1. DiGiulio, Sarah

Article Content

Hematopoietic stem cell transplant (HSCT) should be included as an option for patients with advanced cutaneous T-cell lymphoma-specifically mycosis fungoides and Sezary syndrome. That is the message from Christiane Querfeld, MD, PhD, Director of the Cutaneous Lymphoma Program and Assistant Professor of Dermatology and Dermatopathology at City of Hope Cancer Center & Beckman Research Institute and lead author of a recent review article on the topic.


As she explains in the article (Dermatologic Clinics 2015;33:807-818), because there is no cure and none of the standard regimens or investigational regimens have shown a sustained response to treatment, allogeneic transplant has the potential to cure patients with these diseases.


She and her colleagues (first coauthors are Pooja Virmani, MBBS, MD, and Jasmine Zain, MD) review the current data, which has to date been minimal, on conditioning regimens, treatment-related complications, and outcomes for such patients who do undergo HSCT.


The article concludes that for patients with advanced-stage mycosis fungoides (stages IIB to IV) with relapsed or refractory disease or for aggressive CTCL subtypes such as Sezary syndrome, allogeneic HSCT has been shown to result in complete clearance of skin lesions, blood involvement, and other evidence of disease, with some patients achieving long-term remission.


No Clear Guidelines

But, a big challenge for using HSCT for these patients is that there are no clear guidelines to select appropriate patients for stem cell transplant, Querfeld added in an email message.


The authors also note that the use of genetic profiling and gene sequencing is likely to allow better prognostic characterization of these tumors and may allow better selection of patients who require transplant for disease control. In addition, dedicated transplant protocols should be developed in multicenter trials to address the needs of these patients with CTCL with improved conditioning regimens and supportive care measures. The increasing number of targeted agents for CTCL, HDAC, and checkpoint inhibitors in particular, should be incorporated into transplant protocols-either in conditioning regimens or as maintenance strategies, the team said.


More Key Conclusions

Other conclusions:


* There is no consensus about the degree of remission needed before transplant for a successful outcome;


* Both related and unrelated matched donors have been used, and there are now supporting data using cord blood as a source of stem cells;


* Although there is still no consensus on conditioning regimens, remissions have been achieved using reduced-intensity approaches, even in patients with advanced and refractory disease, indicating that intense conditioning may not be required for response;


* Total skin electron-beam therapy before transplant may be associated with improved skin control;


* Relapses still occur after allogeneic transplants, but have been treated successfully with adjustments of immune-suppression, donor lymphocyte infusion, or skin-directed treatments; and


* The use of allogeneic stem cell transplant is associated with a higher incidence of complications, including graft-versus-host disease, infections, and death.