Mycosis fungoides and sezary syndrome: An update

Photodynamic therapy in the treatment of patients with mycosis fungoides

The review highlights the current understanding of the epidemiology, etiology, pathogenesis, existing classifications of mycosis fungoides. Methods for diagnosis and treatment of the pathology are described, among which photodynamic therapy (PDT) plays an important role. The main advantages of PDT for mycosis fungoides include the absence of systemic toxicity, non-invasiveness, selectivity, absence of carcinogenic potential, the possibility of repeated courses of treatment, and good cosmetic results. This review collects and analyzes the results of clinical trials of PDT in patients with mycosis fungoides. The analysis showed high efficiency of PDT in patients with mycosis fungoides with isolated or limited spots and plaques. PDT can be considered as the therapy of choice in patients with facial lesions when a good cosmetic result is one of the main requirements, and radiation therapy, nitrogen mustard or carmustine can leave permanent and visible scars. Plaques located in the axillary or inguinal skin folds that are inaccessible to phototherapy can also be treated with PDT.

Photodynamic therapy in the treatment of patients with mycosis fungoides

The review highlights the current understanding of the epidemiology, etiology, pathogenesis, existing classifications of mycosis fungoides. Methods for diagnosis and treatment of the pathology are described, among which photodynamic therapy (PDT) plays an important role. The main advantages of PDT for mycosis fungoides include the absence of systemic toxicity, non-invasiveness, selectivity, absence of carcinogenic potential, the possibility of repeated courses of treatment, and good cosmetic results. This review collects and analyzes the results of clinical trials of PDT in patients with mycosis fungoides. The analysis showed high efficiency of PDT in patients with mycosis fungoides with isolated or limited spots and plaques. PDT can be considered as the therapy of choice in patients with facial lesions when a good cosmetic result is one of the main requirements, and radiation therapy, nitrogen mustard or carmustine can leave permanent and visible scars. Plaques located in the axillary or inguinal skin folds that are inaccessible to phototherapy can also be treated with PDT.

NBUVB Phototherapy at the Donor Site Can Enhance the Graft Uptake in the Nonhealing of Ulcers of Mycosis Fungoides: A Case Report

Mycosis fungoides is a rare form of non-Hodgkin’s lymphoma, which is formed of mature, skin homing, clonal, malignant T lymphocytes. It can sometimes present with skin ulcers that are difficult to heal because of the presence of large number T lymphocytes and antigen-presenting cells. We present a case of nonhealing ulcers in a patient with mycosis fungoides, which was treated by narrow band ultraviolet B targeted phototherapy followed by split-thickness skin grafting. The graft uptake was well and the donor area also healed without any complications.

The Ectopic Expression of Meiosis Regulatory Genes in Cutaneous T-Cell Lymphomas (CTCL)

Cancer testis (CT) antigens, under normal circumstances are uniquely expressed in testicular germ cells. Recent research has shown that meiosis-specific CT (meiCT) antigens are ectopically expressed in cutaneous T-cell lymphoma (CTCL) and may contribute to increased genomic instability. The aberrant activation of meiosis genes in a mitotic cell is now recognized as a distinctive process, “meiomitosis.” We have previously demonstrated the ectopic expression of several meiCT antigens in nine patient-derived CTCL cell lines and in expanded peripheral T lymphocytes isolated from Sézary Syndrome patients. In this study we analyzed the transcriptional expression of meiCT genes in Sézary Syndrome patients and healthy controls using publicly-available RNA sequencing (RNA-Seq) data. We corroborated our in silico analysis by examining the expression of 5 meiCT proteins in formalin-fixed, paraffin-embedded (FFPE) lesional samples from CTCL patients. Our results show significant differential gene expression of STAG3, SGO2, SYCP3, and DMC1 in a cohort of Sézary Syndrome patients when compared to healthy controls. Additionally, our study demonstrates a heterogenous expression of meiCT genes involved in initiation (STRA8), sister chromatin cohesion (STAG3, SGO2), homologous chromosome synapsis (SYCP3) and homologous recombination (DMC1) in atypical lymphocytes in FFPE samples. Our results further confirm the ectopic expression of meiCT genes in CTCL which indicates that CTCL malignant cells likely undergo the process of cancer meiomitosis, as opposed to a typical mitotic division. The ectopic expression of meiCT genes together with investigations into the functional mechanisms of cancer meiomitosis will help provide a foundation to develop novel diagnostic tests to distinguish CTCL from benign inflammatory dermatoses and may enable us to develop additional targeted therapies for patients with this malignancy.

