Subcutaneous panniculitis-like T-cell lymphoma in a patient receiving etanercept for rheumatoid arthritis

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.

Increased Risk of Cutaneous T-Cell Lymphoma Development after Dupilumab Use for Atopic Dermatitis

There have been several reports of dupilumab use and the development of CTCL; however, the risk of CTCL development has not been adequately evaluated at the population level. The objective of this study is to determine whether dupilumab administration for AD is associated with an increased risk of developing CTCL and to identify at-risk populations within this group. This retrospective cohort study used TriNetX, a deidentified medical record database including over 107 million patients, to identify eligible patients. Treatment and control groups were evaluated for the development of CTCL. Patients of any age with a documented diagnosis of AD were included. The treatment cohort included individuals treated with dupilumab, while the control cohort included AD patients treated with alternative therapies. Selected biologics were excluded from both groups. Subgroup analyses were performed to evaluate three age groups and to identify whether the risk of CTCL development was higher within a given time frame after starting dupilumab. We identified a total of 1,181,533 patients with AD. Of these, 19,612 patients were prescribed dupilumab. Both treatment and control groups included 19,612 patients matched for age, race, and sex. The mean age was 32.3 years (P = 0.96), and females accounted for approximately 52% (P = 0.93) in both groups. Patients treated with dupilumab for AD had an increased relative risk (RR) of developing CTCL compared to those never treated with dupilumab (RR = 4.59, 95% confidence interval 2.459-8.567, P < 0.0001). Subgroup analysis revealed that about half of the CTCL cases after dupilumab therapy (54.5%, 30/55) occurred in patients over the age of 60 years. In contrast, all CTCL cases (100%, 12/12) within the untreated cohort were observed in individuals over the age of 60. Of the patients diagnosed with CTCL following dupilumab use, the majority (62%, 34/55) were diagnosed within the first year. Overall, we find that the use of dupilumab for treating AD is associated with an increased relative risk of developing CTCL. This risk is highest in the first year of therapy and in adult patients. These findings suggest exercising caution in treating select groups of patients with dupilumab.

Development of Cutaneous T-Cell Lymphoma Following Biologic Treatment: A Systematic Review

BACKGROUND

Cutaneous T-cell lymphoma following biologic therapy is extremely rare.

OBJECTIVE

The aim of this systematic review was to investigate the development of cutaneous T-cell lymphoma (CTCL) following treatment with a biologic agent.

METHODS

A systematic literature review was performed for patients who developed CTCL after exposure to biologic therapy. Works were limited to English language and excluded animal studies, guidelines, and protocols. Potentially eligible titles were identified using controlled vocabulary in tandem with key words. The search strategy was peer-reviewed prior to execution.

RESULTS

Twenty-eight total studies revealed sixty-two patients who developed CTCL following exposure to a biologic agent. Of these, 44% were Caucasian, and the median age at diagnosis was 56 years. Seventy-six percent of patients received biologic therapy for a primary inflammatory skin condition. Dupilumab was the most reported (42%) agent amongst the cohort. The median time from initiation of the biologic agent to diagnosis of CTCL in these cases was 4 months (range: 0-84). Mycosis fungoides (65%) and Sézary syndrome (10%) were the most common subtypes of CTCL diagnosed. Twenty-one (34%) patients were reported to be alive with disease, outcome was not reported in 21 patients (34%), ten patients (16%) were alive and in complete remission, eight patients (13%) died of disease and two patients (3%) died due to other causes.

CONCLUSION

While biologic agents may have a role in the development of CTCL, in order to definitively elucidate their role, more methodologically robust studies (such as those that utilize population databases) would need to occur.

Subcutaneous panniculitis-like T cell lymphoma arising in association with chronic lymphocytic leukaemia

Subcutaneous panniculitis-like T cell lymphoma (SPTCL) is a rare cutaneous T cell malignancy of cytotoxic T cell origin. It is frequently associated with autoimmune diseases. It is known to preferentially involve subcutaneous adipose tissue and histologically resembles lupus panniculitis. The aetiology and risk factors of SPTCL are unclear and there are limited studies available since this entity was initially described in 2001. There are even fewer case reports describing the association between SPTCL and chronic lymphocytic leukemia (CLL). In this article, we present a case of SPTCL arising during treatment for CLL. We conducted an extensive review of literature to delve into the possible risk factors for SPTCL development in association with CLL, including pre-existing haematological malignancies, autoimmune conditions, immunomodulation and immunosuppressive chemotherapy.

Follicular eruption with folliculotropic lymphocytic infiltrates associated with anti-tumor necrosis factor alpha therapy: Report and study of 3 cases

BACKGROUND

We have encountered three cases of follicular eruptions with folliculotropic infiltrates of non-atypical lymphocytes associated with anti-tumor necrosis factor alpha (TNF-α) therapy.

