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Campbell BA, Prince HM, Thursky K, Dabaja B, Hoppe R, Specht L, Morris S, Porceddu SV. Breaking Down the Barriers for Patients With Cutaneous T-Cell Lymphoma: Current Controversies and Challenges for Radiation Oncologists in 2024. Semin Radiat Oncol 2025; 35:110-125. [PMID: 39672636 DOI: 10.1016/j.semradonc.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2024]
Abstract
Cutaneous T-cell lymphomas (CTCL) are a rare collection of diseases, frequently associated with diagnostic challenges and complex management dilemmas. The multidisciplinary team is vital for accurate clinico-pathological diagnoses and for collaborative therapeutic decisions throughout the management journey, which frequently involves multiple lines of therapy. Radiotherapy (RT) is a highly effective skin-directed therapy for CTCL, commonly delivered as localised fields or as total skin electron beam therapy (TSEBT). Mycosis fungoides (MF) is the most common of the CTCL, and patients typically experience high rates of morbidity and long natural histories of relapse and progression. Patients with MF typically present with incurable disease; in these patients, RT has an established role in symptom- and disease-control, achieving excellent response rates and proven therapeutic benefits. The role of RT continues to evolve, with modern practices favouring lower doses to reduce toxicity risks and allow for re-irradiation. Less commonly, there are situations where RT has an integral role in the potential cure of patients with MF: firstly, in the setting of unilesional MF where localised RT alone may be curative, and secondly, in the setting of preconditioning prior to curative-intent allogeneic hematopoietic stem cell transplant for patients with advanced MF/Sezary syndrome, where conventional-dose TSEBT is indicated as the most effective single agent for maximal debulking of skin disease. Radiotherapy also has an important role in the management of the less common CTCL, including the curative treatment of localised primary cutaneous anaplastic large cell lymphoma. Despite proven efficacy and quality of life benefits, disparity exists in access to RT and TSEBT. World-wide, stronger multidisciplinary collaborations and greater patient advocacy are required to increase access to RT and improve equity of care for our patients with CTCL.
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Affiliation(s)
- Belinda A Campbell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.; The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia; Department of Clinical Pathology, The University of Melbourne, Parkville, Victoria, Australia.
| | - H Miles Prince
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia; Department of Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Karin Thursky
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia; Department of Health Services Research and Implementation Science, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Bouthaina Dabaja
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard Hoppe
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Lena Specht
- Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stephen Morris
- Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Sandro V Porceddu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.; Department of Radiology, The University of Melbourne, Parkville, Victoria, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Campbell BA, Dobos G, Haider Z, Prince HM, Bagot M, Evison F, van der Weyden C, McCormack C, Ram-Wolff C, Miladi M, Scarisbrick JJ. International study of treatment efficacy in SS shows superiority of combination therapy and heterogeneity of treatment strategies. Blood Adv 2023; 7:6639-6647. [PMID: 37648672 PMCID: PMC10628811 DOI: 10.1182/bloodadvances.2023011041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023] Open
Abstract
Despite increasing availability of therapies, patients with Sezary syndrome (SS) commonly endure multi-line treatment journeys, mostly with partial responses of short duration. Measuring clinical benefit is challenging; time-to-next-treatment (TTNT) provides a robust, objective measurement of efficacy. This international observational study examines patterns of clinical care and therapeutic benefit as measured by TTNT. TTNT was calculated for monotherapies and combination therapies, with consideration to treatment line. 178 patients with SS (73% de novo, 27% secondary) were included, receiving 721 lines of systemic therapy, with median follow-up of 56.9 months. Across all lines, 58 different therapeutic regimens were prescribed (54 were systemic therapies) and classified into 17 treatment groups. The most common first-line treatments were extracorporeal photopheresis (ECP)-containing combination therapy (20%) and retinoid monotherapy (19%). Median TTNT for all first-line therapies was short (5.4 months). First-line, combination therapies had longer median TTNT than monotherapies, 10.0 vs 5.0 months (P = .004), respectively. Later delivery of combination therapies was associated with shorter clinical benefit, with median TTNT reduced to 6.2 and 2.2 months for mid-line (2nd-4th line) and late-line (≥5th line), respectively (P < .001). First-line ECP-containing treatments were associated with longer median TTNT than non-ECP-containing treatments, 9.0 vs 4.9 months (P = .007). For both ECP-monotherapy and ECP-containing combination therapy, significant reductions in TTNT were seen in later lines. These data suggest therapeutic benefit from first-line delivery of combination therapy for SS and favor early inclusion of ECP in the treatment algorithm for those who can access it.
