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Garcia-Mouronte E, Berna-Rico E, de Nicolas-Ruanes B, Azcarraga-Llobet C, Alonso-Martinez de Salinas L, Bea-Ardebol S. Imiquimod as Local Immunotherapy in the Management of Premalignant Cutaneous Conditions and Skin Cancer. Int J Mol Sci 2023; 24:10835. [PMID: 37446011 DOI: 10.3390/ijms241310835] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/24/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Cutaneous cancers are, by far, the most common malignant neoplasms of the human being. Due to the great array of clinical conditions, their worldwide increasing incidence and the steady ageing of the population, non-invasive treatments modalities that show a good clinical response, a proper benefit-risk ratio and cosmetic results are becoming increasingly important in the clinical setting. Imiquimod is a topically applied immunomodulator which is often used in the management of several premalignant and malignant cutaneous disorders. This article is a review of the current literature on its mechanism of action, pharmacokinetics, and therapeutical effects.
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Affiliation(s)
| | - Emilio Berna-Rico
- Dermatology Department, Hospital Universitario Ramon y Cajal, 28034 Madrid, Spain
| | | | | | | | - Sonia Bea-Ardebol
- Dermatology Department, Hospital Universitario Ramon y Cajal, 28034 Madrid, Spain
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2
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Fay CJ, Awh KC, LeBoeuf NR, Larocca CA. Harnessing the immune system in the treatment of cutaneous T cell lymphomas. Front Oncol 2023; 12:1071171. [PMID: 36713518 PMCID: PMC9878398 DOI: 10.3389/fonc.2022.1071171] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/01/2022] [Indexed: 01/15/2023] Open
Abstract
Cutaneous T cell lymphomas are a rare subset of non-Hodgkin's lymphomas with predilection for the skin with immunosuppressive effects that drive morbidity and mortality. We are now appreciating that suppression of the immune system is an important step in the progression of disease. It should come as no surprise that therapies historically and currently being used to treat these cancers have immune modulating functions that impact disease outcomes. By understanding the immune effects of our therapies, we may better develop new agents that target the immune system and improve combinatorial treatment strategies to limit morbidity and mortality of these cancers. The immune modulating effect of therapeutic drugs in use and under development for cutaneous T cell lymphomas will be reviewed.
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3
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Amitay-Laish I, Hodak E. New developments in skin-directed treatments of cutaneous T-cell lymphoma. Presse Med 2022; 51:104125. [PMID: 35562084 DOI: 10.1016/j.lpm.2022.104125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 05/02/2022] [Indexed: 02/05/2023] Open
Abstract
The therapeutic approach for mycosis fungoides, the most common type of primary cutaneous T-cell lymphoma, is based mainly on the stage of the disease, and skin-directed treatment is recommended by all international guidelines as the first-line treatment in early-stage disease. Skin-directed treatments may be also given in combination with systemic therapies in early-stage mycosis fungoides patients recalcitrant to different types of skin-directed treatments, or in certain patients with high-risk features. Advanced-stage mycosis fungoides is treated mainly with systemic treatments, which may be combined with skin-directed treatments. Due to the rarity of mycosis fungoides, controlled clinical trials of the different skin-directed treatment modalities are almost non-existent, with a few exceptions, and therefore recommendations are largely based on cohort studies and expert opinion. This paper reviews the new developments in skin-directed treatments and provides an update on new studies of already well-known therapies, and an update on novel treatments.
