Cutaneous lymphomas appearing during treatment with biologics: 44 cases from the French Study Group on Cutaneous Lymphomas and French Pharmacovigilance Database

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.

Effectiveness and Safety of Dupilumab and Tralokinumab for Treating Atopic Dermatitis and Pruritic Skin Disorders in Oncological Patients: A Narrative Review

Introduction

Atopic dermatitis (AD) and pruritic skin disorders are increasingly recognized in cancer patients. The management of these conditions in patients with a history or with concomitant cancer presents unique challenges, as traditional systemic therapies may pose risks due to their immunosuppressive effects. In recent years, biologic agents such as dupilumab and tralokinumab have emerged as promising treatments for AD, offering targeted modulation of the immune response with potentially fewer systemic side effects. This article aims to review the current evidence on the safety and efficacy of dupilumab and tralokinumab in treating AD and pruritus among cancer survivors, addressing the potential benefits and considerations for this unique patient population.

Methods

A comprehensive analysis of the current medical literature was performed on the PubMed, Ovid, Scopus, Embase, and Cochrane Library databases until December 15, 2024. In conducting this narrative review, Medical Subject Headings (MeSH) terms and medical terminology related to clinical trials and real-life studies were employed, focusing on the pharmacological agents dupilumab, and tralokinumab.

Discussion

Patients with active or past cancer are typically excluded from clinical trials of new medications, complicating the evaluation of cancer progression or recurrence risks in these patients setting. The potential use of biologic drugs like dupilumab and tralokinumab in oncological patients marks a significant breakthrough for treating conditions such as eczema and pruritus, which are common in this patient group. Although there are no explicit contraindications for using dupilumab and tralokinumab in patients with active cancer or a history of malignancy, there is no definitive guidance on their use in such cases. Real-world data is emerging, facilitated by collaboration between dermatologists and oncologists, supporting the effectiveness and safety of dupilumab and tralokinumab for managing AD in cancer patients. Nonetheless, larger studies with longer follow-up periods and dedicated pharmacovigilance programs are needed to substantiate these findings.

Dermatologische unerwünschte Arzneimittelwirkungen bei Behandlung mit Biologika – Pathogenese und Management

Biologika sind für verschiedene Entzündungskrankheiten aus Dermatologie, Allergologie, Rheumatologie und Gastroenterologie sowie für zahlreiche maligne Erkrankungen zugelassen. Dermatologische unerwünschte Arzneimittelwirkungen durch Biologika können primären entzündlichen Dermatosen ähneln, unterscheiden sich von ihnen jedoch in ihrer Pathogenese. In diesem Artikel beschreiben wir die fünf verschiedenen Pathomechanismen dermatologischer, unerwünschter Arzneimittelwirkungen durch Biologika. Durch besseres Verständnis dieser Mechanismen erhoffen wir uns wertvolle Einblicke in die Pathogenese primärer Entzündungskrankheiten zu gewinnen. Außerdem geben wir in diesem Artikel Empfehlungen für die Behandlung und das Management der durch Biologika ausgelösten dermatologischen unerwünschten Arzneimittelwirkungen.

Dermatologic adverse events caused by biologic treatments - Pathogenesis and management

Biologics are approved for various dermatologic, allergic, rheumatic, and gastroenterologic inflammatory diseases, as well as for numerous malignancies. The dermatologic adverse events from treatment with biologics may resemble primary inflammatory diseases but differ in pathogenesis. In this article, we describe five different pathogenic mechanisms of dermatologic adverse events. By studying these mechanisms, we hope to gain valuable insights into the pathogenesis of primary inflammatory diseases. In addition, in this article, we provide recommendations for the treatment and management of the dermatological adverse events induced by biologics.

Critical Review-A Tribute to Louis Brocq Lymphomatoid Papulosis, the Key in Exploring the Relationship of Parapsoriasis and Mycosis Fungoides

