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We have developed and previously reported on a therapeutic vaccination strategy for indolent B-cell lymphoma that combines local radiation to enhance tumor immunogenicity with the injection into the tumor of a TLR9 agonist. As a result, antitumor CD8+ T cells are induced, and systemic tumor regression was documented. Because the vaccination occurs in situ, there is no need to manufacture a vaccine product. We have now explored this strategy in a second disease: mycosis fungoides (MF). We treated 15 patients. Clinical responses were assessed at the distant, untreated sites as a measure of systemic antitumor activity. Five clinically meaningful responses were observed. The procedure was well tolerated and adverse effects consisted mostly of mild and transient injection site or flu-like symptoms. The immunized sites showed a significant reduction of CD25+, Foxp3+ T cells that could be either MF cells or tissue regulatory T cells and a similar reduction in S100+, CD1a+ dendritic cells. There was a trend toward greater reduction of CD25+ T cells and skin dendritic cells in clinical responders versus nonresponders. Our in situ vaccination strategy is feasible also in MF and the clinical responses that occurred in a subset of patients warrant further study with modifications to augment these therapeutic effects. This study is registered at www.clinicaltrials.gov as NCT00226993.

Sézary syndrome (SzS) is an advanced form of cutaneous T-cell lymphoma associated with involvement of the peripheral blood by malignant T cells. The disease is defined by impaired cell-mediated immunity and the production of interferon-γ (IFN-γ) and interleukin-2 (IL-2), possibly as a result of deficient IL-12 production. To understand the mechanism of this impairment, we examined the composition and function of dendritic cells and monocytes in the blood of SzS patients with different levels of peripheral blood tumor burden. Consistent with our previous observations, numbers of monocytes in SzS patients were comparable to numbers observed in healthy donors. In contrast, decreased IL-12 production correlated with a decrease in the numbers of CD11c+ dendritic cells, which was particularly profound among patients with medium (20%-50% circulating malignant T cells) and high (more than 50% circulating malignant T cells) tumor burden. Furthermore, CD123+ dendritic cells, major producers of IFN-α, were significantly diminished in SzS patients, regardless of the level of tumor burden. Granulocyte macrophage–colony-stimulating factor–treated patients experienced an increase in the number of dendritic cells but not in IFN-α or IL-12 production. However, in vitro stimulation of peripheral blood mononuclear cells from SzS patients with rCD40L and IFN-γ significantly increased the production of IL-12. Thus, our results demonstrate a profound defect in circulating dendritic cells in SzS patients that may contribute to the pathogenesis of the cytokine disorders and to the depressed cellular immunity. Importantly, the ability of rCD40L to potently induce IL-12 production from monocytes and residual dendritic cells of SzS patients could potentially serve as an immune-restorative therapeutic agent.

To determine the efficacy of multimodality biologic response therapy for patients with cutaneous T-cell lymphoma (CTCL).Retrospective cohort study over a 14-year period.Tertiary care university hospital.A consecutive sample of patients was studied, all 47 of whom carried the clinical and laboratory diagnosis of CTCL: 68% of patients had stage III or IV disease, and 89% had circulating malignant T cells.All 47 patients received photopheresis for 6 or more cycles. Thirty-one patients received treatment with a combination of photopheresis and 1 or more systemic immunostimulatory agents, including interferon alfa, interferon gamma, sargramostim, or systemic retinoids for 3 or more months.Differences in pretreatment prognostic factors, response rates, and survival between patients receiving multimodality therapy and single-modality therapy or historical controls.A total of 79% of patients responded to therapy: 26% had complete remission, and 53% had a partial remission. Median survival from initiation of therapy was 74 months. Median survival for patients with stages III and IV and peripheral blood involvement was 55 months compared with 31 months for historical controls. Compared with the photopheresis monotherapy group, the patients receiving combination immunomodulatory therapy had a worse prognosis at the time of treatment initiation based on multiple prognostic factors. The positive response rates and median survival times were 84% and 74 months, respectively, compared with 75% and 66 months, respectively, for the combination immunomodulatory and photopheresis monotherapy groups (P =.47 for positive response rates and P =.51 for survival).Patients with advanced CTCL and multiple poor prognostic factors who receive treatment with combination immunomodulatory therapy experience higher clinical response rates and longer survival than historical controls. Although the group who received combination therapy had worse prognostic factors at baseline, they had better response rates and overall survival compared with those receiving photopheresis monotherapy.