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Affiliation(s)
- Belinda A. Campbell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
- Department of Clinical Pathology, The University of Melbourne, Parkville, Australia
| | - Gabor Dobos
- Department of Dermatology, Hôpital Saint Louis, Université Paris Cité, Paris, France
- Department of Dermatology and Allergy, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Zahra Haider
- Department of Dermatology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - H. Miles Prince
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
- Department of Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne Australia
| | - Martine Bagot
- Department of Dermatology, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Felicity Evison
- Health Data Science Team, Research Development and Innovation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Carrie van der Weyden
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Australia
- Department of Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne Australia
| | - Chris McCormack
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Surgery, The University of Melbourne, Parkville, Australia
| | - Caroline Ram-Wolff
- Department of Dermatology, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Maryam Miladi
- Department of Dermatology, Hôpital Saint Louis, Université Paris Cité, Paris, France
| | - Julia J Scarisbrick
- Department of Dermatology, University Hospital Birmingham, Birmingham, United Kingdom
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Miyashiro D, Sanches JA. Mycosis fungoides and Sézary syndrome: clinical presentation, diagnosis, staging, and therapeutic management. Front Oncol 2023; 13:1141108. [PMID: 37124514 PMCID: PMC10140754 DOI: 10.3389/fonc.2023.1141108] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Mycosis fungoides (MF) and Sézary syndrome (SS) are cutaneous T-cell lymphomas. MF is the most common cutaneous lymphoma, and it is classified into classic Alibert-Bazin MF, folliculotropic MF, pagetoid reticulosis, and granulomatous slack skin, each with characteristic clinical presentation, histopathological findings, and distinct clinical behaviors. SS is an aggressive leukemic variant of cutaneous lymphoma, and it is characterized by erythroderma, lymphadenopathy, and peripheral blood involvement by malignant cells. There is a wide range of dermatological manifestations of MF/SS, and prompt recognition is essential for early diagnosis. Skin biopsy for histopathology and immunohistochemical analysis is imperative to confirm the diagnosis of MF/SS. Histopathology may also provide information that may influence prognosis and treatment. Staging follows the TNMB system. Besides advanced stage, other factors associated with poorer prognosis are advanced age, male gender, folliculotropism in histopathology of patients with infiltrated plaques and tumors in the head and neck region, large cell transformation, and elevated lactate dehydrogenase. Treatment is divided into skin-directed therapies (topical treatments, phototherapy, radiotherapy), and systemic therapies (biological response modifiers, targeted therapies, chemotherapy). Allogeneic bone marrow transplantation and extracorporeal photopheresis are other treatment modalities used in selected cases. This review discusses the main clinical characteristics, the histopathological/immunohistochemical findings, the staging system, and the therapeutic management of MF/SS.
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Peacock A, Dehle F, Mesa Zapata OA, Prince HM, Gennari F, Taylor C. Cost-Effectiveness of Extracorporeal Photopheresis for the Treatment of Patients With Erythrodermic (Stage T 4, M 0) Cutaneous T-Cell Lymphoma in the Australian Setting. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:965-974. [PMID: 35667784 DOI: 10.1016/j.jval.2021.11.1364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 10/19/2021] [Accepted: 11/10/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Cutaneous T-cell lymphoma (CTCL) is a rare and incurable disease, and patients currently experience a lack of treatment options in Australia. This analysis evaluated the cost-effectiveness of extracorporeal photopheresis (ECP) compared with standard of care therapy for the treatment of patients with erythrodermic (stage T4, M0) CTCL, who are refractory to previous systemic treatment. METHODS A Markov model was developed from the perspective of the Australian government. Health states were treatment specific and transition probabilities were modeled from time-to-next-treatment data from a published Australian observational study of ECP and comparator treatments. Quality of life utility values were based on psoriasis as a proxy for CTCL, which was validated by consultation with local clinicians. The time horizon for the model was 5 years. The ECP treatment regimen was compared with a weighted treatment comparator based on results of a treatment survey and Australian prescribing data. RESULTS ECP as a second-line treatment option for CTCL was less costly and more effective than other treatment strategies. ECP had an average cost saving of $37 592 and incremental quality-adjusted life-year gained of 0.20 to 0.21, attributed to patients being able to better tolerate ECP thus avoiding subsequent treatment with high-cost alternatives. CONCLUSIONS This is the first published cost-utility analysis of ECP for CTCL. This analysis demonstrates that ECP is a cost-effective option for the treatment of patients with erythrodermic CTCL in Australia.
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Affiliation(s)
- Adrian Peacock
- Health Technology Analysts, Sydney, New South Wales, Australia
| | - Francis Dehle
- Health Technology Analysts, Sydney, New South Wales, Australia
| | | | - H Miles Prince
- Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | | | - Colman Taylor
- Health Technology Analysts, Sydney, New South Wales, Australia; The George Institute for Global Health, Sydney, New South Wales, Australia; The University of New South Wales, Sydney, New South Wales, Australia.
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Ow KV, Brant JM. Non-Hodgkin Lymphoma: Examining Mycosis Fungoides and Sézary Syndrome in the Context of Oncology Nursing. Clin J Oncol Nurs 2021; 25:555-562. [PMID: 34533520 DOI: 10.1188/21.cjon.555-562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mycosis fungoides and Sézary syndrome are the most common non-Hodgkin lymphomas that manifest primarily in the skin. Although early-stage disease has an excellent long-term survival rate, advanced disease carries a poor survival rate. Given the lengthy and complex clinical course, nurses are at the forefront of education and supportive care management for patients and caregivers. OBJECTIVES This article aims to provide an overview of mycosis fungoides and Sézary syndrome and to highlight practice considerations for optimal nursing care. METHODS Clinical presentation, diagnosis, management, and nursing consideration are discussed. FINDINGS Oncology nurses have a vital role in educating patients and their caregivers about the side effects of cancer treatment, appropriate skin care, and infection risk.
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Affiliation(s)
- Karla V Ow
- University of Texas MD Anderson Cancer Center
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