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Affiliation(s)
- Iris Amitay-Laish
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petach Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Emmilia Hodak
- Division of Dermatology, Rabin Medical Center-Beilinson Hospital, Petach Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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4
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Rendón-Serna N, Correa-Londoño LA, Velásquez-Lopera MM, Bermudez-Muñoz M. Cell signaling in cutaneous T-cell lymphoma microenvironment: promising targets for molecular-specific treatment. Int J Dermatol 2021; 60:1462-1480. [PMID: 33835479 DOI: 10.1111/ijd.15451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/31/2020] [Accepted: 01/12/2021] [Indexed: 01/01/2023]
Abstract
Cutaneous T-cell lymphomas (CTCL) result from the infiltration and proliferation of a population of T cells in the skin, inducing changes in the activity of both T cells and surrounding skin cells. In the CTCL microenvironment, cell interactions mediated by cell signaling pathways are altered. Defining changes in cell signaling enables to understand T-cell deregulations in the CTCL microenvironment and thus the progression of the disease. Moreover, characterizing signaling networks activated in CTCL stages can lead to consider new molecular biomarkers and therapeutic targets. Focusing on mycosis fungoides (MF), the most frequent variant of CTCL, and Sézary syndrome (SS), its leukemic variant, this review highlights recent molecular and genetic findings revealing modifications of key signaling pathways involved in (1) cell proliferation, cell growth, and cell survival such as MAP kinases and PI3K/Akt; (2) immune responses derived from TCR, TLR, JAK/STAT, and NF-kB; and (3) changes in tissue conditions such as extracellular matrix remodeling, hypoxia, and angiogenesis. Alterations in these signaling networks promote malignant T-cell proliferation and survival, T-cell migration, inflammation, and suppression of immune regulation of malignant T cells, making a skin microenvironment that allows disease progression. Targeting key proteins of these signaling pathways, using molecules already available and used in research, in clinical trials, and with other disease indications, can open the way to different therapeutic options in CTCL treatment.
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Affiliation(s)
- Natalia Rendón-Serna
- Instituto de Biología, Universidad de Antioquia, Medellin, Colombia.,Centro de Investigaciones Dermatológicas CIDERM, Facultad de Medicina, Universidad De Antioquia, Medellin, Colombia
| | - Luis A Correa-Londoño
- Centro de Investigaciones Dermatológicas CIDERM, Facultad de Medicina, Universidad De Antioquia, Medellin, Colombia
| | - Margarita M Velásquez-Lopera
- Centro de Investigaciones Dermatológicas CIDERM, Facultad de Medicina, Universidad De Antioquia, Medellin, Colombia
| | - Maria Bermudez-Muñoz
- Instituto de Biología, Universidad de Antioquia, Medellin, Colombia.,Centro de Investigaciones Dermatológicas CIDERM, Facultad de Medicina, Universidad De Antioquia, Medellin, Colombia
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5
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Bobrowicz M, Fassnacht C, Ignatova D, Chang YT, Dimitriou F, Guenova E. Pathogenesis and Therapy of Primary Cutaneous T-Cell Lymphoma: Collegium Internationale Allergologicum (CIA) Update 2020. Int Arch Allergy Immunol 2020; 181:733-745. [PMID: 32690848 DOI: 10.1159/000509281] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 11/19/2022] Open
Abstract
Cutaneous T-cell lymphoma (CTCL) is a heterogeneous disease group of unknown etiology with a complex immunological background. As CTCL arises from T cells that have a vital role in the antitumor response, their therapy is largely aimed at reversing the immunological mechanisms leading to or manifesting during this malignancy. Early disease stages can be controlled with skin-directed therapy in most CTCL cases. Still, advanced CTCL has a dismal prognosis and warrants systemic therapy. Despite considerable progress in understanding the pathophysiology of the disease and the numerous systemic treatment options available, long-term remission rates with conventional treatments alone are still low. Allogeneic hematopoietic stem cell transplantation is currently the only curative option for advanced CTCL, including mycosis fungoides and Sézary syndrome. The aims of this review is to summarize the recent findings on the immunology of this heterogeneous disease and to present the advances in its clinical management.
