PUVA plus interferon α2b in the treatment of advanced or refractory to PUVA early stage mycosis fungoides: a case series

Treatment of basal cell carcinoma with intralesional interferon alfa-2b: an open-label clinical trial

INTRODUCTION

Basal cell carcinoma (BCC) is the most common cutaneous cancer. We report the efficacy and aesthetic outcome of intralesional IFN-α 2b injection for the treatment of BCC and compare with the surgical method.

MATERIALS AND METHODS

Intralesional IFN-α 2b was injected in 58 BCC lesions from 20 patients three times a week for three weeks. Control group was retrospectively selected among patients who underwent surgical method (standard surgical excision) for BCC including 58 lesions from 24 patients. All patients were followed up for one year in terms of recurrence and cosmetic outcome.

RESULTS

Two patients (four lesions) failed to complete the treatment period. After three weeks, 40 (68.96%) lesions were completely cured. Nine (15.51%) lesions achieved complete healing in less than 9 sessions. Five (8.62%) lesions were completely cured by an extra week of injection. In aggregate, complete healing was observed in 54 (93.10%) lesions. In the surgery group, complete lesion elimination was detected in 52 (89.65%) lesions (p = 0.40). After one year, cosmetic outcome was significantly more favorable in the study group compared to the surgery group (p = 0.003). Recurrence was not detected in any of the groups after one year follow-up.

CONCLUSION

Intralesional IFN-α 2b injection is an appropriate treatment choice for BCC.

CLINICAL TRIAL REGISTRY

We used Iranian registery of Clinical trials; The IRCT code is: 2017093017756N30.

Harnessing the immune system in the treatment of cutaneous T cell lymphomas

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.

Phototherapy combined with systemic agents for mycosis fungoides

The choice of tactics for managing a patient with mycosis fungoides is determined by the stage of the disease. In the early stages of mycosis fungoides, a treatment approach using external therapy and various ultraviolet irradiation spectra (UVB-311 nm and PUVA therapy) is preferable. With insufficient efficiency and / or short remissions in some patients, it is possible to use combined methods in the early stages: PUVA therapy or UVB-311 nm therapy. in combination with systemic therapy, including interferon (IFN) 2b preparations, methotrexate and retinoids. The results of original studies demonstrate an increase in the overall response rate when combining PUVA therapy with IFN- or retinoids in patients with stages IB-IIB. The effectiveness of combined treatment regimens using UVB-311 nm remains insufficiently studied.

Italian expert-based recommendations on the use of photo(chemo)therapy in the management of mycosis fungoides: Results of an e-Delphi consensus

BACKGROUND

Phototherapy is a mainstay for the treatment of MF. However, there is scarce evidence for its use, mostly due to the lack of a unified schedule.

AIMS

The primary aim of this study was to establish the first structured, expert-based consensus regarding the indications and technical schedules of NB-UVB and PUVA for MF. The secondary aim was to determine the consensus level for each specific item.

MATERIALS & METHODS

E-delphi study. Item-specific expert consensus was defined as the number of "Totally Agree" results to ≥80% of the panelists. Cronbach alpha index ≥0.7 was used as a measure of homogeneity in the responses among questions related to the same topic.

RESULTS

Overall, there was a high homogeneity among responders (0.78). On specific topics, the highest grade was observed for technical items (0.8) followed by indications for early (0.73) and advanced stages (0.7).

CONCLUSIONS

Items related to the most canonical indications of phototherapy and to treatment schedules showed the highest agreements rates. There is consensus about the use of standardized treatment schedules for the induction and consolidation phases for NB-UVB and PUVA in MF.

[Treatment of mycosis fungoides and Sézary syndrome]

Adequate therapeutic management of cutaneous T-cell lymphoma (CTCL) requires the identification of the exact CTCL stage and entity within the current WHO classification. There is no curative therapy for CTCL yet, so that treatment currently aims at improving symptoms and quality of life as well as reducing relapse rates. The treatment has to be stage-adapted. Therapeutic options comprise skin-directed as well as systemic treatment. In early stages, phototherapy and local steroids are the first-line therapeutic options. For the therapy of higher stages, interferon alpha and the RXR-specific retinoid bexarotene are used as first-line medications. Second-line treatment comprises monochemotherapy with agents like gemcitabine or liposomal doxorubicine. Nevertheless, the high relapse rates in higher stages make novel alternative treatment options necessary. As future therapy, especially the fusion protein brentuximab-vedotin directed against CD30 shows promising potential in clinical studies.

