EORTC consensus recommendations for the treatment of mycosis fungoides/Sézary syndrome - Update 2023

Implementing total skin electron irradiation in radiotherapy: a structured change management approach

BACKGROUND

Total skin electron irradiation (TSEI) is a specialized radiotherapy technique used to treat cutaneous T‑cell lymphoma, including mycosis fungoides and Sézary syndrome. Despite its clinical benefits, TSEI is rarely implemented in clinical practice due to significant technical and organizational challenges. This study explores a structured approach to integrating TSEI into clinical routines by applying a comprehensive change management framework in a German radiotherapy department.

METHODS

The implementation process was based on Kotter's eight-step change management model and carried out from 2022 to 2024 by a multidisciplinary team. Key steps included creating a sense of urgency, forming a guiding coalition, developing and communicating a clear vision, and pilot testing to generate short-term successes. A dynamic stakeholder analysis was conducted to continuously identify and manage factors that could promote or hinder the change.

RESULTS

The structured approach facilitated integration of TSEI into routine practice. The project enabled comprehensive staff training, adaptation of technical workflows, and development of necessary protocols and equipment. Key milestones were achieved, including initial patient treatments and positive staff feedback, demonstrating the method's feasibility and acceptance. The stakeholder analysis was instrumental in reducing apprehensions and maintaining alignment among team members.

CONCLUSION

This study demonstrates that a structured change management approach is effective in integrating complex techniques like TSEI into clinical practice. The findings highlight that a systematic framework can help to overcome organizational and technical challenges, thereby enhancing patient care and operational efficiency. Future efforts should continue to employ structured methodologies for the sustainable integration of new medical technologies.

OX40-OX40L Axis in Cutaneous T-Cell Lymphomas: Pathogenic, Prognostic, and Potential Therapeutic Perspectives

Mycosis fungoides (MF) and Sézary syndrome (SS) are the most prevalent forms of cutaneous T-cell lymphoma (CTCL) and are characterized by the proliferation of CD4+ T-helper cells. The pathogenesis of CTCLs involves a critical interaction between neoplastic cells and the tumor microenvironment. This interaction is driven not only by cytokines but also by surface proteins that mediate cell-cell contact. One such protein, OX40 (also known as CD134), is a member of the TNF receptor superfamily and serves as an induced costimulatory molecule that facilitates the interaction between T-cells and antigen-presenting cells. In this narrative review, we explore the literature surrounding the OX40-OX40L interaction in CTCLs, highlighting its pathogenic and prognostic significance. Additionally, we compare the expression and function of OX40-OX40L in chronic inflammatory skin diseases, such as atopic dermatitis and psoriasis, with their role in CTCLs. Finally, we provide an overview of the current state of therapeutic research, discussing the potential of targeting the OX40-OX40L axis in CTCL treatment.

Preclinical in vitro and in vivo evidence for targeting CD74 as an effective treatment strategy for cutaneous T-cell lymphomas

BACKGROUND

Prognosis and quality of life in patients with advanced cutaneous T-cell lymphoma (CTCL), particularly in those with Sézary syndrome (SS) or advanced-stage mycosis fungoides (MF), are poor. Monoclonal antibodies or antibody-drug conjugates (ADCs) have been added into CTCL treatment algorithms, but the spectrum of antibody-targetable cell surface antigens in T-cell non-Hodgkin lymphomas (T-NHLs) is limited.

OBJECTIVES

To evaluate the expression of the major histocompatibility complex class II chaperone CD74 in common subtypes of CTCL by various methods, and to explore the efficacy of targeting CD74 in CTCL cells with an anti-CD74 ADC in vitro and in vivo.

METHODS

We comprehensively investigated the expression of CD74 in well-defined CTCL cell lines by polymerase chain reaction, immunoblotting and flow cytometry. More than 140 primary CTCL samples of all common subtypes were analysed by immunohistochemistry, flow cytometry, immunofluorescence and 'co-detection by indexing' (CODEX) multiplexed tissue imaging, as well as by single-cell RNA sequencing (scRNAseq) analyses. DNA methylation of CTCL cell lines was interrogated by the generation of genome-wide methylation profiling. The effect of a maytansinoid-conjugated humanized ADC against CD74 was investigated in CTCL cell lines in vitro, alone or in combination with gemcitabine, and in vivo after xenotransplantation of CTCL cell lines in NOD-scid Il2rgnull mice.

RESULTS

We demonstrated that CD74 is widely and robustly expressed in CTCL cells. In addition, CD74 expression in SS and MF was confirmed by scRNAseq data analysis and was correlated in CTCL cell lines with CD74 DNA hypomethylation. CD74 was rapidly internalized in CTCL cells and CD74 targeting by the ADC STRO-001 efficiently killed CTCL-derived cell lines. Finally, targeting of CD74 synergized with conventional chemotherapy in vitro and eradicated murine xenotransplants of CTCL cell lines in vivo.

CONCLUSIONS

CD74 is expressed in common CTCL subtypes. Targeting CD74 efficiently killed CTCL cells in vitro and in vivo. We therefore suggest the targeting of CD74 to be a highly promising treatment strategy for CTCL.

ASTCT and USCLC clinical practice recommendations for allogeneic stem cell transplant in mycosis fungoides and Sézary syndrome

INTRODUCTION

Mycosis fungoides (MF) and Sézary syndrome (SS) are the most common subtypes of cutaneous T-cell lymphoma. While MF generally follows an indolent course, a subset of patients will experience progressive and/or treatment-refractory disease. SS is an aggressive cutaneous T-cell lymphoma associated with high morbidity and mortality secondary to immune compromise and opportunistic infection. Although allogeneic hematopoietic cell transplant (allo-HCT) is currently the only available potentially curative treatment modality for MF/SS and is included in the National Comprehensive Cancer Network and the American Society for Transplantation and Cellular Therapy treatment guidelines, there is no published guidance regarding referral criteria, timing and allo-HCT approach to help guide clinicians caring for these patients.

METHODS

Delphi survey of 32 specialists in dermatology (n = 9), transplant hematology/oncology (n = 10), nontransplant hematology/oncology (n = 8), and radiation oncology (n = 5) from across the United States. Consensus required agreement of ≥75% of participants.

RESULTS

Sixteen consensus statements were generated on 4 topics: 1) criteria for referral for consideration for allo-HCT, 2) allo-HCT preparative regimens and procedures, 3) disease status at the time of allo-HCT, and 4) multidisciplinary management in the pre- and post-transplant settings.

CONCLUSION

These clinical practice guidelines provide a framework for decision-making regarding allo-HCT for MF/SS and highlight areas for future prospective investigation.