METHODS

Three patients aged 15 to 56 years treated with anti-TNF-α therapy (one with adalimumab, and two with infliximab) developed follicular eruptions characterized histopathologically by folliculotropic lymphocytic infiltrates. These were studied clinically, histopathologically, immunophenotypically, and molecularly.

RESULTS

All three cases were characterized histopathologically by folliculotropic cell infiltrates of non-atypical T (CD3+) lymphocytes with variable follicular exocytosis. Marked reduction in CD7 staining and marked predominance of CD4+ cells over CD8+ cells were observed in 1 and 2 cases, respectively. T-cell receptor (TCR) gene rearrangement studies were monoclonal in 1 case. Discontinuation of anti-TNF-α therapy in all three cases, with corticosteroid creams in 1 case, led to complete resolution. Rechallenge with adalimumab in 1 case resulted in exacerbation. Replacement of therapy with non-anti-TNF-α biologic agents in 2 cases was not associated with recurrence.

CONCLUSION

Follicular eruptions with folliculotropic lymphocytic infiltrates associated with anti-TNF-α therapy may show some immunophenotypical variations and/or monoclonal TCR gene rearrangements but lack sufficient cytomorphological features of folliculotropic MF. They may resolve with discontinuation of anti-TNF-α therapy.

Progression of undiagnosed cutaneous lymphoma after anti-tumor necrosis factor-alpha therapy

BACKGROUND

Cutaneous lymphoma diagnosed after anti-tumor necrosis factor-α therapy (anti-TNF-α) has been reported in the literature, yet a clear link between both events remains elusive.

OBJECTIVE

To review our experience with cutaneous lymphoma diagnosed during or after the use of anti-TNF-α therapies.

METHODS

This is a multicenter retrospective study and a literature review.

RESULTS

A total of 22 cases, including 20 cutaneous T-cell lymphomas (CTCLs) and 2 cutaneous B-cell lymphomas, were identified. In the CTCL group, 75% of the patients received an anti-TNF-α agent for a presumed inflammatory skin condition. Mycosis fungoides and Sézary syndrome were the most common subtypes of CTCL diagnosed. Advanced disease (stage IIB to IVA) was commonly seen at time of diagnosis and required aggressive therapy, including stem cell transplant in 3 patients; 2 patients in whom cutaneous B-cell lymphomas was diagnosed had an indolent course. A total of 31 cases were gathered from a literature search.

LIMITATIONS

This is a retrospective study.

CONCLUSIONS

Our findings suggest that the disease of most of the identified patients was misdiagnosed as psoriasis or eczema; therefore, a comprehensive morphologic and molecular review of skin biopsy specimens and peripheral blood samples should be considered before initiation of anti-TNF-α therapy in patients with poorly defined dermatitis or atypical presentations of psoriasis.

Cutaneous Lymphomas with Cytotoxic Phenotype

Primary cutaneous cytotoxic lymphomas are T-cell or natural killer-cell lymphomas that express 1 or more cytotoxic markers. These neoplasms constitute a spectrum of diseases. In this review, an overview of clinical, morphologic, and phenotypical features of each subtype is provided. Differential diagnosis is discussed with attention to scenarios in which diagnostic difficulties are most frequently encountered.

Panniculitis with crystals induced by etanercept subcutaneous injection

Panniculitis with lipid crystallization within adipocytes may be seen in several disorders, including crystal-storing histiocytosis, gouty panniculitis, subcutaneous fat necrosis of the newborn, post-steroid panniculitis, sclerema neonatorum, oxalosis and subcutaneous fungal infections by mucormycosis, zygomycosis or aspergillosis. Panniculitis at the sites of subcutaneous injection of drugs are frequent, but to our knowledge no crystals have been described in the drug-induced panniculitis at the sites of subcutaneous injections. We report on a patient who developed a panniculitis with lipid crystallization at the site of etanercept injection.

T-cell non-Hodgkin's lymphomas reported to the FDA AERS with tumor necrosis factor-alpha (TNF-α) inhibitors: results of the REFURBISH study

OBJECTIVES

The risk of non-Hodgkin's lymphoma (NHL) with tumor necrosis factor alpha (TNF-α) inhibitors is unclear, whether related to concomitant thiopurines usage or due to the underlying inflammatory disease. We sought to review all cases of T-cell NHL reported to the Food and Drug Administration (FDA) in patients receiving TNF-α inhibitors for all approved indications and examine the risk of T-cell NHL with TNF-α inhibitors in comparison with the use of thiopurines in inflammatory bowel disease (IBD).