The efficacy and safety of methotrexate versus interferon in cutaneous T-cell lymphomas

OBJECTIVES

Methotrexate (MTX) and interferon (IFN) have been used in the treatment of cutaneous T-cell lymphomas (CTCL) of various subtypes. We review our experience of MTX and IFN use in our patients with CTCL at a tertiary hospital.

MATERIALS AND METHODS

Medical records of patients over 4 years were reviewed. We describe the dosages, time to response, response rates, side effects, progression rate, and reasons for discontinuation.

RESULTS

Response rate was significantly higher in the IFN group than MTX group (86.67% and 47.4% respectively, p = .01). Disease progression occurred 57.89% in the MTX group whilst only 26.67% progressed with IFN therapy. Patients taking IFN therapy experienced proportionally more side effects of any type than those undertaking MTX treatment (86.67% vs. 47.37%, odds ratio 7.22). However, discontinuation rate in the IFN group (26.67%) was much lower than in the MTX arm (89.47%).

CONCLUSIONS

The most significant finding of this study was that patients with CTCL treated with IFN had a better response rate and significantly shorter response time compared with those treated with MTX. Additionally, patients had less disease progression on IFN than with MTX regardless of subtype of T-cell lymphoma and stage of disease.

Management Strategies for Mycosis Fungoides in India

Mycosis fungoides is the most common primary cutaneous T-cell lymphoma. The approach to diagnosis and further follow-up is outlined. Evidence for interventions is based classically on a Tumor Node Metastasis Blood TNMB “stage-based” approach. The treatment options in India are limited. The options as per risk stratification and prognostic index are discussed. Early stages and low-risk patients can be managed with expectant policy or skin-directed therapies including topical steroids and phototherapy; intermediate-risk patients can be opted for interferons or retinoids or low dose methotrexate along with radiotherapy including total skin electron beam therapy while high-risk patients are managed most often with single agent or multiagent palliative chemotherapy. Patients who are intermediate- or high-risk need management by a multispecialty team at tertiary care centers.

STAT3/5-Dependent IL9 Overexpression Contributes to Neoplastic Cell Survival in Mycosis Fungoides

PURPOSE

Sustained inflammation is a key feature of mycosis fungoides (MF), the most common form of cutaneous T-cell lymphoma (CTCL). Resident IL9-producing T cells have been found in skin infections and certain inflammatory skin diseases, but their role in MF is currently unknown.

EXPERIMENTAL DESIGN

We analyzed lesional skin from patients with MF for the expression of IL9 and its regulators. To determine which cells were producing IL9, high-throughput sequencing was used to identify malignant clones and Vb-specific antibodies were employed to visualize malignant cells in histologic preparations. To explore the mechanism of IL9 secretion, we knocked down STAT3/5 and IRF4 by siRNA transfection in CTCL cell lines receiving psoralen+UVA (PUVA) ± anti-IL9 antibody. To further examine the role of IL9 in tumor development, the EL-4 T-cell lymphoma model was used in C57BL/6 mice.

RESULTS

Malignant and reactive T cells produce IL9 in lesional skin. Expression of the Th9 transcription factor IRF4 in malignant cells was heterogeneous, whereas reactive T cells expressed it uniformly. PUVA or UVB phototherapy diminished the frequencies of IL9- and IL9r-positive cells, as well as STAT3/5a and IRF4 expression in lesional skin. IL9 production was regulated by STAT3/5 and silencing of STAT5 or blockade of IL9 with neutralizing antibodies potentiated cell death after PUVA treatment in vitro IL9-depleted mice exhibited a reduction of tumor growth, higher frequencies of regulatory T cells, and activated CD4 and CD8 T lymphocytes.

CONCLUSIONS

Our results suggest that IL9 and its regulators are promising new targets for therapy development in mycosis fungoides. Clin Cancer Res; 22(13); 3328-39. ©2016 AACR.