Total skin electron beam therapy

Primary cutaneous lymphomas are highly radiosensitive. X-rays work well for localized cutaneous lymphomas. However, if disseminated in the skin and covering larger areas, as is commonly the case with the most common type, mycosis fungoides, x-ray therapy is not suited because the dose to underlying organs exceeds their tolerance. By contrast, electrons have a limited range of penetration, and are ideal for treating superficial lesions. Techniques have been developed to yield a fairly uniform dose to the entire skin surface and treating to a depth of about 1-1½ cm. Total skin electron beam therapy (TSEBT) is probably the most effective skin directed therapy for widespread primary cutaneous lymphomas. For many years the total dose used for mycosis fungoides was 30-36 Gy, given in small fractions. This treatment could only be repeated once. However, total doses of 10-12 Gy have now been shown to offer excellent response rates, and the treatment can be repeated up to 6 times, offering as much or probably even more palliation than the high-dose treatment. Today, most patients are treated with low-dose TSEBT, the higher doses reserved for patients with more resistant disease. Attempts have been made to use photon therapy for total skin irradiation, e.g., tomotherapy. However, even with the most meticulous of techniques there is too much dose in deeper structures, resulting in bone marrow toxicity even with low-dose treatment. This is never seen with electrons, even with high-dose therapy. Further research into optimizing TSEBT and exploring combinations with systemic treatments is ongoing.

A Case Report on Juvenile Folliculotropic Mycosis Fungoides: A Misleading Disease

Mycosis fungoides (MF) is the most common form of cutaneous T-cell lymphoma, usually affecting elderly patients. Folliculotropic mycosis fungoides (FMF) is a subtype of MF that affects the hair follicles. While it is the most common variant in adults, it is rarely described in the pediatric population. The clinical manifestations of FMF can mimic common childhood dermatoses, like atopic dermatitis (AD), which often leads to a delay in diagnosis. In the pediatric population, FMF is usually diagnosed at an early stage, and its course is often indolent. There are no guidelines for pediatric FMF; treatment is generally based on the approach used in adults and responds well to phototherapy combining narrow band ultraviolet B (NbUVB) and UVA. We report the case of an 11-year-old child who was treated for several years for atopic dermatitis with follicular involvement, revealing an FMF. This case highlights the value of clinicians' persistence in diagnosing and managing such a rare condition, as well as the essential role of the dermoscopic tool in identifying patterns that may improve the early diagnosis of MF.

Cutaneous T-cell lymphomas: a real-life experience of anticipated use of mogamulizumab in Italy

Mogamulizumab is a humanized monoclonal antibody with enhanced antibody-dependent cell-mediated cytotoxicity that targets chemokine receptor type. Several clinical trials and real-life experiences confirmed the efficacy and safety profiles of mogamulizumab as second-line therapy and beyond, and the biochemical- and dermatology-specific quality of life and physical functioning, with high treatment satisfaction. Systemic drugs are usually used in patients with resistant or advanced forms of cutaneous T-cell lymphomas (especially mycosis fungoides) or with Sézary Syndrome, while early-stage mycosis fungoides can be managed at least initially with local treatments. The most recent Guidelines confirm this approach, but recommend also an anticipated use (starting from the second line) of new therapeutic agents in advanced skin lymphomas. In this report, we discuss eight cases of patients with mycosis fungoides or Sézary Syndrome successfully managed with an anticipated use of mogamulizumab in real-life clinical practice in Italy.

Real-World Pattern-of-Care Analysis of Primary Cutaneous Lymphomas Radiation Therapy Among European Organisation for Research and Treatment of Cancer Members

PURPOSE

We aim to determine the current treatment patterns and recommendations among physicians for cutaneous lymphomas and to identify the types of skin lymphomas for which existing radiation regimens need improvement.

METHODS AND MATERIALS

A questionnaire from the European Organisation for Research and Treatment of Cancer was distributed to all members of the Cutaneous Lymphoma Tumour Group and Radiation Oncology Scientific Council. This online survey included 13 questions regarding treatment practices for patients with cutaneous lymphoma. The survey was conducted from August 21 to December 18, 2023. Frequency distributions and subgroup comparisons were calculated and analyzed.

RESULTS

We collected 51 completed questionnaires from investigators from 19 countries specializing in cutaneous lymphoma treatment. Radiation doses varied significantly (range, 4-60 Gy). Based on the histologic entity, up to one-third of the investigators delivered hypofractionated regimens (range, 14%-35%). Reduced-dose radiation therapy (RT) was considered by 27% to 63% of investigators. Meanwhile, 18 (35%) investigators considered adapting the radiation dose to the response to immunochemotherapy when treating primary cutaneous diffuse large B cell lymphoma-leg type. Regarding total skin electron beam therapy, 91% of centers delivered reduced-dose regimens, and 18% of investigators applied ultrahypofractionated protocols.

CONCLUSIONS

RT in patients with cutaneous lymphoma is highly heterogeneous among the European Organisation for Research and Treatment of Cancer centers. The development of evidence-based recommendations for RT dose, fractionation, and technique for cutaneous lymphomas is required for optimization and standardization of treatment.

Mycosis fungoides and Sezary syndrome - Simplifying the approach for dermatologists. Part 2: Evaluation, staging, prognosis and treatment

Cutaneous T-cell lymphoma is a heterogeneous group of T-cell neoplasms, of which mycosis fungoides and Sezary syndrome are the most common. The prognosis depends on the stage of the disease. The early stage follows a protracted course with a five-year disease-specific survival of greater than 95% and is treated with skin-directed topical therapies, phototherapy, and oral drugs like methotrexate. Advanced disease has a five-year overall survival of less than 25% and requires management by systemic chemotherapeutic agents. This review article is the second part out of the two covering the staging, prognosis, and treatment from a dermatologist's perspective.

Practical recommendations for therapy and monitoring of mogamulizumab patients in Germany

Mycosis fungoides (MF) and Sézary syndrome (SS) are the most common subtypes of the heterogeneous group of cutaneous T-cell lymphomas (CTCL). With the expansion of the biologic treatment landscape, new treatment options have become available in recent years, most notably the C-C chemokine receptor 4 (CCR4)-directed monoclonal antibody mogamulizumab. Based on the phase III pivotal trial, mogamulizumab is recommended by the German S2k guidelines for the second-line treatment of stage IB and above SS and MF, after at least one prior systemic therapy. Since then, new insights on safety and efficacy of mogamulizumab were generated by post hoc analyses and real-world evidence. A panel of CTCL-experts discussed available literature and own experiences and developed relevant recommendations on the use of mogamulizumab in clinical practice in Germany. The recommendations cover patient criteria, prior therapies, use of mogamulizumab as monotherapy or combination therapy, management of side effects, duration of therapy, and monitoring schedules. The aim of these clinical recommendations is to support healthcare professionals in their decision-making and use of mogamulizumab in daily practice.

