"High-dose" UVA1 therapy of widespread plaque-type, nodular, and erythrodermic mycosis fungoides

Treatment of cutaneous T cell lymphoma: 2001

The neoplastic cells of mycosis fungoides (MF) and Sézary syndrome are recognized to be clonal expansions of "memory" T cells that home into the upper dermis and epidermis via the interplay of adhesion molecules and chemokines, and this may account for the marked effectiveness and even curative potential of various skin-directed therapies utilized to treat clinically early disease. However, because neoplastic T cells freely circulate and are detectable in extracutaneous tissues by PCR prior to other methods, effective long-term control of more advanced MF and Sézary syndrome, i.e. reduction of tumor burden and decreased risk of transformation into aggressive lymphoma, often requires long-term administration of a therapy with systemic activity in addition to skin-directed therapies. Therapies with immunomodulatory activities, e.g. interferon alfa, bexarotene or extracorporeal photochemotherapy (ECP), are probably superior to traditional cytotoxic drugs in this regard although the response rates are relatively low. Selected patients with advanced or biologically aggressive CTCL should be considered for an allogeneic stem cell transplantation regimen to induce a graft-versus-tumor response. New and emerging treatments include immunotoxins such as denileukin diftitox that selectively target neoplastic T cells, potent immunomodulatory cytokines such as rIL-12 to enhance innate antitumor immune mechanisms, novel immunotherapeutic approaches that use dendritic cells loaded with tumor-associated antigens or vaccination using synthetic peptides or DNA plasmids that express the variable region of the T cell receptor beta chain, and possibly gene and protein transduction therapy to correct intracellular defects in neoplastic T cells. Overall the future of therapy for CTCL seems quite optimistic.

Medium-dose ultraviolet A1 therapy for pityriasis lichenoides et varioliformis acuta and pityriasis lichenoides chronica

BACKGROUND

Ultraviolet A1 (340-400 nm) was found to be effective in the treatment of cutaneous T-cell-mediated diseases.

OBJECTIVE

The purpose of the present study was to assess the efficacy of UVA1 phototherapy for pityriasis lichenoides et varioliformis acuta (PLEVA) and pityriasis lichenoides chronica (PLC).

METHODS

Eight patients (3 with PLEVA and 5 with PLC) received 60 J/cm(2) UVA1 daily until remission. Four patients also had lesions inaccessible to UVA1 that were used as control lesions. Immunocytologic studies of skin infiltrates and circulating T cells were done.

RESULTS

Six patients showed complete clinical and histologic recovery. Two patients with PLC had a partial improvement. Unirradiated control lesions never improved. Serious short-term adverse effects were not encountered. No effects on circulating lymphocytes were reported.

CONCLUSION

UVA1 therapy is an effective and well-tolerated treatment for PLEVA and PLC. The therapeutic activity seems to be related to direct effects on cutaneous inflammatory infiltrates because the lesions in nonexposed cutaneous areas did not respond.

Practical evaluation and management of cutaneous lymphoma

Accurate evaluation of patients with suspected or known cutaneous lymphoma requires the integration of many sources and types of information, including clinical evaluation, microscopic analysis of tissue, immunophenotyping, gene rearrangement studies, clinical staging, and longitudinal observation. Diagnoses should be based on knowledge of specific lymphoma types as described in modern classification systems. Management of patients with cutaneous lymphoma requires collaboration among dermatologists, dermatopathologists, hematopathologists, and medical, surgical and radiation oncologists. (J Am Acad Dermatol 2002;46:325-57.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should better understand how to evaluate and manage patients for suspected or established lymphoma of the skin. Components include the clinical history and physical examination, optimal biopsy and tissue handling, interpretation of pathology and adjunctive test results, clinicopathologic correlation, and therapy. Participants should also understand the basis for establishing a specific diagnosis of cutaneous lymphoma based on current classification and staging.