Low-dose total skin electron beam therapy plus oral bexarotene maintenance therapy for cutaneous T-cell lymphoma

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.

Condensed low-dose total skin electron beam therapy for mycosis fungoides: an institutional retrospective review and subgroup analysis of patients with large cell transformation

Low-dose total skin electron beam therapy (TSEBT) is an effective treatment option for mycosis fungoides (MF) with proven palliative effects and reduced toxicity. Presented is an institutional analysis of survival/response rate and quality of life for MF patients with subgroup analysis of those possessing pathologic large cell transformation (LCT). This is a single institutional retrospective review of patients with mycosis fungicides treated from 2014 to 2023 with low-dose TSEBT. All patients received 12 Gy in 6 fractions every other day with the modified Stanford technique, with boosts to shadowed sites between treatments, completed in 2 weeks. Outcomes evaluated included clinical response, duration of and time to response, patient-reported quality of life, and physician-scored disease burden. Forty-six patients were included in the study, 28 male and 18 female, with a median age 66.5 (range 32.7-90.6). Stage IB was most common at the time of TSEBT (41.3%). Median follow up was 44.5 months. The overall response rate was 91.3% (52.2% partial response, 19.6% complete and near complete response). The median duration of response was 8.2 months (range, 6.1-28.7), and the median time to best response was 3.5 months (range, 2.7-5.6). Quality of life (QOL) and disease burden continued to show significant benefit after TSEBT (p<0.001). In a subgroup analysis, 18 patients (39.1%) were found to have large cell transformation (LCT) at diagnosis. LCT was associated with higher presenting stage prior to TSEBT (p=0.016) and a better response to treatment (p=0.040). However, median duration of response was only 7.4 months in the patients with LCT vs. 39.4 months in the patients without (p=0.003). Condensed Low-dose TSEBT is a convenient treatment with favorable clinical outcomes and low toxicities in patients with mycosis fungoides. Patients with LCT may have shorter duration of treatment response. Further studies are warranted to validate this finding.

A retrospective study of prognostic factors and treatment outcome in advanced-stage Mycosis Fungoides and Sezary Syndrome

Background: Mycosis fungoides (MF) and Sezary Syndrome (SS) comprise over half of all Cutaneous T-cell lymphoma diagnoses. Current risk stratification is largely based on TNMB staging, few research investigated the prognostic value of clinical exams. Current systemic therapy for advanced disease includes immunomodulatory drugs, chemotherapy, and HADC inhibitors. Few clinical trials or retrospective research compared the efficacy of different drugs.Method: Here, we performed a retrospective analysis of prognostic factors and treatment outcomes of 92 patients diagnosed with MF/SS at the Peking Union Medical College Hospital from 2013-2023.Results: Cox regression analysis identified that age ≥ 50 years, WBC ≥ 8 × 109/L, serum LDH ≥ 250U/L, β2-MG ≥ 4.50 mg/L, and stage IV were associated with reduced overall survival, age ≥ 50 years, serum LDH ≥ 250U/L and stage IV were associated with reduced progression free survival. Kaplan-Meier analysis established that immunomodulatory therapy was associated with longer progression free survival.Conclusion: These results suggested new factors in predicting prognosis and selecting appropriate treatments in patients with advanced MF/SS.

Advances in the pharmacological management of cutaneous T-cell lymphoma

INTRODUCTION

Current treatment guidelines for cutaneous T cell lymphoma (CTCL) advocate a stage-driven approach, considering clinical presentation, symptom burden, and patient comorbidities. Therapy selection hinges on factors like disease subtype, severity, and treatment availability. The primary goal is to enhance the quality of life by mitigating symptoms, as achieving lasting complete remission is infrequent.

AREAS COVERED

Over the past decade (2013-2023), the therapeutic landscape of CTCL has experienced substantial transformation with the introduction of innovative therapies. This review explores the main pivotal developments in traditional treatment schedules and recently introduced drugs, aiming to offer clinicians and researchers a thorough perspective on the decade's progress in the field.