Drug- and Vaccine-Induced Cutaneous T-Cell Lymphoma: A Systematic Review of the Literature

Cutaneous T-cell lymphomas (CTCLs) are a type of non-Hodgkin lymphoma that usually involves the skin. It has different subtypes including mycosis fungoides (MFs), Sézary syndrome (SS), primary cutaneous anaplastic large lymphoma (PC-ALCL), lymphomatoid papulosis (LyP), and subcutaneous panniculitis-like T-cell lymphoma (SPTCL). There are several reports of incidence, relapse, or progression of CTCLs by using specific drugs. We aim to identify drug- and vaccine-induced CTCL characteristics. A systematic search was conducted using MeSH terms/keywords: CTCL and drug-induced or drug-associated or vaccine-associated or vaccine induced through PubMed/Medline, Scopus, Web of Science, and Embase until May 10, 2024. Out of 14,031 papers, 60 articles were included, involving 71 patients with a mean age of 53.5 ± 17 years. Among them, 52.1% were male. Medications were categorized into four groups: conventional, biologics, small molecules, and vaccines. The most frequently reported medications in the first group were fingolimod (n = 8) and methotrexate (n = 7). Infliximab (n = 6) and etanercept (n = 5) were the most commonly reported biologics. Pfizer-BioNTech (n = 11) vaccine and JAK inhibitors (n = 3) were the most reported vaccine and small molecules. LyP (n = 17) was the most frequently reported type of CTCL, followed by PC-ALCL (n = 13), MF (n = 11), SS (n = 8), and SPTCL (n = 8). The most common underlying conditions were rheumatoid arthritis (n = 15) and multiple sclerosis (n = 10). Twenty patients (28%) experienced disease regression after discontinuing the drug, with a mean ± SD of 8.6 ± 8.8 weeks. In 14 patients (20%), chemotherapy and/or radiotherapy were initiated. Six patients passed away after being diagnosed with CTCL: two because of CTCL recurrence and four because of other complications. It is important recognizing CTCL as a possible, although rare, adverse effect of certain drugs and vaccines, and taking a history of vaccinations, especially COVID-19 vaccines, and immunosuppressive drugs such as fingolimod, TNF-a inhibitors, and methotrexate.

The CD39/CD73/Adenosine and NAD/CD38/CD203a/CD73 Axis in Cutaneous T-Cell Lymphomas

Cutaneous T-cell lymphoma (CTCL), characterized by malignant T-cell proliferation primarily in the skin, includes subtypes such as mycosis fungoides (MF) and Sézary syndrome (SS). The tumor microenvironment (TME) is central to their pathogenesis, with flow cytometry and histology being the gold standards for detecting malignant T cells within the TME. Alongside emerging molecular markers, particularly clonality analysis, these tools are indispensable for accurate diagnosis and treatment planning. Of note, adenosine signaling within the TME has been shown to suppress immune responses, affecting various cell types. The expression of CD39, CD73, and CD38, enzymes involved in adenosine production, can be elevated in MF and SS, contributing to immune suppression. Conversely, the expression of CD26, part of the adenosine deaminase/CD26 complex, that degrades adenosine, is often lost by circulating tumoral cells. Flow cytometry has demonstrated increased levels of CD39 and CD73 on Sézary cells, correlating with disease progression and prognosis, while CD38 shows a variable expression, with its prognostic significance remaining under investigation. Understanding these markers' roles in the complexity of TME-mediated immune evasion mechanisms might enhance diagnostic precision and offer new therapeutic targets in CTCL.

New and emerging therapies in cutaneous T-cell lymphoma

Mycosis fungoides (MF) is the most common cutaneous T-cell lymphoma (CTCL) that typically presents in the early phase as inflammatory erythematous patches or plaques, with epidermotropism as the histopathological hallmark of the disease. Traditionally, in the early stages, non-aggressive options represent the first-line strategy: topical corticosteroids, phototherapy, radiotherapy, and occasionally adopting a "wait-and-see" approach for minimally symptomatic patients. In patients with advanced or recurrent disease, good results can be achieved with immune modifiers, chemotherapeutic agents, total skin irradiation, or extracorporeal photochemotherapy, and maintenance therapy is often required. The past decade has seen an expansion of therapies that can be used in this setting by increasing new therapeutic strategies. The key advancements coming from recently published trials are resumed in this article.

Management of mycosis fungoides and Sézary syndrome with mogamulizumab in combination with psoralen plus UVA: two case reports

This report describes the cases of two patients with mycosis fungoides and Sézary syndrome (MF/SS) who achieved clinical benefit with mogamulizumab combination therapies. Case 1 is a 56-year-old male with stage IIIB (T4NxM0B1) MF, which later progressed into SS, with ongoing skin symptoms (erythema, lichenified skin, and pruritis) and axillary and inguinal lymphadenomegaly. Skin-directed and systemic therapies failed to achieve a long-lasting response in this patient. Mogamulizumab (1 mg/kg once weekly for 4 weeks; once every 2 weeks thereafter) yielded temporary improvement in skin symptoms, but progression in the skin was confirmed after ~2 months. Subsequently, the combination of mogamulizumab with psoralen plus ultraviolet light A (PUVA) yielded a partial response; however, PUVA was discontinued due to phototoxicity and mogamulizumab was continued as monotherapy. At the latest evaluation, clinical improvement in the skin and reduced lymphadenomegaly were evident with ongoing mogamulizumab monotherapy; the patient is awaiting allogeneic hematopoietic stem cell transplantation. Case 2 is an 80-year-old male with stage IIIB (T4NxM0B1) granulomatous variant MF who presented with diffuse erythema with desquamation, ectropion, and inguinal lymphadenopathy. Treatment with oral prednisone and bexarotene failed to achieve adequate, long-lasting responses. Mogamulizumab (1 mg/kg once weekly for 4 weeks; once every 2 weeks thereafter) monotherapy yielded an initial improvement, characterized by less intense erythema, but the improvement was not sustained. Mogamulizumab was supplemented with oral prednisone and then PUVA; this combination resulted in improvement in the skin. PUVA was stopped due to unavailability, and methotrexate (10 mg once weekly) was initiated alongside continued mogamulizumab; this led to improvement in erythema. The patient continued mogamulizumab plus methotrexate with improving clinical status, prior to their death, which was deemed to be unlikely to be related to treatment. Our experience suggests that, in principle, mogamulizumab can be used in combination with other therapies; however, further research is needed.