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Affiliation(s)
| | - Christina Fassnacht
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Desislava Ignatova
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Yun-Tsan Chang
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland.,Department of Dermatology, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Florentia Dimitriou
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Emmanuella Guenova
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland, .,Faculty of Medicine, University of Zurich, Zurich, Switzerland, .,Department of Dermatology, Lausanne University Hospital (CHUV), Lausanne, Switzerland, .,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland,
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Abstract
BACKGROUND Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma, a malignant, chronic disease initially affecting the skin. Several therapies are available, which may induce clinical remission for a time. This is an update of a Cochrane Review first published in 2012: we wanted to assess new trials, some of which investigated new interventions. OBJECTIVES To assess the effects of interventions for MF in all stages of the disease. SEARCH METHODS We updated our searches of the following databases to May 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched 2 trials registries for additional references. For adverse event outcomes, we undertook separate searches in MEDLINE in April, July and November 2017. SELECTION CRITERIA Randomised controlled trials (RCTs) of local or systemic interventions for MF in adults with any stage of the disease compared with either another local or systemic intervention or with placebo. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcomes were improvement in health-related quality of life as defined by participants, and common adverse effects of the treatments. Key secondary outcomes were complete response (CR), defined as complete disappearance of all clinical evidence of disease, and objective response rate (ORR), defined as proportion of patients with a partial or complete response. We used GRADE to assess the certainty of evidence and considered comparisons of psoralen plus ultraviolet A (PUVA) light treatment as most important because this is first-line treatment for MF in most guidelines. MAIN RESULTS This review includes 20 RCTs (1369 participants) covering a wide range of interventions. The following were assessed as either treatments or comparators: imiquimod, peldesine, hypericin, mechlorethamine, nitrogen mustard and intralesional injections of interferon-α (IFN-α) (topical applications); PUVA, extracorporeal photopheresis (ECP: photochemotherapy), and visible light (light applications); acitretin, bexarotene, lenalidomide, methotrexate and vorinostat (oral agents); brentuximab vedotin; denileukin diftitox; mogamulizumab; chemotherapy with cyclophosphamide, doxorubicin, etoposide, and vincristine; a combination of chemotherapy with electron beam radiation; subcutaneous injection of IFN-α; and intramuscular injections of active transfer factor (parenteral systemics). Thirteen trials used an active comparator, five were placebo-controlled, and two compared an active operator to observation only. In 14 trials, participants had MF in clinical stages IA to IIB. All participants were treated in secondary and tertiary care settings, mainly in Europe, North America or Australia. Trials recruited both men and women, with more male participants overall. Trial duration varied from four weeks to 12 months, with one longer-term study lasting more than six years. We judged 16 trials as at high risk of bias in at least one domain, most commonly performance bias (blinding of participants and investigators), attrition bias and reporting bias. None of our key comparisons measured quality of life, and the two studies that did presented no usable data. Eighteen studies reported common adverse effects of the treatments. Adverse effects ranged from mild symptoms to lethal complications depending upon the treatment type. More aggressive treatments like systemic chemotherapy generally resulted in more severe adverse effects. In the included studies, CR rates ranged from 0% to 83% (median 31%), and ORR ranged from 0% to 88% (median 47%). Five trials assessed PUVA treatment, alone or combined, summarised below. There may be little to no difference between intralesional IFN-α and PUVA compared with PUVA alone for 24 to 52 weeks in CR (risk ratio (RR) 1.07, 95% confidence interval (CI) 0.87 to 1.31; 2 trials; 122 participants; low-certainty evidence). Common adverse events and ORR were not measured. One small cross-over trial found once-monthly ECP for six months may be less effective than twice-weekly PUVA for three months, reporting CR in two of eight participants and ORR in six of eight participants after PUVA, compared with no CR or ORR after ECP (very low-certainty evidence). Some participants reported mild nausea after PUVA but no numerical data were given. One participant in the ECP group withdrew due to hypotension. However, we are unsure of the results due to very low-certainty evidence. One trial comparing bexarotene plus PUVA versus PUVA alone for up to 16 weeks reported one case of photosensitivity in the bexarotene plus PUVA group compared to none in the PUVA-alone group (87 participants; low-certainty evidence). There may be little to no difference between bexarotene plus PUVA and PUVA alone in CR (RR 1.41, 95% CI 0.71 to 2.80) and ORR (RR 0.94, 95% CI 0.61 to 1.44) (93 participants; low-certainty evidence). One trial comparing subcutaneous IFN-α injections combined with either acitretin or PUVA for up to 48 weeks or until CR indicated there may be little to no difference in the common IFN-α adverse effect of flu-like symptoms (RR 1.32, 95% CI 0.92 to 1.88; 82 participants). There may be lower CR with IFN-α and acitretin compared with IFN-α and PUVA (RR 0.54, 95% CI 0.35 to 0.84; 82 participants) (both outcomes: low-certainty evidence). This trial did not measure ORR. One trial comparing PUVA maintenance treatment to no maintenance treatment, in participants who had already had CR, did report common adverse effects. However, the distribution was not evaluable. CR and OR were not assessable. The range of treatment options meant that rare adverse effects consequently occurred in a variety of organs. AUTHORS' CONCLUSIONS There is a lack of high-certainty evidence to support decision making in the treatment of MF. Because of substantial heterogeneity in design, missing data, small sample sizes, and low methodological quality, the comparative safety and efficacy of these interventions cannot be reliably established on the basis of the included RCTs. PUVA is commonly recommended as first-line treatment for MF, and we did not find evidence to challenge this recommendation. There was an absence of evidence to support the use of intralesional IFN-α or bexarotene in people receiving PUVA and an absence of evidence to support the use of acitretin or ECP for treating MF. Future trials should compare the safety and efficacy of treatments to PUVA, as the current standard of care, and should measure quality of life and common adverse effects.