ABSTRACT

Both parapsoriasis and LyP appear clinically as inflammatory dermatoses with a paradoxical link to cMF. A key element in addressing the relationship of parapsoriasis and MF were the results of the French and Dutch long-term registries tracking the emergence of lymphomas in the setting of LyP. Both cMF and cALCL emerged almost equally in these long-term studies. This ultimately supports that the stem cells in both cMF and cALCL are probably derived from a common stem cell shared by CD4+/CD8+ memory stem cells defining cMF and CD30+ stem cells defining cALCL. The discovery of inducible Skin Associated Lymphoid Tissue (iSALT) mesenchymal hubs incorporating Tregs, with their pleiotropic functions represents a paradigm shift and formed a translational tool in this analysis of the paradox. LyP can be recast as activated inhibitory lymphomatoid T-cell hubs derived from inducible iTregs in iSALT and the source of the common stem cell LyP line. iSALT Treg integrated mesenchymal hubs provided an emerging translational tool in redefining integrated lymphomatoid pathways. Brocq's complex scheme defining parapsoriasis as hybrid inflammatory dermatoses with a paradoxical link to cMF became a template to preserve parapsoriasis as a clinical diagnosis. Two major iSALT Treg generated inhibitory integrated lymphomatoid hubs emerged. The major CD30+TNF lymphomatoid hub has been linked to cALCL. Clinically defined chronic regressing and relapsing parapsoriasis with the histopathology of patch stage MF can be redefined as lymphomatoid parapsoriasis. This twin inhibited oncogenic memory based hub is defined by Treg modulated, CD4+/CD8+memory linked PD-1/DL-1 cytoxic complex and lichenoid histopathology.

Deciphering the spectrum of cutaneous lymphomas expressing TFH markers

T-follicular helper (TFH) markers are expressed in the microenvironnement of marginal zone B-cell lymphoma (MZL), and in lymphomas arising from TFH-cells, sometimes making the differential diagnosis difficult. In the skin, the "TFH-spectrum" is poorly defined, going from primary cutaneous lymphoproliferative disorder with small/medium CD4+ T-cells (SMLPD) to cutaneous localizations of systemic angioimmunoblastic T-cell lymphoma (cAITL), and may pass through intermediate forms (primary cutaneous T-follicular helper derived lymphoma, not otherwise specified (PCTFHL,NOS)). We retrospectively analyzed 20 MZL, 13 SMLPD, 5 PCTFHL, and 11 cAITL clinically, histologically, and molecularly, to define tools to differentiate them. Characteristics that might favor the diagnosis of MZL over SMLPD are: multiple skin nodules (p < 0.001), nodular architecture (p < 0.01), residual germinal centers with follicular dendritic cell network (p < 0.001), monotypic plasma cells (p < 0.001), and few staining with PD1 (p = 0.016) or CXCL13 (p = 0.03). PCTFHL and cAITL presented as multiple (p < 0.01) lesions, in older patients (p < 0.01), with systemic symptoms and/or biological alterations (p < 0.01). Immunophenotypic loss of T-cell markers (p < 0.001), BCL6 (p = 0.023) and/or CD10 staining (p = 0.08), and a higher proliferative index (≥ 30%, p = 0.039) favoured these diagnoses over SMLPD. Pathogenic variants were observed by genomic sequencing in 47% of MZL (TNFAIP3 (32%), EP300 (21%), NOTCH2 (16%), KMT2D (16%), CARD11 (10.5%)), 8% of SMLPD (TET2), 40% of PCTFHL (SOCS1 (20%), ARID1A (20%)) and 64% of cAITL (TET2 (63.6%), RHOA (36.4%), NOTCH1 (9%)). This study characterizes the various clinical and histological features between cutaneous lymphomas expressing TFH markers and highlights the value of the interest of screening for genomic mutations in difficult cases.

Atopic Dermatitis with Multiple Comorbidities Treated with Dupilumab. A Case Report and Review of the Literature Regarding the Safety of Dupilumab

Dupilumab is the only available biological treatment for moderate-to-severe atopic dermatitis (AD). Even so, limited clinical data regarding its safety profile are available. Interactions with other drugs and the adverse effects of Dupilumab on patients with multiple comorbidities, such as chronic heart disease, diabetes, chronic kidney disease, etc., are not known yet. Moreover, there have been described cases of cutaneous lymphomas induced by Dupilumab. Therefore, the clinician that wants to start treatment for moderate-to-severe atopic dermatitis, which does not respond to conventional drugs, might be reluctant to choose biologic agents such as Dupilumab. In this paper, we reported a case of severe atopic dermatitis with multiple comorbidities in which the patient was successfully treated with Dupilumab despite numerous underlying conditions. We also conducted a review of the current literature on the safety profile of Dupilumab in special categories of patients with comorbidities, such as heart, kidney, and liver disease, oncologic conditions, and during pregnancy.