Dimethyl fumarate and extracorporeal photopheresis combination-therapy synergize in inducing specific cell death and long-term remission in cutaneous T cell lymphoma

Primary cutaneous T cell lymphomas (CTCL) are characterized by high relapse rates to initially highly effective therapies. Combination therapies have proven beneficial, particularly if they incorporate extracorporeal photopheresis (ECP). The NF-κB inhibitor dimethyl fumarate (DMF) has proven a new, effective drug in CTCL in a clinical phase II study. In vitro experiments with patient-derived SS cells and the CTCL cell lines HH, HuT 78, and SeAx revealed a synergistic effect of DMF and ECP on cell death induction in CTCL cells. Furthermore, an additional increase in the capacity to inhibit NF-κB in CTCL was detected for the combination treatment compared to DMF monotherapy. The same synergistic effects could be measured for ROS production via decreased Thioredoxin reductase activity and glutathione levels. Consequently, a cell death inhibitor screen indicated that the DMF/ECP combination treatment induces a variety of cell death mechanisms in CTCL. As a first step into clinical translation, 4 patients were already treated with the DMF/ECP combination therapy with an overall response rate of 100% and a time to next treatment in skin and blood of up to 57 months. Therefore, our study introduces the combination treatment of DMF and ECP as a highly effective and long-lasting CTCL therapy.

"Missed" Diagnosis of Mycosis Fungoides: A Case Report

Mycosis fungoides (MF) is the most common subtype of primary cutaneous T-cell lymphoma characterized by malignant proliferation of T cells with epidermotropism in the skin. MF has an indolent course, presents as erythematous scaly patches or plaques, and may progress to generalized erythroderma, cutaneous tumors, or extracutaneous invasion. MF is often misdiagnosed at early stages due to nonspecific clinical findings. Patients with MF are at high risk for developing secondary malignancies, including hematological malignancies. We hereby report a case of MF misdiagnosed and associated with underlying diffuse large B-cell lymphoma.

Single-cell RNA sequencing comparison of CD4+, CD8+ and T-cell receptor γδ+ cutaneous T-cell lymphomas reveals subset-specific molecular phenotypes

BACKGROUND

Malignant clones of primary cutaneous T-cell lymphomas (CTCL) can show a CD4+, CD8+ or T-cell receptor (TCR)-γδ+ phenotype, but their individual impact on tumour biology and skin lesion formation remains ill defined.

OBJECTIVES

To perform a comprehensive molecular characterization of CD4+ vs. CD8+ and TCR-γδ+ CTCL lesions.

METHODS

We performed single-cell RNA sequencing (scRNAseq) of 18 CTCL skin biopsies to compare classic CD4+ advanced-stage mycosis fungoides (MF) with TCR-γ/δ+ MF and primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (Berti lymphoma).

RESULTS

Malignant clones of TCR-γ/δ+ MF and Bertilymphoma showed similar clustering patterns distinct from CD4+ MF, along with increased expression of cytotoxic markers such as NKG7, CTSW, GZMA and GZMM. Only advanced-stage CD4+ MF clones expressed central memory T-cell markers (SELL, CCR7, LEF1), alongside B1/B2 blood involvement, whereas TCR-γδ+ MF and Berti lymphoma harboured a more tissue-resident phenotype (CD69, CXCR4, NR4A1) without detectable cells in the blood. CD4+ MF and TCR-γδ+ MF skin lesions harboured strong type 2 immune activation across myeloid cells, while Berti lymphoma was more skewed toward type 1 immune responses. Both CD4+ MF and TCR-γδ+ MF lesions showed upregulation of keratinocyte hyperactivation markers such as S100A genes and KRT16. This increase was entirely absent in Berti lymphoma, possibly reflecting an aberrant keratinocyte response to invading tumour cells, which could contribute to the formation of the typical ulceronecrotic lesions within this entity.

CONCLUSIONS

Our scRNAseq profiling study reveals specific molecular patterns associated with distinct CTCL subtypes.

Matrine Enhances the Antitumor Efficacy of Chidamide in CTCL by Promoting Apoptosis

BACKGROUND

Cutaneous T-cell Lymphoma (CTCL) is a rare group of non-Hodgkin lymphoma originating from the skin, which is characterized by T-cell lymphoproliferative disorders. Chidamide, a Chinese original antineoplastic agent with independent intellectual property rights, and matrine, an extract of Chinese herbal medicine, both have been reported to exert effects on the treatment of tumors individually. However, chidamide combined with matrine has not been tested for the treatment of CTCL.

METHODS

Both HH and Hut78 CTCL cell lines were treated with chidamide (0.4 μmol/L), matrine (0.6 g/L), or chidamide combined with matrine for 24, 48, and 72 h. Cell viability was estimated by MTS assay at each time point. Flow cytometry was then conducted to detect cell apoptosis. The exact mechanism of chidamide combined with matrine on CTCL cells was detected by Western blotting and further validated in xenograft models of NOD/SCID mice.

RESULTS AND DISCUSSION

Compared to the single drug, chidamide combined with matrine showed a more significant effect on proliferation inhibition and apoptosis induction on CTCL cells both in vitro and in vivo. The results from the in vitro and in vivo studies suggested that matrine could enhance the anti-tumor effect of chidamide by increasing the protein expression of cleaved caspase- 3 and decreasing the expression of E-cadherin, NF-κB, p-Bad, and Bcl-2 to activate apoptosis.

CONCLUSION

Our data have demonstrated chidamide combined with matrine to exhibit elevated antitumor activity in both CTCL cells and xenograft models of NOD/SCID mice, which may be a potential treatment option for CTCL.

Pediatric Cutaneous T-Cell Neoplasms: Clinical and Pathological Features, Updated Classifications, and Critical Differential Diagnoses

Cutaneous T-cell lymphoid neoplasms in childhood are exceedingly rare, presenting with a wide spectrum of clinical presentation and outcomes. Due to numerous clinical and pathological mimics, an integrated evaluation of clinical, histopathological, immunohistochemical, and molecular findings is critical for a diagnosis. Here, we review the clinical and pathological features, updated classifications, and critical differential diagnoses of cutaneous T-cell lymphoid neoplasms in children.