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Affiliation(s)
- Arash Valipour
- Department of Dermatology, Venereology and Allergology, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
- Evidence-Based Medicine Frankfurt, Institute of General Practice, Goethe University, Frankfurt, Germany
| | - Manuel Jäger
- Department of Dermatology, Venereology and Allergology, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
- Hautklinik, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Peggy Wu
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, Faculty of Medicine Carl Gustav Carus, Technischen Universität (TU) Dresden, Dresden, Germany
| | - Charles Bunch
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Tobias Weberschock
- Department of Dermatology, Venereology and Allergology, Johann Wolfgang Goethe-University Hospital, Frankfurt am Main, Germany
- Evidence-Based Medicine Frankfurt, Institute of General Practice, Goethe University, Frankfurt, Germany
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Revisiting Imiquimod for Treatment of Folliculotropic Mycosis Fungoides: A Case Report and Review of the Literature. Dermatol Ther (Heidelb) 2019; 9:807-814. [PMID: 31407190 PMCID: PMC6828915 DOI: 10.1007/s13555-019-00317-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Indexed: 11/13/2022] Open
Abstract
Folliculotropic mycosis fungoides (FMF) is an aggressive variant of mycosis fungoides (MF) characterized by infiltration of the hair follicle epithelium by neoplastic T cells. FMF demonstrates poor response rates to standard skin-directed therapies such as phototherapy and topical corticosteroids. Imiquimod, an immunomodulatory agent that stimulates the antitumor immune response, has been used successfully in treatment of early-stage MF. We report a 21-year-old patient with unilesional FMF who achieved clinical remission with imiquimod application. This case highlights a potential for use of imiquimod as a treatment option for patients with FMF and limited skin involvement.
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Gilson D, Whittaker S, Child F, Scarisbrick J, Illidge T, Parry E, Mohd Mustapa M, Exton L, Kanfer E, Rezvani K, Dearden C, Morris S, McHenry P, Leslie T, Wakelin S, Hunasehally R, Cork M, Johnston G, Chiang N, Worsnop F, Salim A, Buckley D, Petrof G, Callachand N, Flavell T, Salad A. British Association of Dermatologists and U.K. Cutaneous Lymphoma Group guidelines for the management of primary cutaneous lymphomas 2018. Br J Dermatol 2018; 180:496-526. [DOI: 10.1111/bjd.17240] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2018] [Indexed: 02/07/2023]
Affiliation(s)
- D. Gilson
- Leeds Cancer Centre St James's University Hospital Leeds LS9 7TF U.K
| | - S.J. Whittaker
- St John's Institute of Dermatology Guy's and St Thomas NHS Foundation Trust St Thomas’ Hospital London SE1 7EH U.K
| | - F.J. Child
- St John's Institute of Dermatology Guy's and St Thomas NHS Foundation Trust St Thomas’ Hospital London SE1 7EH U.K
| | - J.J. Scarisbrick
- Queen Elizabeth Hospital University Hospital Birmingham Birmingham B15 2TH U.K
| | - T.M. Illidge
- Institute of Cancer Sciences University of Manchester The Christie NHS Foundation Trust Manchester M20 4BX U.K
| | - E.J. Parry
- Tameside Hospital Integrated Care NHS Foundation Trust Ashton‐under‐Lyne OL6 9RW U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
| | - L.S. Exton
- British Association of Dermatologists Willan House, 4 Fitzroy Square London W1T 5HQ U.K
| | - E. Kanfer
- Haematology Department Hammersmith Hospital Du Cane Road London W12 0HS U.K
| | - K. Rezvani
- The University of Texas MD Anderson Cancer Centre Houston TX U.S.A
| | - C.E. Dearden
- Chronic Lymphocytic Leukaemia (CLL) Unit The Royal Marsden NHS Foundation Trust Sutton SW3 6JJ U.K
| | - S.L. Morris
- Guy's and St Thomas’ NHS Foundation Trust Guy's Hospital London SE1 9RT U.K
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9
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Marron TU, Hammerich L, Brody J. Local Immunotherapies of Cancer. Oncoimmunology 2018. [DOI: 10.1007/978-3-319-62431-0_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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10
