Photodynamic therapy: An option in mycosis fungoides

Photodynamic Therapy as an Effective Treatment for Cutaneous Lymphomas

Topical photodynamic therapy (PDT) is a non-invasive treatment modality frequently used in dermatology to treat superficial skin cancers but also some inflammatory or infectious dermatoses. PDT appears a more and more promising therapeutic option also for cutaneous lymphomas, either of T- or B-cell origin. It is a well-tolerated treatment and has excellent cosmetic outcomes, less side effects compared to other therapies (steroids, surgery, radiotherapy, and so on), no particular contraindications, and is easily repeatable in case of relapses. However, how PDT works in the treatment of cutaneous lymphoproliferative diseases is poorly understood and the literature data are still controversial. Further randomized, controlled clinical trials involving a greater number of patients and centers with a long follow-up are necessary to assess the efficacy of PDT and establish a unique standardized treatment protocol in relation to the lymphomatous disease and the type, thickness, and location of the lesions.

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.

European Dermatology Forum guidelines on topical photodynamic therapy 2019 Part 2: emerging indications - field cancerization, photorejuvenation and inflammatory/infective dermatoses

In addition to approved indications in non-melanoma skin cancer in immunocompetent patients, topical photodynamic therapy (PDT) has also been studied for its place in the treatment of, as well as its potential to prevent, superficial skin cancers in immune-suppressed patients, although sustained clearance rates are lower than for immune-competent individuals. PDT using a nanoemulsion of ALA in a daylight or conventional PDT protocol has been approved for use in field cancerization, although evidence of the potential of the treatment to prevent new SCC remained limited. High-quality evidence supports a strong recommendation for the use of topical PDT in photorejuvenation as well as for acne, refractory warts, cutaneous leishmaniasis and in onychomycosis, although these indications currently lack approvals for use and protocols remain to be optimized, with more comparative evidence with established therapies required to establish its place in practice. Adverse events across all indications for PDT can be minimized through the use of modified and low-irradiance regimens, with a low risk of contact allergy to photosensitizer prodrugs, and no other significant documented longer-term risks with no current evidence of cumulative toxicity or photocarcinogenic risk. The literature on the pharmacoeconomics for using PDT is also reviewed, although accurate comparisons are difficult to establish in different healthcare settings, comparing hospital/office-based therapies of PDT and surgery with topical ointments, requiring inclusion of number of visits, real-world efficacy as well as considering the value to be placed on cosmetic outcome and patient preference. This guideline, published over two parts, considers all current approved and emerging indications for the use of topical photodynamic therapy in Dermatology prepared by the PDT subgroup of the European Dermatology Forum guidelines committee. It presents consensual expert recommendations reflecting current published evidence.

Epigenetically Enhanced PDT Induces Significantly Higher Levels of Multiple Extrinsic Pathway Apoptotic Factors than Standard PDT, Resulting in Greater Extrinsic and Overall Apoptosis of Cutaneous T-cell Lymphoma

Aminolevulinate-based photodynamic therapy (ALA-PDT) selectively eliminates diseased tissues primarily through the induction of intrinsic apoptotic pathway. ALA-PDT is a first-line therapy for actinic keratosis, however, it is less effective for cutaneous T-cell lymphoma (CTCL). We have previously demonstrated that the resistance of CTCL to apoptosis correlates with decreased expression of death receptors such as FAS, and that methotrexate functions as an epigenetic regulator that reestablishes the susceptibility of CTCL to extrinsic pathway apoptosis. We showed previously that MTX augments the effectiveness of PDT by sensitizing cells to apoptosis by induction of apoptotic factors, a process we call "epigenetically enhanced" PDT (ePDT). Here, in CTCL cell lines, leukemic CTCL cells, and normal blood T cells, we analyzed multiple components of the FAS, TRAIL, and TNF families using multispectral imaging of immunostained cytopreparations, a quantitative technique with five-fold greater sensitivity than standard immunocytology. ePDT induced significantly greater FAS, FASL, TRAIL-R1 & -R2, and TNFα levels than standard PDT. This correlated with significantly greater induction of extrinsic pathway apoptosis and/or overall apoptosis in all CTCL samples. There was no appreciable effect on normal T cells. These data set the stage for clinical trials of ePDT as a novel localized treatment of CTCL.

Photodynamic therapy as an alternative treatment for mycosis fungoides: a systemic review and meta-analysis

INTRODUCTION

Mycosis fungoides is the most common cutaneous T cell lymphoma. Selection of appropriate treatment for mycosis fungoides (MF) is based on prognostic factors and overall clinical stage at diagnosis. In the past decade, clinical success has been reported using photodynamic therapy (PDT) as an alternative target-specific therapy to treat mycosis fungoides. This review aimed to summarize the current advances in management of mycosis fungoides by administration of photodynamic therapy.

EVIDENCE ACQUISITION

Twenty-four articles, published between 1994 and 2017, were reviewed to assess the efficacy of PDT for MF.

EVIDENCE SYNTHESIS

Methyl-aminolevulinic acid has increased lipophilic properties; red light at around 630 nm achieves deepest and best tissue penetration. However, the total number of PDT sessions depends on the clinical response.

CONCLUSIONS

Further multicenter clinical studies are warranted to assess the cost-effectiveness of PDT.