EXPERT OPINION

Despite the progress made in CTCL therapeutics, ranging from topical chemotherapeutics to immunomodulatory agents, several unmet needs persist. Firstly, there is a pressing need for the incorporation of readily available predictors for treatment response, encompassing clinical, pathological, and molecular features. Secondly, a more profound comprehension of the tumor microenvironment is imperative to optimize the landscape of targetable molecules. Lastly, the undertaking of studies on combination regimens should be encouraged as it enhances therapy efficacies by synergistically combining agents with diverse modes of action.

Expert opinions and clinical experiences with chlormethine gel as maintenance treatment for patients with mycosis fungoides

Maintenance treatment can be recommended for patients with mycosis fungoides (MF) whose disease responds to primary treatment. While positive outcomes have been observed in small studies with maintenance therapy, there is a lack of practical guidelines and agreement on when and how maintenance therapy for MF should be approached. In this article, we discuss expert opinions and clinical experiences on the topic of maintenance therapy for patients with MF, with a focus on chlormethine gel. Ideally, patients should have a durable response before initiating maintenance therapy. The definition of and required duration of durable response are topics that are open to debate and currently have no consensus. Chlormethine gel has several attributes that make it suitable for maintenance therapy; it can be easily applied at home, can be combined with other treatment options for maintenance, and has a manageable safety profile. Chlormethine gel as maintenance therapy can be applied at decreasing frequencies after active treatment with chlormethine gel or other therapies until the minimally effective dose is reached. Patients generally tend to adhere well to chlormethine gel maintenance regimens and may remain on treatment for several years. The experiences described here may be useful for clinicians when deciding on maintenance treatment regimens for their patients. Development of guidelines based on clinical trial outcomes will be important to ensure the most effective maintenance treatment strategies are used for patients with MF.

Die Wirkung von Mogamulizumab auf die aberrante T-Zell-Population im peripheren Blut - eine monozentrische retrospektive Analyse

Hintergrund

Die Wirkung von Mogamulizumab bei kutanen T‐Zell‐Lymphomen (CTCL) auf die T‐Zellen (TZ) im peripheren Blut und deren potenzielle Rolle bei der Steuerung von Behandlungsintervallen wird noch erforscht.

Methodik

Wir untersuchten in einer retrospektiven monozentrischen Analyse die Wirkung von Mogamulizumab auf die CD3+ TZ und die aberrante T‐Zellpopulation (TZP), CD4+/CD7– und die CD4+/CD26– TZ, die mittels Durchflusszytometrie analysiert wurden.

Ergebnisse

Dreizehn Patienten mit CTCL wurden eingeschlossen. Nach vier Zyklen kam es zu einer durchschnittlichen Reduktion der CD3+ TZ um 57%, der CD4+/CD7− um 72% und der CD4+/CD26− TZ um 75% im Vergleich zum individuellen Ausgangswert eines jeden Patienten. Die Reduktionen der CD4+/CD7+ und CD4+/CD26+ TZ fielen mit durchschnittlich 54% und 41% geringer aus. Ein signifikanter Rückgang der aberranten TZP war bereits nach der ersten Infusion zu beobachten. Ein medianes Plateau der TZP trat bereits während der Induktionsphase ein. Bei 5/13 Patienten kam es zu einem Progress der Erkrankung, ohne dass eine eindeutige Korrelation mit der aberranten TZP bestand.

Schlussfolgerungen

Bereits nach einer Gabe Mogamulizumab reduzierte sich die aberrante TZP und – in geringerem Maße – die normale TZP. Wir konnten keine eindeutige Korrelation der TZP mit der Wirksamkeit von Mogamulizumab beobachten. Es werden weitere Untersuchungen mit einer größeren Anzahl von Patienten benötigt.

The effect of mogamulizumab on the aberrant T cell population in the peripheral blood - A monocentric retrospective analysis

BACKGROUND AND OBJECTIVES

The effect of mogamulizumab in cutaneous T-cell lymphoma (CTCL) on T cells (TC) in the peripheral blood and its potential role to navigate treatment intervals are explored.