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Lewis DJ, Byekova YA, Emge DA, Duvic M. Complete resolution of mycosis fungoides tumors with imiquimod 5% cream: a case series. J DERMATOL TREAT 2017. [PMID: 28635518 DOI: 10.1080/09546634.2017.1294728] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To demonstrate the clinical efficacy of topical 5% imiquimod for mycosis fungoides (MF) tumors. BACKGROUND Treatment of tumor-stage MF represents a therapeutic challenge because of a limited number of effective topical therapies. Single tumors can be treated with localized radiation but may recur. Systemic therapies are also an option but are associated with serious adverse effects. Imiquimod is a topical agent whose efficacy has been documented in treating MF patches and plaques as well as one case of tumor-stage disease. METHODS We present two stage IIB MF patients, including one with large cell transformation, whose tumors were treated with imiquimod 5% cream after failing prior therapies. RESULTS The MF tumors in both patients demonstrated a complete response to imiquimod 5% cream without recurrence over 8 years and 2 years of follow-up, respectively. One patient experienced application site irritation and flu-like symptoms as adverse effects. CONCLUSIONS Our case series is only the second report in the literature demonstrating complete resolution of MF tumors with topical imiquimod. An additional therapeutic option for tumor-stage MF, imiquimod may represent an effective alternative to localized radiation for isolated MF tumors and warrants further investigation in the treatment of various stages of MF.
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Affiliation(s)
- Daniel J Lewis
- a School of Medicine , Baylor College of Medicine , Houston , TX , USA.,b Department of Dermatology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Yevgeniya A Byekova
- c Department of Dermatology , The University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Drew A Emge
- d Department of Internal Medicine , Baylor College of Medicine , Houston , TX , USA
| | - Madeleine Duvic
- b Department of Dermatology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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11
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Abstract
The article discusses imiquimod treatment for refractory early stage mycosis fungoides, with a review of the literature and three case studies.
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Affiliation(s)
- Alexa Rose Shipman
- Department of Dermatology, University Hospital Birmingham, Birmingham, UK
| | - Julia Scarisbrick
- Department of Dermatology, University Hospital Birmingham, Birmingham, UK
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12
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Hammerich L, Bhardwaj N, Kohrt HE, Brody JD. In situ vaccination for the treatment of cancer. Immunotherapy 2016; 8:315-30. [DOI: 10.2217/imt.15.120] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Vaccination has had a tremendous impact on human health by harnessing the immune system to prevent and eradicate infectious diseases and this same approach might be used in cancer therapy. Cancer vaccine development has been slowed hindered by the paucity of universal tumor-associated antigens and the difficulty in isolating and preparing individualized vaccines ex vivo. Another approach has been to initiate or stimulate an immune response in situ (at the tumor site) and thus exploit the potentially numerous tumor-associated antigens there. Here, we review the many approaches that have attempted to accomplish effective in situ vaccination, using intratumoral administration of immunomodulators to increase the numbers or activation state of either antigen present cells or T cells within the tumor.
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Affiliation(s)
- Linda Hammerich
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Nina Bhardwaj
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Holbrook E Kohrt
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Joshua D Brody
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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13
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Hammerich L, Binder A, Brody JD. In situ vaccination: Cancer immunotherapy both personalized and off-the-shelf. Mol Oncol 2015; 9:1966-81. [PMID: 26632446 PMCID: PMC5528727 DOI: 10.1016/j.molonc.2015.10.016] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/20/2015] [Accepted: 10/20/2015] [Indexed: 01/15/2023] Open
Abstract
As cancer immunotherapy continues to benefit from novel approaches which cut immune 'brake pedals' (e.g. anti-PD1 and anti-CTLA4 antibodies) and push immune cell gas pedals (e.g. IL2, and IFNα) there will be increasing need to develop immune 'steering wheels' such as vaccines to guide the immune system specifically toward tumor associated antigens. Two primary hurdles in cancer vaccines have been: identification of universal antigens to be used in 'off-the-shelf' vaccines for common cancers, and 2) logistical hurdles of ex vivo production of individualized whole tumor cell vaccines. Here we summarize approaches using 'in situ vaccination' in which intratumoral administration of off-the-shelf immunomodulators have been developed to specifically induce (or amplify) T cell responses to each patient's individual tumor. Clinical studies have confirmed the induction of systemic immune and clinical responses to such approaches and preclinical models have suggested ways to further potentiate the translation of in situ vaccine trials for our patients.