Cutaneous T-cell lymphoma (CTCL) is typically a skin-infiltrating malignancy of clonally derived CD4+ T lymphocytes. Because the host antitumor response appears to play an important role in disease control, systemic therapeutic agents are used in such a manner as to preserve the integrity of the host antitumor response while selectively targeting the malignant cells. The new biologic response-modifying treatment options currently used to treat CTCL are reviewed.

A 24-year-old white woman presented with a 9-month history of proximal extremity nodules, associated with fevers and arthralgias, that had only a partial response to a combination of oral prednisone, topical betamethasone ointment, and topical calcipotriene ointment. Examination revealed a healthy-appearing woman with a low-grade fever. There were annular and polycyclic eroded plaques and firm subcutaneous nodules on her proximal arms and dusky red, atrophic plaques on her right thigh and the middle of her back (Figure 1A). Laboratory evaluation revealed a microcytic anemia (hemoglobin, 11.2 g/dL; mean corpuscular volume, 77 fL) and normal liver function test results. Results of several skin biopsies showed histological and immunophenotypic features of subcutaneous panniculitic T-cell lymphoma (Figure 2A and B). A positron emission tomographic scan showed multiple foci of intense fludeoxyglucose F 18 uptake superficially within the upper extremities and proximal right lower extremity consistent with the cutaneous T-cell malignancy, without extracutaneous disease (Figure 3A). She initially responded to bexarotene (Targretin; LigandPharmaceuticals Inc,SanDiego,Calif) (150mg/d)and interferonalfa(1.8 10 U,3timesweekly).However,within 2 months of initiating these therapies, her disease had progressed rapidly with an increase in size, number, and degree of infiltration of the lesions and worsening of her constitutional symptomswith increased fatigueand low-grade fevers. She was prescribed prednisone (15 mg/d orally).

The authors describe a patient who was suspected of having cutaneous T cell lymphoma involvement of the brain despite repeatedly negative cerebrospinal fluid (CSF) cytology, inconclusive flow cytometry, and no discrete lesion for brain biopsy. The diagnosis was made by polymerase chain reaction (PCR) analysis that showed a monoclonal T cell receptor gamma-chain gene rearrangement in the CSF, identically sized to that present in a skin biopsy specimen. Thus, PCR could be used early and routinely to diagnose central nervous system spread of T cell lymphomas, because of its potentially superior sensitivity and specificity to CSF cytology.

Cutaneous T cell lymphoma is a clonally derived, skin-invasive malignancy of CD4+ T lymphocytes with the phenotype of mature helper T cells. Previous work has demonstrated that the Sezary form, or typically leukemic form of cutaneous T cell lymphoma, is characterized by prominent immunologic defects, including depressed cell-mediated immunity associated with marked defects in the production of interleukin-12 and other type 1 helper T cell cytokines. Recent clinical trials with recombinant human interleukin-12 for cutaneous T cell lymphoma have demonstrated that it is a potent therapeutic agent, which induces cytotoxic T cell responses. Nevertheless, a high rate of refractoriness to recombinant human interleukin-12 occurred in these studies that may be related to the downmodulation of interleukin-12 receptor expression by chronic interleukin-12 use. In an effort to enhance the overall response rate and to overcome the refractoriness to recombinant human interleukin-12 therapy, we studied the immunologic effects in vitro of adding interleukin-2 to interleukin-12 as a model to achieve these goals. We examined the stimulation of interferon-gamma production, natural killer cell activity and interleukin-12 receptor expression by T cells of cutaneous T cell lymphoma patients. The addition of interleukin-12 to cutaneous T cell lymphoma patient peripheral blood cells resulted in the production of interferon-gamma (mean = 7914 pg per ml +/- 2161, n = 15) as did interleukin-2 alone (mean = 7222 pg per ml +/- 2228, n = 15). Importantly, the addition of interleukin-2 to the interleukin-12 synergistically enhanced the levels of interferon-gamma produced (mean = 16 792 pg per ml +/- 2492 n = 15) (p

Cutaneous T-cell lymphoma (CTCL) is typically a skin-infiltrating malignancy of clonally derived CD4+ T lymphocytes. Because the host antitumor response appears to play an important role in disease control, systemic therapeutic agents are used in such a manner as to preserve the integrity of the host antitumor response while selectively targeting the malignant cells. The new biologic response-modifying treatment options currently used to treat CTCL are reviewed.

8575 Background: CTCL is a heterogeneous group of non-Hodgkin lymphomas that arises in the skin (patches, plaques, tumors, and/or erythroderma) but can involve the lymph, blood, and/or viscera. Add...