METHODS

We investigated within a retrospective monocentric analysis the effect of mogamulizumab on the CD3+ TC and the aberrant T cell population (TCP), i.e., the CD4+ /CD7- and the CD4+ /CD26- TC, analyzed by flow cytometry.

RESULTS

Thirteen patients with CTCL were included. After four cycles there was a mean reduction of 57% in CD3+ TC, 72% in the CD4+ /CD7- and 75% in the CD4+ /CD26- TCP compared to the individual baseline of each patient. The reduction in CD4+ /CD7+ and CD4+ /CD26+ TC was lower, averaging 54% and 41%. A significant decrease in aberrant TCP was already evident after the first administration. A median plateau of TCP already occurred during the IP. Progressive disease occurred in 5/13 patients without a clear correlation to aberrant TCP.

CONCLUSIONS

Already after one dose of mogamulizumab, aberrant TCP and, to a lesser extent, normal TC decrease. We did not observe a clear correlation between TCP and the efficacy of mogamulizumab, but further studies with larger numbers of patients are needed.

CD25 expression could be a prognostic marker of bexarotene monotherapy for cutaneous T-cell lymphomas

Bexarotene is often administered to phototherapy-resistant early cutaneous T-cell lymphoma (CTCL) patients as one of the first-line therapies in real-world practice. Since bexarotene reduces the expression of CCR4 in CTCL cells and CCL22 to decrease serum CCL22 levels, bexarotene inhibits the migration of CTCL cells, as well as other CCR4+ cells, such as cytotoxic T cells and regulatory T cells, in the lesional skin of CTCL. In this report, the efficacy of bexarotene in 28 cases of CTCL, as well as its correlations with immunohistochemical profiles of tumour-infiltrating leucocytes (TILs), was retrospectively investigated. The overall response rate at 1 and 4 months for the total cohort was 70.8% (95% CI, 50.6%-86.3%) and 47.8% (95% CI, 29.2%-67.0%), respectively. The disease control rate for the total cohort at 4 months was 65.2% (95% CI, 44.8%-81.3%). The mean event-free survival for all patients was 4.1 months (0.3-68.5 months). In addition, the immunoreactive cells were calculated using digital microscopy, suggesting that the ratio of CD25+ cells among TILs was significantly increased in patients who responded to bexarotene (p = 0.0209), whereas there were no significant differences in the ratios of CD8+ cells, granulysin+ cells, and Foxp3+ cells among TILs between responder and non-responder patients. Collectively, the ratio of CD25 expression among TILs might be a predictive biomarker for the efficacy of bexarotene.

Folliculotropic Mycosis Fungoides: Current Guidance and Experience from Clinical Practice

Introduction

Folliculotropic mycosis fungoides (FMF) is the most frequent variant of mycosis fungoides (MF), with clinical features which differ from the classic form. As for therapeutic options, the latest guidelines on MF agree on a stage-driven strategy, in consideration of clinical presentation, symptom burden and patient’s comorbidities.

Materials and Methods

A search on MEDLINE, PubMed, Scopus and Cochrane Library was conducted to gather the latest evidence on FMF clinical management. Manuscripts published in the last five years (January 2017–April 2022) were included. Our single-center experience was also described.

Results

A total of 15 articles were analyzed, with a total of 432 patients (disease stage from IA to IVA2). The most widely-used treatment was psoralen ultra-violet A (PUVA) in monotherapy or in association with other drugs. Oral retinoid-based therapy was also described as a therapeutic option alone or in combination. Other therapy reported were based on Brentuximab Vedotin, Mogamulizumab, Carmustine, topical steroids, tazarotene and excimer laser, interferon, nitrogen mustard, imiquimod, systemic chemotherapy, extracorporeal photopheresis and stem cell transplantation.