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Affiliation(s)
- Linda Hammerich
- Icahn School of Medicine at Mount Sinai Hess Center for Science and Medicine, United States
| | - Adam Binder
- Icahn School of Medicine at Mount Sinai Hess Center for Science and Medicine, United States
| | - Joshua D Brody
- Icahn School of Medicine at Mount Sinai Hess Center for Science and Medicine, United States.
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14
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Weberschock T, Strametz R, Lorenz M, Röllig C, Bunch C, Bauer A, Schmitt J. Interventions for mycosis fungoides. Cochrane Database Syst Rev 2012:CD008946. [PMID: 22972128 DOI: 10.1002/14651858.cd008946.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Mycosis fungoides is the most common type of cutaneous T-cell lymphoma, a malignant, chronic disease initially affecting the skin. Several therapies are available, which may induce clinical remission for a time. OBJECTIVES To assess the effects of interventions for mycosis fungoides in all stages of the disease. SEARCH METHODS We searched the following databases up to January 2011: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2010), and LILACS (from 1982). We also checked reference lists of included studies for further references to relevant RCTs. We searched online trials registries for further references to unpublished trials and undertook a separate search for adverse effects of interventions for mycosis fungoides in non-RCTs in MEDLINE in May 2011. SELECTION CRITERIA Randomised controlled trials (RCTs) of interventions for mycosis fungoides in people with any stage of the disease. At least 90% of participants in the trials must have been diagnosed with mycosis fungoides (Alibert-Bazin-type). DATA COLLECTION AND ANALYSIS Two authors independently assessed eligibility and methodological quality for each study and carried out data extraction. We resolved any disagreement by discussion. Primary outcomes were the impact on quality of life and the safety of interventions. When available, we reported on our secondary outcomes, which were the improvement or clearance of skin lesions, disease-free intervals, survival rates, relapse rates, and rare adverse effects. When possible, we combined homogeneous studies for meta-analysis. We used The Cochrane Collaboration's 'Risk of bias' tool to assess the internal validity of all included studies in six different domains. MAIN RESULTS The review included 14 RCTs involving 675 participants, covering a wide range of interventions. Eleven of the included trials assessed participants in clinical stages IA to IIB only (please see Table 1 for definitions of these stages).Internal validity was considerably low in studies with a high or unclear risk of bias. The main reasons for this were low methodological quality or missing data, even after we contacted the study authors, and a mean dropout rate of 26% (0% to 72%). Study size was generally small with a minimum of 4 and a maximum of 103 participants. Only one study provided a long enough follow-up for reliable survival analysis.Included studies assessed topical treatments, such as imiquimod, peldesine, hypericin, nitrogen mustard, as well as intralesional injections of interferon-α (IFN-α). The light therapies investigated included psoralen plus ultraviolet A light (PUVA), extracorporeal photopheresis (photochemotherapy), and visible light. Oral treatments included acitretin, bexarotene, and methotrexate. Treatment with parenteral systemic agents consisted of denileukin diftitox; a combination of chemotherapy and electron beam radiation; and intramuscular injections of active transfer factor. Nine studies evaluated therapies by using an active comparator; five were placebo-controlled RCTs.Twelve studies reported on common adverse effects, while only two assessed quality of life. None of these studies compared the health-related quality of life of participants undergoing different treatments. Most of the reported adverse effects were attributed to the interventions. Systemic treatments, and here in particular a combined therapeutic regimen of chemotherapy and electron beam, bexarotene, or denileukin diftitox, showed more adverse effects than topical or skin-directed treatments.In the included studies, clearance rates ranged from 0% to 83%, and improvement ranged from 0% to 88%. The meta-analysis combining the results of 2 trials comparing the effect of IFN-α and PUVA versus PUVA alone showed no significant difference in the relative risk of clearance: 1.07 (95% confidence interval 0.87 to 1.31). None of the included studies demonstrated a significant increase in disease-free intervals, relapse, or overall survival. AUTHORS' CONCLUSIONS This review identified trial evidence for a range of different topical and systemic interventions for mycosis fungoides. Because of substantial heterogeneity in design, small sample sizes, and low methodological quality, the comparative safety and efficacy of these interventions cannot be established on the basis of the included RCTs. Taking into account the possible serious adverse effects and the limited availability of efficacy data, topical and skin-directed treatments are recommended first, especially in the early stages of disease. More aggressive therapeutic regimens may show improvement or clearance of lesions, but they also result in more adverse effects; therefore, they are to be considered with caution. Larger studies with comparable, clearly-defined end points for all stages of mycosis fungoides, and a focus on safety, quality of life, and duration of remission as part of the outcome measures, are necessary.