Breaking Down the Barriers for Patients With Cutaneous T-Cell Lymphoma: Current Controversies and Challenges for Radiation Oncologists in 2024

Cutaneous T-cell lymphomas (CTCL) are a rare collection of diseases, frequently associated with diagnostic challenges and complex management dilemmas. The multidisciplinary team is vital for accurate clinico-pathological diagnoses and for collaborative therapeutic decisions throughout the management journey, which frequently involves multiple lines of therapy. Radiotherapy (RT) is a highly effective skin-directed therapy for CTCL, commonly delivered as localised fields or as total skin electron beam therapy (TSEBT). Mycosis fungoides (MF) is the most common of the CTCL, and patients typically experience high rates of morbidity and long natural histories of relapse and progression. Patients with MF typically present with incurable disease; in these patients, RT has an established role in symptom- and disease-control, achieving excellent response rates and proven therapeutic benefits. The role of RT continues to evolve, with modern practices favouring lower doses to reduce toxicity risks and allow for re-irradiation. Less commonly, there are situations where RT has an integral role in the potential cure of patients with MF: firstly, in the setting of unilesional MF where localised RT alone may be curative, and secondly, in the setting of preconditioning prior to curative-intent allogeneic hematopoietic stem cell transplant for patients with advanced MF/Sezary syndrome, where conventional-dose TSEBT is indicated as the most effective single agent for maximal debulking of skin disease. Radiotherapy also has an important role in the management of the less common CTCL, including the curative treatment of localised primary cutaneous anaplastic large cell lymphoma. Despite proven efficacy and quality of life benefits, disparity exists in access to RT and TSEBT. World-wide, stronger multidisciplinary collaborations and greater patient advocacy are required to increase access to RT and improve equity of care for our patients with CTCL.

Chlormethine Gel for Treatment of Patients with Mycosis Fungoides: Best Practices and Guidance to Clinicians

BACKGROUND

Mycosis fungoides (MF) is the most common form of cutaneous T cell lymphoma. While multiple guidelines provide treatment recommendations, there are currently no clear treatment algorithms for MF. Chlormethine gel is recommended by major treatment guidelines as a first-line option for stage IA-IIA disease, and, on the basis of these guidelines, used in combination with other therapies in patients with advanced-stage MF in clinical practice.

OBJECTIVES

To provide guidance regarding the use of chlormethine gel for patients with all stages of MF, based on clinical expertise.

METHODS

Opinions on best practices regarding the use of chlormethine gel were collected through discussions that involved eight clinicians with extensive experience in treating patients with MF.

RESULTS

Chlormethine gel can be used as monotherapy in first- or second-line treatment of early-stage MF. In first-line, chlormethine gel monotherapy is prescribed for stage IA MF, and is particularly convenient for patients unable/unwilling to travel for hospital-based phototherapy, patients with thick plaques or palmoplantar involvement, when ultraviolet treatment is contraindicated, and for sanctuary sites. Chlormethine gel is also an appropriate first-line monotherapy for patients with stage IB or IIA MF; it may be used as part of combination regimens in these patients as well. For patients with late-stage MF, skin-directed treatments such as chlormethine gel should be combined with systemic therapies.

CONCLUSIONS

Chlormethine gel is a safe and effective treatment option that can be used in all stages of MF, either as monotherapy or in combination, depending on disease stage and patient characteristics and needs.

Sézary syndrome mimicking Steven-Johnson syndrome: A case report

RATIONALE

Sézary syndrome is a rare and subtype of non-Hodgkin T cell lymphomas. It typically presents as papules, macules, nodules, or ulcers, frequently accompanied by lymphadenopathy and systemic symptoms. This study describes uncommon clinical and diagnostic features to distinguish Sézary syndrome from serious skin and mucous membrane disorders through a detailed case report and comprehensive literature review.

PATIENT CONCERNS/DIAGNOSIS/INTERVENTION/OUTCOMES

A 70-year-old female patient was diagnosed with progressive Sézary syndrome associated with extensive cutaneous scaly and ulcerative lesions after 5 cycles of anthracycline-based chemotherapy which is initially misleading to Steven-Johnson syndrome (SJS). SJS was clinically excluded due to no mucosal involvement. She received a single agent of steroid as a lymphoma salvage treatment due to poor performance and nutrition status. Facial and left arm skin biopsy revealed T lymphoma cells infiltrating the upper dermis. Unfortunately, she died due to progressive lymphoma disease and upper gastrointestinal bleeding.

LESSONS

Unlike mycosis fungoides, Sézary syndrome involves more than bathing suit areas of skin and it may present with scaly, ulceration, or even hemorrhagic bullae and Sézary cells in peripheral blood. Sometimes, it's hard to differentiate from SJS or toxic epidermal necrolysis (TEN). Mucosa involvement is a crucial feature shown in patients with SJS/TEN.

Case report: Canadian consensus on chlormethine gel use in mycosis fungoides-CTCL: literature review and real-world experience

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma (CTCL), representing the majority of all lymphomas arising in the skin. The disease treatment focuses on managing symptoms and preventing disease evolution. To date, there is no gold standard for MF-CTCL treatment. Chlormethine, a DNA alkylating agent, is a long-known treatment for CTCL. The new chlormethine 0.02% gel (CL-gel) formulation provides proven efficacy and ease of application, improving patient compliance and outcome. The current consensus paper and real-world experience with CL-gel in the treatment of early-stage MF-CTCL may help meet the unmet need for treatments in Canada. A modified Delphi process comprised a virtual meeting and an online follow-up. A panel of 9 board-certified dermatologists with expertise in cutaneous lymphoma and 1 radiation oncologist discussed the systematic literature review results, drew from clinical experience and the opinion of the panel to adopt and agree on five consensus statements. The panel shared real-world patient cases to illustrate the use of chlormethine gel in a variety of patients across Canada. Five real-world patient cases were provided to illustrate the panels' use of chlormethine gel.

Folliculotropic mycosis fungoides of the face successfully treated combining CO2 laser and conventional photodynamic therapy (c-PDT)

A 57-year-old male with a three-year history of folliculotropic mycosis fungoides (FMF), previously treated systemically, received CO2 laser-assisted photodynamic therapy (PDT) following the recurrence of FMF on the face. The procedure involved a CO2 laser (SmartXide DOT Deka) and the photosensitizing agent methyl aminolevulinate (MAL) (METVIX 160 mg/g Cream, Galderma Medical), in conjunction with a red light-emitting diode lamp (Aktilite CL128, Galderma, wavelength 630 nm). The primary endpoint was the clinical remission of the lesions; the secondary one the evaluation of treatment tolerance, measured using the 11-point (0-10) Numeric Rating Scale (NRS) for burning/pain, heat, and swelling. After a single treatment session and four weeks of follow-up, the patient's facial lesions achieved complete clinical remission.

