Skin Findings Predict Response to Alemtuzumab Therapy for Leukemic Cutaneous T-Cell Lymphoma

By Will Boggs MD

May 01, 2014

NEW YORK (Reuters Health) - Patients with leukemic cutaneous T-cell lymphoma (CTCL) who have diffuse erythema are more likely to experience complete response to alemtuzumab therapy, according to results from a small series.

"There are nuances to alemtuzumab therapy," Dr. Rachael A. Clark and Dr. Thomas S. Kupper from Brigham and Women's Hospital, Boston, Massachusetts told Reuters Health in a joint email. "By looking at the morphology of the lesions on the individual patient much can be inferred about the trafficking properties of the malignant clone and therefore its likelihood to respond to alemtuzumab."

"The statement, 'alemtuzumab is an appropriate therapy for all L-CTCL/Sezary patients,' is false," they said, "though it can be an outstanding treatment for carefully selected patients."

Dr. Clark and colleagues describe 23 patients with peripheral blood disease who were treated with low-dose alemtuzumab, i.e., 10 mg subcutaneously, three times a week.

Among 17 patients who presented with diffuse erythema without superimposed plaques or tumors, 13 had complete remission, and four had residual or emergent skin disease controllable by skin-directed therapy alone.

In contrast, none of the six patients who presented with discrete patches, plaques, or tumors with or without background diffuse erythema experienced full remission after alemtuzumab. One responded fully to subsequent electron beam therapy, and five had recurrent and/or progressive disease.

Of 10 patients who presented with greater than 80% malignant T cells with the central memory phenotype (CCR7+/L-selectin+), eight experienced full remission with low-dose alemtuzumab alone and two after subsequent skin-directed therapies, according to the April 23rd JAMA Dermatology online report.

On the other hand, of nine patients who presented with fewer T cells having this phenotype, only three cleared after low-dose alemtuzumab; the other six had persistent or progressive disease.

"All patients treated with low-dose alemtuzumab had clearance of peripheral blood disease," the researchers note, "but only patients presenting with diffuse erythema without superimposed plaques or tumors also had complete and long-lasting clearance of skin disease."

"The standard approach should be to individualize therapy to each patient," Dr. Clark and Dr. Kupper concluded. "The paper should not be viewed as an algorithm for how to use low-dose alemtuzumab but rather a cautionary tale that not all L-CTCL patients are equally good candidates."

They added, "We were surprised that the eyes of a well trained dermatologist were as powerful as a complex translational research program in predicting which patients would do well."

SOURCE: http://bit.ly/QWkjOJ

JAMA Dermatol 2014.

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