic presentation.

RELEVANCE

The prognostic implications of CD20-positive T-cell lymphoma require further exploration, along with the potential role of CD20 antibody in treatment of this rare malignancy.

Marginal vitiligo: an unusual depigmenting disorder

BACKGROUND

Marginal vitiligo, or inflammatory vitiligo with raised borders is a unique subset of vitiligo vulgaris presenting with scattered depigmented, pruritic patches surrounded by a raised, erythematous border. Alternative diagnoses include discoid lupus erythematosus and cutaneous T-cell lymphoma.

PURPOSE

To properly guide treatment, it is important to exclude other conditions that present with a similar pattern of depigmentation. This requires the ability to identify specific cutaneous and histologic clues that support this diagnosis.

MATERIAL AND METHODS

A 22 year-old man presented with a history of depigmented, pruritic patches and surrounding raised, erythematous borders. Several areas of depigmentation on the scalp were associated with alopecia. Punch biopsy of the rim of a patch was performed and sent for routine hematoxylin and eosin staining and direct immunofluorescence.

RESULTS AND CONCLUSION

Histopathology revealed a spongiotic dermatitis with superficial dermal lymphocytic infiltrate and eosinophils; DIF demonstrated no immunoreactants. A diagnosis of inflammatory vitiligo with raised borders was thus made based on consistent clinical and histopathologic features. The symptoms improved with topical clobetasol 0.05% cream twice daily.

Primary cutaneous lymphomas: single center experience of dermatology and hematology clinics

PURPOSE

To present the clinical characteristics, treatments performed, response to treatment, and follow up of 40 patients diagnosed with primary cutaneous lymphoma.

METHODS

In this retrospective study included were 23 males and 17 females from our center with confirmed diagnosis of primary cutaneous lymphoma over an 8-year period. Data were retrieved from the patient medical records.

RESULTS

The median patient age at diagnosis was 59.5 years (range 33-86). Skin biopsies showed that 31 patients (77.5%) had mycosis fungoides (MF), 2 (5%) had anaplastic large cell lymphoma, 3 (7.5%) had diffuse large B cell lymphoma, 3 (7.5%) had poikilodermic mycosis fungoides, and 1 (2.5%) had non-classified non-Hodgkin lymphoma (NHL). In patients with T cell lymphoma clinical stage IA prevailed (42.5%). The 3 patients with B cell lymphoma had stage IE and 2 of them had B symptoms. Sezary cells were detectable in the peripheral blood of 3 patients. Twenty-three patients (57.5%) used only topical corticosteroids, 2 (5%) were treated with PUVA (psoralen ultraviolet A), 1 (2.5%) was treated with PUVA and chemotherapy, 8 (20%) received combination chemotherapy, 1 patient (2.5%) received PUVA+ interferon+topical nitrogen mustard, and 1 (2.5%) received chemotherapy+topical nitrogen mustard+interferon. Among 16 patients with the valuable response to treatment 5 (33%) showed complete remission (CR) and 9 (60%) partial remission (PR). The median follow up time for all patients was 1.5 months (range 1-135). While mean overall survival (OS) time was 123 months (95% CI 100.6-145.3), the estimated median OS was not reached.

CONCLUSION

Early diagnosis of MF is rather favorable in terms of high and long-term response rates to topical treatments.

Subcutaneous panniculitis-like T-cell lymphoma

Subcutaneous panniculitis like T-cell lymphoma derived from α/β T-cells (SPTCL-AB) belongs to the group of primary cutaneous T-cell lymphoma, and it represents less than the 1% of all primary cutaneous T-cell lymphomas. It affects patients in the 4th decade of life (median age of 36 years) with a female preference (male/female ratio 0.5) with 19% of patients being 20 years or younger. It can be sometime complicated by a hemophagocytic syndrome, and patients without hemophagocytic syndrome had a significantly better survival (5-year OS: 91% vs. 46%). Histopathologically, SPTCL-AB is characterized by a lobular lymphocytic panniculitis. Tumor cells distribute between individual adipose lobules, proliferating and forming "rim" and "capping" images, conferring a lace-like appearance at scanning magnification. This is not an entirely disease-specific feature, and can also be seen in other lobular lymphocytic panniculitis, either of inflammatory and neoplastic origin. Tumor cells are phenotypically CD45RO+, βF1+ (a monoclonal antibody able to identify the alpha/beta chain of TCR), CD3+, CD4-, CD8+, and express cytotoxic granules (TIA-1, granzyme and perforin), whereas they show variable deletion of T-cell restricted antigens like CD2, CD5 and CD7. The majority of cases show a monoclonal rearrangement for TCR beta and gamma genes and do not show genomic integration of EBV. The present review will focus on histopathologic, immunophenotypical and molecolare data useful to overcome to a specific diagnosis of SPTCL-AB and to differentiate SPTCL-AB from other lymphomas of T-cell or NK/T cell origin and with benign panniculitidis sharing with SPTCL-AB a predominant lobular lymphocytic pattern of involvement of subcutaneous tissue.