The Diagnosis, Staging, and Treatment Options for Mycosis Fungoides

Background

Cutaneous T-cell lymphoma (CTCL) represents a spectrum of diseases composed of malignant T lymphocytes. The most common type is mycosis fungoides (MF). An accurate diagnosis of early MF may be difficult because of the varied clinical and histologic expressions of the disease.

Methods

The authors review the epidemiology, possible risk factors, clinical manifestations, diagnostic techniques, staging, prognosis, and treatment options for MF.

Results

The varied and often nonspecific clinical and bistologic presentations of MF may delay diagnosis and staging, thus necessitating further studies such as immunophenotyping and T-cell receptor gene rearrangement analysis.

Conclusions

A multidisciplinary approach to the diagnosis, staging, and treatment of MF assists in optimizing outcomes from management of patients with this disease.

Malignant T cells express lymphotoxin α and drive endothelial activation in cutaneous T cell lymphoma

Lymphotoxin α (LTα) plays a key role in the formation of lymphatic vasculature and secondary lymphoid structures. Cutaneous T cell lymphoma (CTCL) is the most common primary lymphoma of the skin and in advanced stages, malignant T cells spreads through the lymphatic to regional lymph nodes to internal organs and blood. Yet, little is known about the mechanism of the CTCL dissemination. Here, we show that CTCL cells express LTα in situ and that LTα expression is driven by aberrantly activated JAK3/STAT5 pathway. Importantly, via TNF receptor 2, LTα functions as an autocrine factor by stimulating expression of IL-6 in the malignant cells. LTα and IL-6, together with VEGF promote angiogenesis by inducing endothelial cell sprouting and tube formation. Thus, we propose that LTα plays a role in malignant angiogenesis and disease progression in CTCL and may serve as a therapeutic target in this disease.

Improved pruritus correlates with lower levels of IL-31 in CTCL patients under different therapeutic modalities

Pruritus is one of the cardinal symptoms found in patients with leukemic cutaneous T cell lymphoma (CTCL). The nature of the pruritus experienced by CTCL patients is complex, involving different pathways and cell mediators, thus making it poorly responsive to conventional anti-itch therapies. Recent reports highlight the role of interleukin 31 (IL-31) as a novel cytokine involved in the pathogenesis of pruritus in atopic dermatitis and CTCL. Here we provide both in vivo and in vitro evidence suggesting that histone deacetylase (HDAC) inhibitors may mitigate itch through lowering of levels of IL-31-expressing T cells. Furthermore, we demonstrate that chemokine receptor type-4 (CCR4)-bearing T cells are a main source of IL-31 in CTCL, and that neutralizing the IL-31 pathway through targeting of the CCR4-expressing T cells may represent a promising therapeutic strategy for symptomatic relief in CTCL.

Sézary Syndrome

Sézary syndrome (SS), a type of cutaneous T-cell lymphoma with a poor prognosis, is characterized by erythroderma and leukemic involvement. Because of the rarity of SS and difficulty in diagnosis, data on this aggressive malignancy are scarce. In this review, the diagnosis and pathology of SS are summarized and an update is provided, highlighting microscopic features and novel molecular findings. The diagnostic challenge of SS is described, with an emphasis on the differential diagnosis of erythroderma and key points in distinguishing SS from other cutaneous T-cell malignancies. Finally, the prognosis is discussed, focusing on large, recent studies of SS patients.