Discussion

FMF is characterized by specific clinical-pathologic features. Advanced forms assume characteristics more similar to classic MF (infiltrated plaques and nodules), whilst early stages can present in a wide range of clinical forms (acneiform lesions, follicular-like keratoses, erythematous patches). As for therapeutic options, in absence of specific guidelines, a high number of treatments are described in clinical practice, with variable results. Phototherapy in all its forms, especially as PUVA, appears to have the greatest initial therapeutic success. Retinoids, although widely used, appear to be poorly effective in monotherapy, particularly acitretin. Combination treatment with phototherapy seems to be advisable. Ionizing treatments, such as radiotherapy and TSEBT, appear effective, at least in the short term. Overall, an integrated approach is mandatory for the inconstant course of the disease and its multidisciplinary nature.

The SARS-CoV-2 main protease (Mpro): Structure, function, and emerging therapies for COVID-19

The main proteases (Mpro), also termed 3-chymotrypsin-like proteases (3CLpro), are a class of highly conserved cysteine hydrolases in β-coronaviruses. Increasing evidence has demonstrated that 3CLpros play an indispensable role in viral replication and have been recognized as key targets for preventing and treating coronavirus-caused infectious diseases, including COVID-19. This review is focused on the structural features and biological function of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) main protease Mpro (also known as 3CLpro), as well as recent advances in discovering and developing SARS-CoV-2 3CLpro inhibitors. To better understand the characteristics of SARS-CoV-2 3CLpro inhibitors, the inhibition activities, inhibitory mechanisms, and key structural features of various 3CLpro inhibitors (including marketed drugs, peptidomimetic, and non-peptidomimetic synthetic compounds, as well as natural compounds and their derivatives) are summarized comprehensively. Meanwhile, the challenges in this field are highlighted, while future directions for designing and developing efficacious 3CLpro inhibitors as novel anti-coronavirus therapies are also proposed. Collectively, all information and knowledge presented here are very helpful for understanding the structural features and inhibitory mechanisms of SARS-CoV-2 3CLpro inhibitors, which offers new insights or inspiration to medicinal chemists for designing and developing more efficacious 3CLpro inhibitors as novel anti-coronavirus agents.

Retrospective Analysis of 118 Patients With Cutaneous T-Cell Lymphomas: A Single-Center Experience

Cutaneous T-cell lymphomas (CTCL) represent rare non-Hodgkin lymphomas (NHL) with an incidence less than 1 per 100,000 inhabitants. The most common type of CTCL is mycosis fungoides (MF), which represents approximately 60% of all CTCL, followed by Sézary syndrome (SS), approximately 5%. We retrospectively analyzed the outcome of 118 patients with MF (n=96) and SS (n=22) treated between the years 1998 and 2021 at the Charles University General Hospital in Prague, Czech Republic. The ratio between men and women was 1.2:1 (62 men, and 56 women). The median age at diagnosis was 62 years (23 to 92 years). From the MF cohort 48 patients (50% out of MF cohort) presented with advanced stage disease. Ninety patients (77%) received a systemic treatment at any time from the diagnosis; the median number of therapy lines was two. At the time of database lock, the overall survival (OS) of 96 patients with MF reached 17.7 years with the median follow-up 4.0 years. With the median follow-up 2.6 years, the median OS of 22 patients with SS was 3.5 years. The most common type of systemic therapy for MF included low-dose methotrexate (61%), interferon-alpha (58%), bexarotene (28%), and chlorambucil (25%). The most common type of therapy for SS included bexarotene (64%), extracorporeal photopheresis (50%), and interferon-alpha (45%). Only the minority of patients received innovative targeted agents including brentuximab vedotin, mogamulizumab, or pembrolizumab. Besides the retrospective analysis of the CTCL cohort, current standards and future perspectives of selected innovative agents are summarized and discussed. The analyzed cohort represents the largest cohort of CTCL patients in the Czech Republic. Overall, the survival parameters of our CTCL cohort are comparable to those previously published by other groups. In conclusion, our analysis of 118 real world cohort of consecutive CTCL patients treated at the single center confirmed the efficacy of immune response modifiers and underlines the urgent need for ample implementation of innovative agents and their combinations into earlier lines of therapy.