Circadian rhythms in haematological malignancies: therapeutic potential and personalised interventions

The circadian clock, a fundamental cellular mechanism, regulates the rhythmic expression of numerous genes and biological processes across various organs. Disruptions in this system, driven by genetic or environmental factors, have been reported to be involved in cancer progression. This review explores the role of the circadian clock in cancer hallmarks and its impact on cellular homeostasis within haematological malignancies. Drawing on findings from in vitro, in vivo, and clinical trials, this review highlights the potential of clock genes as diagnostic and prognostic biomarkers, and as therapeutic targets for optimising treatment timing. It discusses how circadian rhythms can enhance treatment efficacy through both pharmacological and non-pharmacological interventions, outlining strategies for optimising dosing schedules and implementing personalised chronobiological interventions, with a particular focus on haematological malignancies, including cutaneous lymphoma. Ongoing research holds promise for advancing personalised therapeutic approaches and ultimately improving cancer care standards.

Clinical Reasoning: Progressive Peripheral Neuropathy in a 66-Year-Old Woman With Sezary Syndrome

Evaluating patients with neuropathy is common, especially in elderly patients with comorbidities. Neuropathy can often be a manifestation of systemic diseases, cancer, or drug-induced toxicity; thus, the differential diagnosis is challenging. The mechanism of nerve damage can vary significantly, affecting the patient's therapeutic management. We describe a 66-year-old woman who presented with subacute and progressively worsening motor weakness of the lower extremities with bilateral numbness and tingling after a recent respiratory tract infection. Her medical history included diabetes mellitus and Sezary syndrome in the context of cutaneous T-cell lymphoma. This case emphasizes the significance of a detailed evaluation and considering clinical signs and electrophysiologic findings in patients with neuropathy and a history of hematologic malignancy. Early recognition and management can be crucial in shaping the clinical course of the disease.

[Cutaneous T-cell lymphomas]

Primitive cutaneous T-cell lymphomas are lymphomas clinically restricted to skin at diagnosis in opposite to skin localizations of systemic lymphomas. Cutaneous T-cell lymphomas are the most frequent. Beside mycosis fungoides and related forms, CD30+ lymphoproliferations (lymphomatoid papulosis, anaplastic large cell primitive cutaneous T-cell lymphomas) and erythrodermic T-cell lymphomas which constitute the main entities, other rare lymphomas are described: panniculitis like alpha/beta lymphoma, gamma/delta lymphoma, epidermotropic CD8+ aggressive lymphoma, small to medium T-cell lymphomas and acral CD8+ lymphoproliferations. Clinical skin examination and skin biopsy examination are crucial for diagnosis but recent advances in molecular genetics bring promising tools for diagnostic. Thanks to international cooperative groups, treatment of mycosis fungoides, CD30+ lymphoproliferations and erythrodermic lymphomas is now well established which is not the case for the other entities. Treatments may be classified in five categories: skin directed therapies, systemic non-chemotherapeutic treatments, immunomodulators, targeted immunotherapies and chemotherapies.

Cutaneous T-cell lymphoma: Consensus on diagnosis and management in Taiwan

Cutaneous T cell lymphomas (CTCLs), with mycosis fungoides (MF) and Sézary syndrome (SS) as the classic types, are the commonest group of primary cutaneous lymphomas. The diverse clinical manifestation and non-specific histologic findings of early lesions in CTCLs render diagnosis challenging. Treatment modalities also vary and include topical and oral medications, chemotherapy, phototherapy, and radiation therapies. Local dermatological, hemato-oncologic and radiotherapeutical experts in Taiwan convened meetings in 2023 to review and discuss the latest evidence and updates regarding diagnosis and management of CTCLs. A consensus was developed with the aim to raise awareness and understanding, provide practical guidance for early diagnosis and appropriate management, and ultimately optimize care to maximize benefits of patients.

Pegylated interferon-α2a in cutaneous T-cell lymphoma - a multicenter retrospective data analysis with 70 patients

BACKGROUND

Interferon-alpha is an important therapeutic option for the treatment of the cutaneous T-cell lymphomas (CTCL). Since the approved recombinant interferon-α-2a (IFN-α2a) has no longer been produced since January 2020, pegylated interferon-α2a (pegIFN-α2a) can be used as an alternative treatment, even though it is not approved for the treatment of CTCL. The aim of this multicentre study was to generate comprehensive data on the efficacy and tolerability of pegIFN-α2a in the treatment of CTCL.

PATIENTS AND METHODS

A multicenter retrospective study was conducted with 70 patients with CTCL from twelve German skin centers.

RESULTS

In total, 70 patients were included in the study, with 57.2% male and a mean age of 58.8 ± 14.9 years. Mycosis fungoides was present in 71.4% of cases and Sézary Syndrome in 28.6%. An overall response rate of 55.2% was observed with pegIFNα-2a therapy. In 50% of cases, therapy was discontinued after 63.6 ± 33.5 weeks. The most common reason for discontinuation was adverse events, which occurred in 68.6% of cases and which were classified as severe in 29.2%. Blood count changes, fatigue and liver toxicity occurred most frequently.

CONCLUSIONS

Our analysis provides comprehensive data on the efficacy and tolerability of pegIFNα-2a therapy in patients with CTCL. In terms of response rates and side effect profile, pegIFNα-2a appears to be comparable to IFN-α2a therapy.

ASTCT and USCLC Clinical Practice Recommendations for Allogeneic Stem Cell Transplant in Mycosis Fungoides and Sézary Syndrome

Mycosis fungoides (MF) and Sézary syndrome (SS) are the most common subtypes of cutaneous T-cell lymphoma (CTCL). While MF generally follows an indolent course, a subset of patients will experience progressive and/or treatment-refractory disease; Sézary syndrome is an aggressive lymphoma associated with high morbidity and mortality. Although allogeneic hematopoietic cell transplant (allo-HCT) is the only currently available potentially curative treatment modality for MF/SS there is no published guidance on referral criteria, transplant timing orallo-HCT approach. To develop consensus clinical practice recommendations, we performed a Delphi survey of 32 specialists in dermatology (n = 9), transplant hematology/oncology (n = 10), non-transplant hematology/oncology (n = 8), and radiation oncology (n = 5) from across the United States. Consensus required agreement of ≥75% of participants. Sixteen consensus statements were generated on four topics: (1) criteria for referral for consideration for allo-HCT, (2) allo-HCT preparative regimens and procedures (3) disease status at the time of allo-HCT, and (4) multidisciplinary management in the pre- and post-transplant settings. These clinical practice guidelines provide a framework for decision-making regarding allo-HCT for MF/SS and highlight areas for future prospective investigation.