CD4/CD8 double negative mycosis fungoides with PD-1 (CD279) expression--a disease of follicular helper T-cells?

CD4/CD8 double negative mycosis fungoides (MF) is a rare phenotypic variant of this epidermotropic cutaneous T-cell lymphoma. Clinically, this MF form manifests with unusual appearances such as annular lesions confined to one body region as in our patient in whom the lesions were found on the left lower leg. The cellular origin of CD4/CD8 double negative MF is unknown. In our case, the intraepidermal CD4/CD8 double negative clonal T-lymphocytes (CD2+, CD4-, CD8-, CD30-, beta-F1+) expressed programmed death-1 but were negative for CXCL-13 and cytotoxic molecules (TIA-1, granzyme B, perforin). Our observation may give an insight into the histogenesis of this unique MF variant and may also be of therapeutic significance because programmed death-1 may serve as a target for therapeutic intervention.

Small bowel obstruction due to mycosis fungoides: an unusual presentation

Visceral involvement usually occurs in the late stages of mycosis fungoides (MF). Small bowel involvement in MF is uncommon. When involved, it could cause significant morbidity and mortality. In this study, the authors present an 89-year-old woman diagnosed with T1, N0, B1, M0; stage 1A MF, treated with topical temovate with good response who presented 3 months later with small bowel obstruction due to biopsy-proven localization of MF in the gastrointestinal tract.

The histone deacetylase inhibitors vorinostat and romidepsin downmodulate IL-10 expression in cutaneous T-cell lymphoma cells

BACKGROUND AND PURPOSE

Vorinostat and romidepsin are histone deacetylase inhibitors (HDI), approved for the treatment of cutaneous T-cell lymphoma (CTCL). However, the mechanism(s) by which these drugs exert their anti-cancer effects are not fully understood. Since CTCL is associated with immune dysregulation, we investigated whether these HDI modulated cytokine expression in CTCL cells.

EXPERIMENTAL APPROACH

CTCL cell lines and primary CTCL cells were treated in vitro with vorinostat or romidepsin, or with STAT3 pathway inhibitors. Cell cycle parameters and apoptosis were analysed by propidium iodide and annexin V/propidium iodide staining respectively. Cytokine expression was analysed using QRT-PCR and elisa assays. STAT3 expression/phosphorylation and transcriptional activity were analysed using immunoblotting and transfection/reporter assays respectively.

KEY RESULTS

Vorinostat and romidepsin strongly down-regulated expression of the immunosuppressive cytokine, interleukin (IL)-10, frequently overexpressed in CTCL, at both the RNA and protein level in CTCL cell lines and at the RNA level in primary CTCL cells. Vorinostat and romidepsin also increased expression of IFNG RNA and decreased expression of IL-2 and IL-4 RNA, although to a lesser extent compared to IL-10. Transient exposure to vorinostat was sufficient to suppress IL-10 secretion but was not sufficient to irreversibly commit cells to undergo cell death. STAT3 pathway inhibitors decreased production of IL-10 and vorinostat/romidepsin partially decreased STAT3-dependent transcription without effects on STAT3 expression or phosphorylation.

CONCLUSIONS AND IMPLICATIONS

These results demonstrate that HDI modulate cytokine expression in CTCL cells, potentially via effects on STAT3. Immunomodulation may contribute to the clinical activity of HDI in this disease.

Current approaches to diagnostics of mycosis fungoides

The authors describe strong and weak sides of current methods for diagnostics of mycosis fungoides. Diagnostics of mycosis fungoides is mainly based on the clinical presentation of this disease, which is a significant problem for a dermatovenerologist, especially at early stages of the disease when rashes are of different types. Laboratory methods used to confirm the diagnosis are microscopic examination and immunophenotypic analysis of skin biopsy samples from the affected region as well as determination of clonality of T-lymphocytes in the skin using the PCR method.

