Skin

Disclaimer

This manual is not a substitute for consultation with an appropriate specialist.
The contents of this manual have been developed through consensus of a Provincial Tumour Group. Please note the various update dates for each section as some of the content of the manual may not be up to date.

1. Introduction

Revised 7 June 2010

Patients with CTCL including mycosis fungoides or Sézary syndrome can be referred to the Skin Lymphoma Group at the BC Cancer Agency, Vancouver Centre to arrange for appropriate treatment or for management opinion only. The Skin Lymphoma Group consists of representatives from Dermatology, Radiation Oncology, Medical Oncology and Pathology. Referrals can be made through the Admitting Department of the Vancouver Centre.

2. Staging

Patients with biopsy-confirmed CTCL are staged according to the extent of their skin disease and treatment is determined by their stage. The staging system used is as follows:

T0	No skin involvement
T1	Patches or plaques, covering<10% of the body surface
T2	Same as above but covering >10% of the body surface
T3	Tumours with or without patches or plaques
T4	Generalized erythema
NP0	No abnormal peripheral lymph nodes
NP1-	Abnormal peripheral lymph nodes, biopsy negative
	(i.e., dermatopathic lymphadenopathy)
NP1+	Abnormal peripheral lymph nodes, biopsy positive
NV0	No abnormal visceral lymph nodes
NV1	Abnormal visceral lymph nodes (no information regarding biopsy)
NV1-	Abnormal visceral lymph nodes, biopsy negative
NV1+	Abnormal visceral lymph nodes, biopsy positive
M0	No visceral organ involvement
M1	Visceral organ involvement (on basis of histology)
B0	<5% circulating Sézary cells and <250 Sézary cells per cc
B1	>5% circulating Sézary cells, or>250 Sézary cells per cc

Prior to staging, each patient has a careful clinical examination. If any superficial lymph nodes are enlarged, and the disease is otherwise clinically confined to the skin, the largest node is biopsied. A CT scan of the abdomen and pelvis is done to assess the intra-abdominal and pelvic lymph nodes. If an abnormal node is demonstrated, (usually in the pelvis) and the disease is clinically confined to the skin, biopsy is considered. A quantitative Sézary cell count is performed to assess the presence and number of circulating lymphoma cells as well as a CBC and LDH.

3. Management

3.1 Pre-lymphoma
3.2 Cutaneous T Cell Lymphoma (CTCL)
3.3 Limited Disease (T1/2/3, NP0, M0, B0)
3.4 Advanced Disease
3.5 Relapsed Disease after TBE, Clinically Limited to the Skin

3.1 Pre-lymphoma

Large plaque parapsoriasis (poikiloderma vasculare atrophicans) can progress to mycosis fungoides. Treatment of large plaque parapsoriasis includes UVB or PUVA therapy. Patients with large plaque parapsoriasis should be followed at regular intervals (at least every six months). Sequential biopsies of the thickest lesions may be necessary to confirm progression to a true Cutaneous T cell lymphoma such as mycosis fungoides or Sézary syndrome.

Follicular mucinosis or lesions similar to lymphomatoid papulosis may be associated with mycosis fungoides in 10-15% of cases. Assessment at the Vancouver Cancer Centre may be useful. True lymphomatoid papulosis is a separate disease and does not evolve into T-cell lymphoma (see section on Lymphoma, special problems).

3.2 Cutaneous T Cell Lymphoma (CTCL)

CTCL includes a number of clinical syndromes, the most common of which are mycosis fungoides and the Sézary syndrome. Mycosis fungoides presents with patches, plaques, or tumors. In the initial stages disease is confined to the skin. Sézary syndrome is a leukemic variant of CTCL, characterized by erythroderma (stage T4), lymphadenopathy, pruritus and circulating neoplastic (Sézary) cells (stage B1).

3.3 Limited Disease (T1/2/3, NP0, M0, B0)

a) Patch or Plaque stage disease limited to geographical region that can be reasonably encompassed by limited radiation field(s)

b) Diffuse patch or plaque stage disease: Patients with diffuse involvement of the skin are treated with topical therapy. There is no evidence that one topical therapy is superior in terms of efficacy or side effects. Treatment is continued in an adjuvant fashion until 1 year AFTER clearance of clinical disease

Skin Directed therapies include:

Topical Chemotherapy : daily use Nitrogen Mustard or CCNU
Light therapy: 2-3 weekly PUVA or Narrow Band UVB
Total Skin Electron Beam Radiation Therapy: duration 1 month but not currently available in BC

3.4 Advanced Disease

a) Advanced / refractory cutaneous disease : Occasionally if disease is refractory to one of these topical therapies, multi-agent therapy may be recommended. This may include:

Combination of topical therapy
Addition of oral agents: Acitretin 10-25 mg/ day

However, after exhaustion of above mentioned therapies, with progressive disease, systemic chemotherapy can be used (see below).

b) Systemic disease: occasionally patients present with systemic disease and will need to be on systemic chemotherapy. There is no clear evidence that one medication is superior than another in terms of efficacy. The usual order of use is:

chlorambucil/prednisone
gemcitabine
Bexarotene (see chemo protocol: ULYMFBEX)
other

c) Special circumstances:

occasionally > 5% circulating tumour cells/ Sézary cells are seen. These patients are usually treated as above. However, for patients with refractory disease, who have circulating tumour cells, Extra-Corporeal Photoimmunotherapy has been used. (See chemo protocol ULYMFECP)
refractory lesions/tumours can be treated with localized radiation therapy

Reference:
EORTC consensus recommendations for the treatment of mycosis Fungoides/ Sézary Syndrome EJC 42(2006) p1014-1030

3.5 Relapsed Disease after TBE, Clinically Limited to the Skin

Those patients relapsing after electron beam irradiation often present difficult problems from the point of view of therapy. As with those patients presenting with advanced disease a number of treatments are available (see 3.4 above).