Radiotherapy in cutaneous lymphomas: Recommendations from the EORTC cutaneous lymphoma tumour group

The number of primary cutaneous lymphoma patients receiving low-dose radiotherapy is increasing, though controlled clinical trials defining the standard radiation dose for each specific entity have not yet been completed. Radiation oncologists are left with making highly individualized decisions that would be better enriched by additional clinical evidence. In this expert opinion, we aim to provide a clear recommendation to improve the current practice of radiation oncology. In addition, existing literature has been reviewed to develop recommendations for all types of primary cutaneous lymphoma. A prospective trial is urgently needed to identify the factors influencing patient outcomes following different radiation doses.

Deciphering the Etiologies of Adult Erythroderma: An Updated Guide to Presentations, Diagnostic Tools, Pathophysiologies, and Treatments

Erythroderma, an inflammatory skin condition characterized by widespread erythema with variable degrees of exfoliation, pustulation, or vesiculobullous formation, is associated with high morbidity and mortality. Determining the underlying cause of erythroderma frequently presents a diagnostic challenge, which may contribute to the condition's relatively poor prognosis. This review covers the clinical presentation, pathophysiology, diagnosis, and treatment of erythroderma. It discusses similarities and differences among the many underlying etiologies of the condition and differences between erythrodermic and non-erythrodermic presentations of the same dermatosis. Finally, this article explores current research that may provide future tools in the diagnosis and management of erythroderma.

Multidisciplinary and personalized approach to the management of mycosis fungoides with chlormethine gel: a collection of clinical experiences

Topical chlormethine (CL) gel formulation was approved by the EMA in 2017 for the treatment of adult patients with mycosis fungoides (MF). To expand the knowledge on the management of MF, this paper provides an overview of clinical practice evidence about the MF diagnostic phase and a collection of clinical experiences to better characterize the use of CL gel in daily practice. Collected cases underline the importance of the concomitant biopsy and clinical evaluation in the diagnostic phase, with the contribution of a multidisciplinary team, and support the use of CL gel as a first-line or adjuvant treatment in selected patients.

The Landscape of Cutaneous T-Cell Lymphoma (CTCL) in the Middle East and North Africa (MENA) and the Establishment of the MENA CTCL Working Group

The high cancer burden in the Middle East and North Africa (MENA region) is coupled with an increasing cancer incidence. While the MENA region constitutes 6% of the world's population, it remains underrepresented in clinical trials. Cutaneous T-cell lymphomas (CTCLs) represent a heterogeneous group of rare extranodal non-Hodgkin lymphomas with variable clinical presentation. In the MENA region, where darker skin colors are more common than in the West, CTCL generally presents at a younger age and with distinct clinical features that necessitate special expertise and management across disciplines: rare forms of CTCL are more common (hypo- and hyperpigmented MF) and a higher prevalence of pediatric MF is noticed. The multidisciplinary approach to cancer management is growing worldwide and is necessary for the comprehensive management of CTCL. The MENA CTCL group was established with the aim of creating a collaborative environment for the diagnosis and treatment of CTCL in the region. Its first meeting was held in May 2023. The group plans to increase the global representation of the MENA region and establish CTCL registries and patient advocacy groups in the region.

Cutaneous T-cell Lymphoma

Cutaneous T-cell lymphoma is a group of non-Hodgkin T-cell lymphomas that develop in and affect the skin but can potentially spread to other organs. There are many subtypes, the most common of which are mycosis fungoides, Sezary syndrome, lymphomatoid papulosis, and primary cutaneous anaplastic large cell lymphoma. Cutaneous lymphoma is a common cause of recalcitrant chronic skin rash and notoriously mimics other dermatologic and hematologic conditions, often resulting in diagnostic delays of months to years. This review provides an introduction to cutaneous T-cell lymphoma, with a primary focus on the clinical presentation, diagnosis, immunopathogenesis, and management of the condition.

Mogamulizumab and Concomitant Hypofractionated Low-Dose Total Skin Electron Beam Therapy (2 × 4 Gy) in Cutaneous T-Cell Lymphoma: Proof of Principle, Report of Two Cases

Patients with advanced-stage mycosis fungoides (MF IIB-IVB) and Sézary syndrome (SS) have poor prognoses, with survival ranging from 4.7 to 1.4 years depending on the disease stage. There is a need for therapeutic approaches that lead to long-lasting responses and improved quality of life and survival. Mogamulizumab, a humanized antibody against the CCR4 molecule, and low-dose total skin electron beam therapy (TSEBT) are two known established treatments for MF and SS as a monotherapy. However, little is known about the potential additive effect on the combination of both treatments. We report here for the first time the concurrent use of low-dose hypofractionated TSEBT (2 × 4 Gy) with mogamulizumab. Based on two relapsed/refractory and advanced-stage CTCL patients, we show that this combination may be well tolerated in advanced-stage MF or SS and may potentially lead to an additive treatment effect on response times, particularly in the skin and blood within two weeks. We propose that this combination may be a treatment option for patients with SS. Further research is needed to understand the efficacy and tolerability profile of this therapeutic combination and to determine if there is an additive effect of the combination on the response rates when compared with the monotherapy.

Immune-related adverse events associated with mogamulizumab: a comprehensive review of the literature

INTRODUCTION

Mogamulizumab is an anti-C-C chemokine receptor 4 antibody that is increasingly being used to treat T-cell malignancies such as cutaneous T-cell lymphoma, adult T-cell leukemia-lymphoma, and peripheral T-cell lymphoma. Because CCR4 is expressed on both malignant T-cells and regulatory T-cells (Tregs), mogamulizumab can be associated with increased immune-related adverse events (irAEs). While there is abundant literature on mogamulizumab-associated rash (MAR) and graft-versus-host disease (GVHD), other reported irAEs have not been collated into a single review.

AREAS COVERED

This narrative review covers irAEs associated with mogamulizumab in patients with T-cell lymphomas, focusing on events other than MAR and GVHD. We searched PubMed and Google Scholar for case reports, case series, chart reviews, and clinical trials published from inception to March 2024. Identified events include alopecia, vitiligo, arthritis, psoriasis, myocarditis, myositis/polymyositis, hepatitis, and others.

EXPERT OPINION

Mogamulizumab's ability to augment the host immune response through Treg depletion adds to its efficacy but has wide-ranging implications for autoimmunity across multiple organ systems, similar to immune checkpoint inhibitor therapy. Occurrence of irAEs may be associated with improved overall clinical response, although long-term follow-up studies are needed.

Real-world study of pegylated interferon α-2a to treat mycosis fungoides/Sézary syndrome using time to next treatment as a measure of clinical benefit: an EORTC CLTG study

BACKGROUND

Mycosis fungoides (MF) and Sézary syndrome (SS) are chronic malignant diseases that typically necessitate diverse strategies to achieve remission. Systemic interferon (IFN)-α (subtypes 2a and 2b) has been used to treat MF/SS since 1984; however, its production was recently stopped. The recombinant pegylated (PEG) form of IFN-α-2a remains the only alternative IFN treatment, although it has not been approved for use in MF/SS.