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Affiliation(s)
- Tobias Weberschock
- Evidence-based Medicine Frankfurt, Institute for General Practice, Goethe University, Frankfurt, Germany.
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Lupus Erythematosus–Like Reaction in Imiquimod-Treated Skin: A Report of 2 Cases. Am J Dermatopathol 2011; 33:523-7. [DOI: 10.1097/dad.0b013e3181f2bf9e] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Poligone B, Heald P. Innovative therapy of cutaneous T-cell lymphoma: beyond psoralen and ultraviolet light and nitrogen mustard. Dermatol Clin 2010; 28:501-10. [PMID: 20510760 DOI: 10.1016/j.det.2010.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cutaneous T-cell lymphoma is a malignancy of skin-homing T cells. This unique population of lymphocytes requires alternative therapies to those used in nodal lymphomas. Although phototherapy and nitrogen mustard have been standard treatments for decades, newer therapies have been arriving with increased frequency. Moreover, some therapies, currently used to treat other diseases, have been used with good effect. These innovative therapies are discussed, with review of current data and examples of how these therapies may be used today.
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Affiliation(s)
- Brian Poligone
- Department of Dermatology, University of Rochester School of Medicine, Rochester, NY, USA.
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Abstract
Small-molecule agonists at Toll-like receptor 7 (TLR7) and TLR8 have sparked a vivid interest in cancer research owing to their profound antitumoral activity. The lead compound of the imidazoquinoline family, imiquimod, is marketed as a topical formulation. It is efficacious against many primary skin tumors and cutaneous metastases. Using different imidazoquinoline species, distinct functions of TLR7 and TLR8 have been discovered. The predominant antitumoral mode of action of these agents is TLR7/8-mediated activation of the central transcription factor nuclear factor-kappaB, which leads to induction of proinflammatory cytokines and other mediators. Cutaneous dendritic cells are the primary responsive cell type and initiate a strong Th1-weighted antitumoral cellular immune response. Recent research has shown that dendritic cells themselves acquire direct antitumoral activity upon stimulation by imiquimod. In addition, there are a number of secondary effects on the molecular and cellular level that can be explained through the activation of TLR7/8. The proinflammatory activity of imiquimod, but not resiquimod, appears to be augmented by suppression of a regulatory mechanism, which normally limits inflammatory responses. This is achieved independently of TLR7/8 through interference with adenosine receptor signaling pathways. Finally, at higher concentrations imiquimod exerts Bcl-2- and caspase-dependent proapoptotic activity against tumor cells.
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Wagstaff AJ, Perry CM. Topical imiquimod: a review of its use in the management of anogenital warts, actinic keratoses, basal cell carcinoma and other skin lesions. Drugs 2008; 67:2187-210. [PMID: 17927284 DOI: 10.2165/00003495-200767150-00006] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Topical imiquimod 5% cream (Aldara) is an immune response modulator that is indicated for the treatment of external anogenital warts, superficial basal cell carcinoma and actinic keratoses. The cream is applied two to five times per week for varying periods, depending on the indication. Topical imiquimod cream has also been evaluated in the treatment of several other skin conditions. Immunomodulatory therapy with topical imiquimod 5% is an effective option for the approved indications. The drug appears to be relatively well tolerated, with the option of breaks from treatment as required for local skin reactions (which are common). Systemic reactions have been reported. Treatment of human papillomavirus- and UV-associated skin lesions with topical imiquimod offers a noninvasive, tissue-sparing alternative to ablative treatment options. However, well designed trials of the sustained, long-term efficacy and tolerability of topical imiquimod versus those of common treatment approaches including surgery and other topical alternatives are required before the place of the drug in the management of these lesions can be finalised. Nonetheless, while other treatments for anogenital warts, superficial basal cell carcinoma or actinic keratoses are available, the advantages of self treatment linked with the demonstrated efficacy of topical imiquimod offer an attractive alternative for many patients.