We report the case of a 43-year-old male patient with persistent multifocal, skin-restricted, CD30-positive, large T-cell lymphoma. Combination therapy of systemic interferon alfa and oral bexarotene was initiated on an experimental basis in the hope of circumventing therapies such as methotrexate, radiotherapy, or multiple-agent chemotherapy that may be required in such cases. This treatment was associated with rapid and marked regression of the patient's cutaneous lesions.

Objectives To search for circulating clonal T-cell populations in patients with systemic sclerosis (SSc), and to determine whether T-cell clonality in the blood predicts therapeutic response to photopheresis. Design Analysis of clonal T-cell receptor γ gene rearrangements before photopheresis treatment and blinded clinical evaluation of cutaneous response to photopheresis in a case series. Setting University hospital setting. Patients Thirteen consecutive patients with SSc. Interventions Photopheresis in 11 patients. Main Outcome Measures Clonality of T cells in the blood before photopheresis and clinical response to photopheresis. Results Screening of blood samples from 13 SSc patients for clonal T-cell receptor γ gene rearrangements revealed a monoclonal T cell population in 6 (46%) of 13 SSc patients. Clinical response to photopheresis in 11 patients was evaluated in a blinded manner using skin severity scores. Clonality of T cells appeared to be associated with a higher chance of response to photopheresis therapy, as 4 (67%) of 6 patients in the clone-positive group vs 1 (20%) of 5 in the clone-negative group experienced a clinically significant response to treatment. Conclusions A high proportion of patients with SSc have detectable expanded clonal T-cell populations in the peripheral blood, and such patients appear more likely to respond to photopheresis.

Cutaneous T-cell lymphoma (CTCL) is most often a skin-infiltrating malignancy of clonal CD4+ T-cells. Therapy is based on staging and the likelihood of progression. Biological response modifiers and chemotherapeutic agents are used to preserve the integrity of the host antitumour response while selectively targeting the malignant cells. The biological response-modifying treatment options currently used to treat CTCL are bexarotene, denileukin diftitox, interferon-alpha, interferon-gamma and interleukin-12, as well as extracorporeal photopheresis and phototherapy. A combination therapy approach maximises response in patients with advanced CTCL. Biological response modifiers in combination with photopheresis are used for patients with the leukaemic phase of the disease. Among the majority of patients with advanced stage disease so treated, immune response augmentation appears to prolong survival. Future areas of research should assess not only survival and optimal treatment combinations, but also quality of life during the treatment period.

Background: Peripheral eosinophilia occurs in a small subpopulation of patients with cutaneous T-cell lymphoma (CTCL) and denotes a poor prognosis. Clinical studies have suggested that the Sezary cell is a T H 2 type helper T cell that produces cytokines that enhance the differentiation and activation of eosinophils. Interferon alfa (IFN-α) and interleukin 12 are effective therapeutic agents for CTCL and other hematologic disorders. Objective: Our purpose was to determine the inhibitory activity of IFN-α and IL-12 on IL-5 production in vitro by peripheral blood mononuclear cells (PBMCs) obtained from patients with CTCL and eosinophilia. Methods: Suppression of IL-5 production by IFN-α and IL-12 was assessed by comparing IL-5 production by PBMCs from patients with Sezary syndrome and eosinophilia when cultured alone or in the presence of either IFN-α or IL-12. Results: A marked increase in IL-5 production by PBMCs from patients with Sezary syndrome and eosinophilia was observed. IL-5 production was markedly reduced when PBMCs were exposed to IFN-α or IL-12. Conclusion: These results suggest that IFN-α and perhaps IL-12 may produce a therapeutic response in patients with CTCL and eosinophilia through direct suppression of IL-5 production by malignant Sezary cells. (J Am Acad Dermatol 2001;44:28-32.)

Chlamydia pneumoniae is a common cause of pulmonary infection, with serum positivity in at least 50% of the general population. In this study, we report that human PBMCs exposed to C. pneumoniae are resistant to apoptosis induced by the potent photoactivated chemotherapeutic agents 8-methoxypsoralen and hypericin. In contrast, PBMCs treated with a heat-inactivated inoculum exhibit normal susceptibility to apoptosis. We also observed that human PBMCs are responsive to C. pneumoniae infection by secretion of key immune regulatory cytokines, including IL-12 and IL-10. While IL-12 may play an important role in limiting C. pneumoniae proliferation within cells, IL-10 serves an anti-inflammatory function by down-regulating proinflammatory cytokines such as IL-12 and TNF-α. Depletion of endogenous IL-10, but not of IL-12, abolished the apoptosis resistance of C. pneumoniae-infected PBMCs. Furthermore, addition of exogenous IL-10, but not IL-12, significantly increased the resistance of control inoculum-treated PBMCs to photoactivated 8-methoxypsoralen- and hypericin-induced apoptosis. Therefore, we conclude that C. pneumoniae possesses an antiapoptotic mechanism. The resistance to apoptosis observed in PBMCs exposed to C. pneumoniae is due, at least partially, to the IL-10 induced during C. pneumoniae infection.