OBJECTIVES

To assess the effectiveness and safety of PEG-IFN-α-2a in monotherapy and in combination with other treatments using time to next treatment (TTNT) as a measure of clinical therapeutic benefit in a real-world setting.

METHODS

We conducted an international, multicentre retrospective study of patients with MF and SS (of any stage) treated with PEG-IFN-α-2a from July 2012 to February 2022. Patients were included across 11 centres in 10 countries. The primary endpoints were to determine the TTNT of PEG-IFN-α-2a and adverse events (AEs) in MF/SS.

RESULTS

In total, 105 patients were included [mean (SD) age 61 (13.1) years]; 42 (40.0%) had stage IA-IIA and 63 (60.0%) had stage IIB-IVB disease. PEG-IFN-α-2a was combined with other therapies in 67 (63.8%) patients, most commonly with extracorporeal photopheresis (36%) and bexarotene (22%). Patients with stage I-IIA disease achieved an overall response rate (ORR) of 57%; the ORR in those with stage IIB-IVB disease was 51%. Combination treatment resulted in a median TTNT of 10.4 months (range 0.6-50.7) vs. 7.0 months (range 0.7-52.4) for those who received monotherapy (P < 0.01). Overall, the mean (SD) TTNT was 9.2 (10.6) months and the ORR was 53.3% (n = 56). A complete response was seen in 13% of patients and a partial response in 40%. AEs were described in 68.6% (n = 72) of patients. Flu-like symptoms (n = 28; 26.7%), lymphopenia (n = 24; 22.9%) and elevated liver function (n = 10; 9.5%) were the most frequently reported. Grade 3-4 AEs were reported in 23 (21.9%) patients, mostly related to myelosuppression.

CONCLUSIONS

PEG-IFN-α-2a for MF/SS resulted in an ORR of 53.3% and a mean (SD) TTNT of 9.2 (10.6) months. Combination regimens were superior to monotherapy and doses of 180 µg PEG-IFN-α-2a weekly were related to a higher ORR.

Cutaneous T-cell lymphoma care across Europe: insights from the HORIZON programme

In this perspective we provide BJD readers with an overview of the HORIZON programme. It illuminates the diverse perspectives of specialists across five prominent European centres of excellence in the field of CTCL.

Cutaneous T-cell Lymphoma Diagnostic and Therapeutic Trends amidst the COVID-19 Pandemic

is missing (Short communication).

An Overview of Methotrexate Indications in Skin Diseases

Methotrexate is an immunosuppressive drug with remarkable therapeutic results in the treatment of autoimmune and proliferative skin diseases. Although it has been more than half a century since it was first introduced into the therapeutic arsenal of dermatologists, there are currently no standardized therapeutic protocols regarding the prescription of methotrexate in dermatology, with the exception of psoriasis treatment. This review aims to highlight the indications and benefits of methotrexate beyond psoriasis, with a focus on a wide range of inflammatory, vesiculobullous, and proliferative dermatological pathologies.

Evolution of patients with Sézary syndrome after mogamulizumab discontinuation for any cause except progression: a multicentre retrospective study (Moga-stop Study)

The results of this study suggest that progressive discontinuation of mogamulizumab (Moga) should be considered once a response is obtained in patients with Sézary syndrome, even after a short treatment duration. This may minimize the risk of adverse effects, costs and resistance to Moga. Additionally, our study emphasizes that Moga rechallenge should be encouraged as a first choice in relapsing patients.

Sézary Syndrome in West Sweden: Exploring Epidemiology, Clinical Features, and Treatment Patterns in a Registry-Based Retrospective Analysis

Sézary syndrome (SS) is a rare primary cutaneous T-cell lymphoma variant. Despite various treatment options, it remains incurable, with a poor prognosis. There is an urgent need for additional descriptive research to enhance our understanding and treatment of SS. The aim of this retrospective register-based study was to outline patients' demographic characteristics; investigate the clinical, histopathological, and molecular findings; and assess treatment effectiveness with a focus on time to next treatment (TTNT) and disease progression. Data on 17 patients with SS were obtained from the primary cutaneous lymphoma register in West Sweden between 2012 and 2024. The results revealed that not all patients exhibited the classical triad of symptoms at diagnosis, emphasizing the need for personalized diagnostic approaches. The median survival was only 2.1 years, which reflects the aggressive nature of SS. The longest median TTNT was observed in triple therapy involving retinoids, interferon alpha, and extracorporeal photopheresis (ECP). There was no significant difference in TTNT between various lines of treatment. Early initiation of ECP treatment did not result in improved outcomes. This study highlights the importance of combination therapy for improved outcomes and underscores the need for future studies to identify optimal treatment approaches.

Delving into the Metabolism of Sézary Cells: A Brief Review

Primary cutaneous lymphomas (PCLs) are a heterogeneous group of lymphoproliferative disorders caused by the accumulation of neoplastic T or B lymphocytes in the skin. Sézary syndrome (SS) is an aggressive and rare form of cutaneous T cell lymphoma (CTCL) characterized by an erythroderma and the presence of atypical cerebriform T cells named Sézary cells in skin and blood. Most of the available treatments for SS are not curative, which means there is an urgent need for the development of novel efficient therapies. Recently, targeting cancer metabolism has emerged as a promising strategy for cancer therapy. This is due to the accumulating evidence that metabolic reprogramming highly contributes to tumor progression. Genes play a pivotal role in regulating metabolic processes, and alterations in these genes can disrupt the delicate balance of metabolic pathways, potentially contributing to cancer development. In this review, we discuss the importance of targeting energy metabolism in tumors and the currently available data on the metabolism of Sézary cells, paving the way for potential new therapeutic approaches aiming to improve clinical outcomes for patients suffering from SS.

Skin-directed therapy and biologic response modifiers in mycosis fungoides

The most common and widespread type of cutaneous T-cell lymphoma is mycosis fungoides (MF), and it has a multiphasic clinical and biological course, with early stages being indolent for many years and later stages being faster and more aggressive. The clinical stage has a significant impact on the management and course of treatment: in the early stages, skin-directed therapies (SDT) plus/or biologic response modifiers (BRM); in the later stages, radiotherapy and/or systemic therapies. Even though national and international societies and groups periodically update their clinical recommendations, there is still no universally accepted approach. This paper reviews and discusses the various SDT and BRM options, either separately or in combination.