Guidelines for phototherapy of mycosis fungoides and Sézary syndrome: A consensus statement of the United States Cutaneous Lymphoma Consortium

BACKGROUND

Ultraviolet light (UVL) is a long established treatment for mycosis fungoides (MF) and Sézary syndrome (SS), subtypes of cutaneous T-cell lymphoma (CTCL). Treatments have traditionally included broadband, narrowband ultraviolet B light (UVB) and psoralen plus ultraviolet A light photochemotherapy (PUVA), but more recently, treatment options have expanded to include UVA1 and excimer laser. UVL is used either as monotherapy or as an adjuvant to systemic therapy, demonstrating efficacy in many cases that equal or surpass systemic medications. Despite its utility and duration of use, the current practice of using UVL guidelines for psoriasis to treat patients with MF/SS is problematic because the goals of prolonging survival and preventing disease progression are unique to CTCL compared to psoriasis.

OBJECTIVES

We sought to develop separate guidelines for phototherapy for MF/SS for both clinical practice and for clinical trials.

METHODS

Literature review and cutaneous lymphoma expert consensus group recommendations.

RESULTS

This paper reviews the published literature for UVB and UVA/PUVA in MF/SS and suggests practical standardized guidelines for their use.

LIMITATIONS

New standardization of phototherapy.

CONCLUSIONS

These guidelines should allow the comparison of results with phototherapy in MF/SS across different stages of patients, centers, and in combination with other agents in practice and in clinical trials.

The Use of Interferons in the Treatment of Cutaneous T-Cell Lymphoma

Interferons are polypeptides that naturally occur in the human body as a part of the innate immune response. By harnessing these immunomodulatory functions, synthetic interferons have shown efficacy in combating various diseases including cutaneous T-cell lymphoma. This article closely examines the qualities of interferon alfa and interferon gamma and the evidence behind their use in the 2 most common types of cutaneous T-cell lymphomas, namely, mycosis fungoides and Sézary syndrome.

Systematic review of combination therapies for mycosis fungoides

BACKGROUND

A variety of therapeutic options are available for mycosis fungoides, the most prevalent subtype of cutaneous T cell lymphomas, but thus far, no regimen has been proven to be curative. A combination of treatments is a well-established strategy to increase the therapeutic efficacy. However, data from clinical trials analyzing such combinations for the treatment of mycosis fungoides are scarce.

OBJECTIVE

To analyze the available evidence on combination therapies with emphasis on the combination of psoralen with UVA phototherapy (PUVA), interferon-alpha and bexarotene with another treatment.

METHODS

Systematic literature review of the databases Embase, Cochrane, Medline, and Medline in Process.

RESULTS

Combination of PUVA with interferon-alpha or retinoids did not result in an increased overall response rate. Addition of methotrexate but not retinoids to interferon-alpha may increase the overall response rate. Bexarotene was investigated in one trial each with vorinostat, methotrexate or gemcitabine, whereby only methotrexate possibly enhanced the effect of bexarotene.

CONCLUSION

For mycosis fungoides, no combination treatment has been demonstrated to be superior to monotherapy. Based on our analysis, we conclude that in certain clinical situations, patients may benefit from a combination of PUVA with interferon-alpha or a retinoid or a combination of the latter two. Furthermore, patients in advanced stages may benefit from the combination of methotrexate and interferon-alpha or bexarotene. Finally, the combination of bexarotene with either vorinostat or gemcitabine did not increase the overall response rate but resulted in more pronounced side effects and cannot be recommended.

Menus for managing patients with cutaneous T-cell lymphoma

In the management of patients with cutaneous T-cell lymphoma (CTCL), there are numerous distinct therapy options. Each of these therapies is discussed in terms of when to use it, what factors limit the success of the treatment, and what to expect. A menu is defined as a list of items from which to choose. The treatments for CTCL are presented in various menus where they are options for a particular goal in a particular setting of CTCL. The best recognized clinical scenarios of CTCL are those recognized by the staging system: limited patch plaque (T1), disseminated patch plaque (T2), erythroderma (T4), and tumor (T3). Each phase of the disease will have the menu of therapy options presented for a given goal of management.