Safety and Danger Considerations of Novel Treatments for Atopic Dermatitis in Context of Primary Cutaneous Lymphomas

The impact of new and emerging therapies on the microenvironment of primary cutaneous lymphomas (PCLs) has been recently raised in the literature. Concomitantly, novel treatments are already used or registered (dupilumab, upadacitinib) and others seem to be added to the armamentarium against atopic dermatitis. Our aim was to review the literature on interleukins 4, 13, 22, and 31, and JAK/STAT pathways in PCLs to elucidate the safety of using biologics (dupilumab, tralokinumab, fezakinumab, nemolizumab) and small molecule inhibitors (upadacitinib, baricitinib, abrocitinib, ruxolitinib, tofacitinib) in the treatment of atopic dermatitis. We summarized the current state of knowledge on this topic based on the search of the PubMed database and related references published before 21 October 2021. Our analysis suggests that some of the mentioned agents (dupilumab, ruxolitinib) and others may have a direct impact on the progression of cutaneous lymphomas. This issue requires further study and meticulous monitoring of patients receiving these drugs to ensure their safety, especially in light of the FDA warning on tofacitinib. In conclusion, in the case of the rapid progression of atopic dermatitis/eczema, especially in patients older than 40 years old, there is a necessity to perform a biopsy followed by a very careful pathological examination.

Risk of mycosis fungoides in psoriatic patients: a critical review

Psoriasis has been controversially associated with risk of non-Hodgkin lymphoma (NHL) and mycosis fungoides (MF). Also patients who developed MF after systemic treatment for psoriasis have been reported, and some authors suggested that the association between MF and psoriasis is not infrequent. We performed an extensive literature review in order to examine the risk of developing MF in psoriatic patients with a systematic search of the English-language databases. An increased risk for lymphoma overall in psoriatic patients has been found only by three out of seven studies. The risk of developing MF in psoriatic patients has been investigated by different studies in different populations and with different methodologies presenting bias and limitations, and it seems reasonable that misclassification between psoriasis and MF may explain the association reported. In contrast to the large number of psoriatic patients treated with biologicals, only 27 case reports of MF after biological therapy for psoriasis have been reported, and in 10 cases, the initial psoriasis diagnoses were then revised as MF. A true association between MF and psoriasis is possible, but the real incidence and prevalence are still unknown. The reported higher risk of developing MF in psoriatic patients should be reconsidered in the light of the bias of misclassification and the low magnitude reported in previous studies. There is not enough evidence to support a causal relation among biological therapies and MF in psoriatic patients.

Leukaemic variants of cutaneous T-cell lymphoma: Erythrodermic mycosis fungoides and Sézary syndrome

Mycosis fungoides (MF) and Sézary syndrome (SS) are the most common types of cutaneous lymphoma, accounting for approximately 60% of cutaneous T-cell lymphomas. Diagnosis requires correlation of clinical, histologic, and molecular features. A multitude of factors have been linked to the aetiopathogenesis, however, none have been definitively proven. Erythrodermic MF (E-MF) and SS share overlapping clinical features, such as erythroderma, but are differentiated on the degree of malignant blood involvement. While related, they are considered to be two distinct entities originating from different memory T cell subsets. Differential expression of PD-1 and KIR3DL2 may represent a tool for distinguishing MF and SS, as well as a means of monitoring treatment response. Treatment of E-MF/SS is guided by disease burden, patients' ages and comorbidities, and effect on quality of life. Current treatment options include biologic, targeted, immunologic, and investigational therapies that can provide long term response with minimal side effects. Currently, allogeneic stem cell transplantation is the only potential curative treatment.

Immunotherapy for Cutaneous T-Cell Lymphoma: Current Landscape and Future Developments

Mycosis fungoides (MF) and Sézary syndrome (SS) are chronic, progressive primary cutaneous T-cell lymphomas (CTCLs) for which there are no curative treatments. Skin-directed therapies, such as phototherapy, radiation therapy, or topical nitrogen mustard, provide only short-term remissions. Numerous attempts with different chemotherapeutic regimes failed to achieve meaningful clinical responses. Immunotherapy seems to be a promising avenue to achieve long-term disease control in CTCL. There is compelling evidence indicating that MF and SS are immunogenic lymphomas, which can be recognized by the patient's immune system. However, CTCL uses different strategies to impair host's immunity, eg, via repolarizing the T-cell differentiation from type I to type II, recruiting immunosuppressive regulatory T-cells, and limiting the repertoire of lymphocytes in the circulation. Many currently used therapies, such as interferon-α, imiquimod, extracorporeal phototherapy, and allogeneic bone marrow transplant, seem to exert their therapeutic effect via activation of the antitumor cytotoxic response and reconstitution of the host's immune system. It is likely that novel immunotherapies such as immune checkpoint inhibitors, cancer vaccines, and chimeric antigen receptor-T cells will help to manage CTCL more efficiently. We also discuss how current genomic techniques, such as estimating the mutational load by whole genome sequencing and neoantigen calling, are likely to provide clinically useful information facilitating personalized immunotherapy of CTCL.