METHODS

The FDA Adverse Event Reporting System (AERS) was queried for all lymphomas following treatment with the following TNF-α inhibitors: infliximab, adalimumab, certolizumab, etanercept, and their trade names. Full reports for T-cell NHL cases were identified using the Freedom of Information Act. In addition, T-cell NHL reported in patients IBD with the use of the thiopurines-azathioprine, 6-mercaptopurine, and their trade names were also collected. A search of MEDLINE was performed for additional T-cell NHL with TNF-α inhibitors or thiopurines, not reported to the FDA but available in published literature. The histological subtypes of T-cell NHL reported with TNF-α inhibitors were compared with reported subtypes in Surveillance Epidemiology and End Results (SEER) -17 registry. Reported risk of T-cell NHL in IBD with TNF-α inhibitors, thiopurines, or concomitant use was calculated using Fisher's exact test using 5-aminosalicylates as control drugs.

RESULTS

A total of 3,130,267 reports were downloaded from the FDA AERS (2003-2010). Ninety-one cases of T-cell NHL with TNF-α inhibitors were identified in the FDA AERS and nine additional cases were identified on MEDLINE search. A total of 38 patients had rheumatoid arthritis, 36 cases had Crohn's disease, 11 had psoriasis, 9 had ulcerative colitis, and 6 had ankylosing spondylitis. Sixty-eight of the cases (68%) involved exposure to both a TNF-α inhibitor and an immunomodulator (azathioprine, 6-mercaptopurine, methotrexate, leflunomide, or cyclosporine). Hepatosplenic T-cell lymphoma (HSTCL) was the most common reported subtype, whereas mycosis fungoides/Sezary syndrome and HSTCL were identified as more common with TNF-α-inhibitor exposure compared with SEER-17 registry. Nineteen cases of T-cell NHL with thiopurines were identified in the FDA AERS and one additional case on MEDLINE. Reported risk of T-cell NHL was higher with TNF-α inhibitor use in combination with thiopurines (95% confidence interval (CI) 4.98-354.09; P<0.0001) and thiopurines alone (95% CI 8.32-945.38; P<0.0001) but not with TNF-α inhibitor use alone (95% CI 0.13-10.61; P=1.00).

CONCLUSIONS

Risk of T-cell NHL is increased with TNF-α inhibitor use in combination with thiopurines but not with TNF-α inhibitors alone.

Sources of information on lymphoma associated with anti-tumour necrosis factor agents: comparison of published case reports and cases reported to the French pharmacovigilance system

BACKGROUND

Anti-tumour necrosis factor (TNF) agents, through their intense immunoregulatory effect, have been suspected to increase the risk of malignant lymphoma. However, the classical epidemiological approaches conducted over about the last 10 years have not totally succeeded in addressing the question of a causal or artifactual association. Therefore, the analysis of a substantial set of case reports, although usually considered as poorly generalizable to the general population, could be particularly informative. Two main sources of case reports in postmarketing settings are available; publications in medical journals and reports to pharmacovigilance systems.

OBJECTIVE

The aim of the study was to compare the characteristics of case reports from both these sources in order to understand whether they provided the same information for the investigation of the causal link between lymphoma and anti-TNF agents.

METHODS

All case reports of malignant lymphoma in patients treated with an anti-TNF agent published in MEDLINE and all reports to the French pharmacovigilance system up to 1 February 2010 were identified. Cases of malignant lymphoma identified in postmarketing surveillance from both sources were compared regarding the following variables: age, sex, anti-TNF agent involved, indication for use, type of lymphoma, prior or concomitant immunosuppressive drugs and time to onset of lymphoma.

RESULTS

A total of 81 published case reports and 61 cases reported to the French pharmacovigilance system were compared. In published reports, patients were younger (p = 0.03) and more frequently receiving a first anti-TNF treatment (p = 0.03), particularly infliximab (p = 0.03). Conversely, in the pharmacovigilance system reports, a succession of different anti-TNFs (p = 0.03) and adalimumab (p < 0.0001) were more frequently reported. Lymphomas in patients treated with anti-TNF agents for Crohn's disease were more prevalent in published cases than in pharmacovigilance reports (p < 0.0001), and in particular involved hepatosplenic T-cell lymphoma. Conversely, rheumatoid arthritis was the main indication for anti-TNF agents in pharmacovigilance reports (p = 0.01). Time to onset was markedly shorter in published cases (median 12 months) than in pharmacovigilance reports (median 30 months; p = 0.0001).

CONCLUSIONS

Characteristics of published cases and those reported to the French pharmacovigilance system differed markedly for all characteristics tested, except sex and the use of prior or concomitant immunosuppressive drugs. Published case reports favoured convincing arguments for drug causation whereas cases reported to the pharmacovigilance system were more disparate but could describe more accurately the reality of lymphoma occurrence in this particular population. These results argue for the use of the pharmacovigilance reports when case reports are used to investigate the causal link between lymphoma and anti-TNF agents at the population level. Data from cases notified to the French pharmacovigilance system did not indicate an increased risk of lymphoma during the early phase of anti-TNF treatment. To confirm this hypothesis, a study combining pharmacovigilance reports from several countries, or, if feasible, a cohort study both with a large sample size and a long duration of follow-up would be required.