Cutaneous lymphoma incidence patterns in the United States: a population-based study of 3884 cases

There have been no prior large population-based studies focusing on cutaneous lymphomas (CL) in the United States. Using the Surveillance, Epidemiology and End Results (SEER) program data, we analyzed age-adjusted CL incidence rates (IRs) and survival rates by sex and race/ethnicity. There were 3884 CLs diagnosed during 2001-2005. Cutaneous T-cell lymphomas (CTCLs) accounted for 71% (age-adjusted incidence rate [IR] = 7.7/1 000 000 person-years), whereas cutaneous B-cell lymphomas(CBCLs) accounted for 29% (IR = 3.1/1 000 000 person-years). Males had a statistically significant higher IR of CL than females (14.0 vs 8.2/1 000 000 person-years, respectively; male-female IR ratio [M/F IRR] = 1.72; P < .001). CL IRs were highest among blacks and non-Hispanic whites (both 11.5/1 000 000 person-years), followed by Hispanic whites (7.9) and Asian/Pacific Islanders (7.1). The CTCL IR was highest among blacks (10.0/1 000 000 person-years), whereas the CBCL IR was highest among non-Hispanic whites (3.5). Over the past 25 years, the CL IR increased from 5.0/1 000 000 person-years during 1980-1982 to 14.3 during 2001-2003. During 2004-2005, the CL IR was 12.7. This recent apparent change could be incomplete case ascertainment or potential leveling off of IRs. CLs rates vary markedly by race and sex, supporting the notion that they represent distinct disease entities.

Perforin expression in feline epitheliotropic cutaneous lymphoma

Cutaneous lymphomas are uncommon in people and companion animals. The tumors can be broadly categorized into epitheliotropic and nonepitheliotropic forms, which appear to have different biological behaviors. The present case describes a feline cutaneous epitheliotropic lymphoma. Masses in a 9-year-old cat were first identified on the tail. The cat was treated with chemotherapy, but additional skin masses developed on the flank, face, and ears. Local radiation induced transient tumor regression, but eventual dissemination prompted euthanasia 13 months after initial tumor appearance. Granular lymphocytes were consistently detected on blood smears, and histologically, the tumor involved the skin and superficial subcutis. Tumor lymphocytes expressed cluster of differentiation 3 (CD3) and perforin molecules, suggestive of a cytotoxic phenotype. Location, histopathological features, and perforin expression were similar to a distinct entity in human medicine designated primary cutaneous, CD8-positive, epidermotropic, cytotoxic, T-cell lymphoma.

Comparative genomic hybridization identifies 17q11.2 approximately q12 duplication as an early event in cutaneous T-cell lymphomas

Mycosis fungoides (MF) and Sézary syndrome (SS) are primary cutaneous T-cell lymphomas (CTCL), a heterogeneous group of extranodal non-Hodgkin lymphomas. In the three cases of MF and four of SS studied, comparative genomic hybridization detected chromosomal imbalances in all SS cases and in one MF case. In all five abnormal cases, the long arm of chromosome 17 was completely or partially duplicated; in three of these five cases, it was the sole genomic event. Notably, a minimal common duplicated region at 17q11.2 approximately q12, corresponded to the mapping of HER2/neu and STAT family genes. The only recurrent loss involved chromosome 10, with deletion of the entire long arm in one case and deletion of band 10q23 in another. Sporadic imbalances included gains at chromosome arms 1q, 2q, 7p, 7q, and 12p. Genomic duplication at 17q11.2 approximately q12 emerged as a primary karyotypic abnormality common to both MF and SS, which suggests that this is an early clonal event.

Cutaneous T-cell lymphoma: overview and nursing perspectives

Cutaneous T-cell lymphoma (CTCL) is an uncommon and complex malignancy of the immune system with a wide range of clinical presentations primarily involving the skin. An extensive menu of skin-directed and/or systemic treatment options exists. Best practices in management involve multidisciplinary collaboration. Nursing care for patients who have CTCL is a critical component in the successful management of the disease and requires special attention to the patient's physical, emotional, and spiritual needs. Nurses can make a significant impact by being accessible, offering emotional support, demonstrating advocacy, and providing ongoing education for the patient and family.