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Gniadecki R, Assaf C, Bagot M, Dummer R, Duvic M, Knobler R, Ranki A, Schwandt P, Whittaker S. The optimal use of bexarotene in cutaneous T-cell lymphoma. Br J Dermatol 2007; 157:433-40. [PMID: 17553039 DOI: 10.1111/j.1365-2133.2007.07975.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The management goal in cutaneous T-cell lymphomas (CTCLs) is to improve symptoms and induce remission. Early-stage disease is generally treated with skin-directed therapies. However, if these do not control the disease, systemic therapy becomes necessary. Bexarotene, a novel rexinoid, is an oral, noncytotoxic drug that has been approved in Europe for the treatment of refractory advanced-stage CTCL and in the U.S.A. for refractory CTCL. We provide guidance on the use of bexarotene in the management of CTCL, based on data from phase II/III clinical trials and the authors' clinical experience, and suggest how the potential of the drug can be maximized. The clinical trial results with bexarotene are reviewed, especially in comparison with interferon-alpha, which is the other commonly used noncytotoxic systemic therapy for CTCL. A treatment algorithm for bexarotene in refractory CTCL is suggested. As bexarotene may take time to achieve a maximum response, this algorithm recommends that therapy should be continued for a sufficient period to allow for a delayed onset of action. In addition, possible combination therapies with bexarotene are discussed. We conclude that bexarotene is effective in the management of CTCL, and has the advantage of oral administration. An on-going randomized clinical trial comparing psoralen plus ultraviolet A (PUVA) with PUVA plus bexarotene will provide valuable information about this combination regimen in early-stage disease, but further data are needed on the relative efficacies of other combination therapies with bexarotene in CTCL.
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Affiliation(s)
- R Gniadecki
- Department of Dermatology, University of Copenhagen, Bispebjerg Hospital, Bispebjerg bakke 23, DK-2400 Copenhagen, Denmark.
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Abstract
Cutaneous T-cell lymphomas are a heterogeneous group of rare lympho-proliferative disorders. In most cases, they are characterised by the accumulation of clonal CD4+ lymphocytes in the skin. Extracutaneous involvement is present in late stages only. Unfortunately, only few drugs are registered for these disfiguring diseases. Skin-directed therapies using topical formulations are the preferred first-line modalities for cutaneous lesions in early stages. In this field there are interesting developments using topical retinoids and gene therapy products, such as adeno-IFN-gamma. Systemic treatment uses biologicals, such as fusion molecules, monoclonal antibodies and immune response modifiers (IFNs, retinoids), and well-tolerated antiproliferative drugs, such as histone deacetylase inhibitors or liposomal doxorubicin.
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Affiliation(s)
- Reinhard Dummer
- Department of Dermatology, University Hospital of Zürich, Gloriastrasse 31, CH-8091 Zürich, Switzerland.
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Dummer R, Cozzio A, Meier S, Beyeler M, Laetsch B, Doebbeling U, Urosevic M. Standard and experimental therapy in cutaneous T-cell lymphomas. J Cutan Pathol 2006; 33 Suppl 1:52-7. [PMID: 16412213 DOI: 10.1111/j.0303-6987.2006.00497.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cutaneous T-cell lymphomas are a heterogeneous group of lymphoproliferative disorders, characterized by the accumulation of clonal lymphocytes in the skin. Skin-directed therapies are the preferred first-line modalities. There are interesting new developments in topical therapy using retinoids and gene-therapy products such as adenovirus- interferon (IFN)-gamma. Systemic treatment uses biologicals such as fusion molecules, monoclonal antibodies and immune response modifiers (IFNs and retinoids), and well-tolerated antiproliferative drugs such as methotrexate. Evidence-based treatment recommendation exists but is hampered by the lack of large multicenter randomized trials.
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Affiliation(s)
- Reinhard Dummer
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.
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