We have demonstrated previously that cells from both the skin and peripheral blood from patients with cutaneous T cell lymphoma (CTCL) have elevated levels of protein and mRNA for Th2 cytokines, interleukin-4 (IL-4) and IL-5, and depressed levels of Thl cytokines, IL-2 and interferon-gamma (IFN-gamma). Furthermore, IL-12 in vitro can restore IFN-gamma production by these patients' cells to near normal levels. Because retinoids exert therapeutic activity in CTCL and are potent modulators of growth and differentiation of hematopoietic cells, we investigated the role of retinoids in modulating Thl cytokine production. Peripheral blood mononuclear cells (PBMC) from normal donors and patients with CTCL were cultured with medium, IL-2, 13-cis-retinoic acid, all-trans-retinoic acid, acetretin or etretinate alone, or IL-2 plus the retinoids for 24 h, and levels of IFN-gamma were determined using ELISA. IL-2 or retinoids alone could induce low but significant levels of IFN-gamma. However, when IL-2 was cultured with each retinoid, a synergistic augmentation of IFN-gamma levels (4-fold to 90-fold) was observed except in the case of etretinate. All-trans-retinoic acid (ATRA) was the most potent IFN-y inducer. Similar studies performed using PBMC from CTCL patients indicated the IFN-gamma augmentation occurred but in a blunted manner. The IFN-y-inducing effect of ATRA and 13-cis-retinoic acid could be abrogated by addition of anti-IL-12 antibodies, suggesting that IL-12 plays a role in the synergistic upregulation of IFN-gamma. Using an IL-12 p40-specific radioimmunoassay (RIA), we confirmed the presence of IL-12 in IL-2 plus retinoid-treated culture supernatants. Purified monocytes cultured with IL-2 plus ATRA did not secrete IL-12. Only when monocytes were cocultured with lymphocytes was there an increase in IL-12 production, suggesting the involvement of a paracrine feedback loop requiring both monocytes and lymphocytes. These data suggest that retinoids can induce Th1 cytokines from normal and CTCL PBMC and that this induction may be mediated through IL-12 production.

In this issue of Blood , Kim and colleagues demonstrate that zanolimumab offers promise for treating refractory early- and advanced-stage mycosis fungoides and Sezary syndrome. Cutaneous T-cell lymphomas (CTCLs) are malignancies of skin-homing T cells with the most common subtype, mycosis

Purpose: To evaluate the treatment outcome and natural history of patients with the diagnosis of unilesional mycosis fungoides, treated according to a prospective radiotherapy protocol in our institution since July 1975. Methods and Materials: A total of 325 patients with the diagnosis of mycosis fungoides have been referred to the Department of Radiation Oncology at Allegheny University of Health Sciences from July 1975 through September 1996. Of these, 18 patients (5%) were classified as having unilesional mycosis fungoides and were irradiated with a curative intent using local electron fields. One patient received 22 Gy; 1 patient received 40 Gy, and the rest of the patients 30.6 Gy. Daily fractions ranged from 1.8 to 2.0 Gy. Treatments prior to radiation consisted of topical steroids and/or antifungal creams in the majority of patients, with temporary partial responses. One patient had received 2 years of topical mechlorethamine (HN2) and another patient had received topical carmustine solution (BCNU) without response prior to irradiation. Results: The responses were measured clinically; posttreatment skin biopsy was not performed routinely unless there was clinical evidence of disease persistence. Complete response rate was 100%; all treated lesions cleared completely within 4 to 8 weeks after the completion of radiation. With a median follow-up of 43 months (range 12 to 240 months), 2 relapses have occurred, 2 and 71 months after the completion of radiation. Both relapses were confined to the skin and were remote from the original site. Both relapses responded to topical application of HN2. There have been no recurrences in the irradiated field nor systemic dissemination. No long-term side effects were found related to treatment, and all the patients are currently alive and without evidence of disease. Actuarial relapse-free and overall survival at 10 years are, respectively, 86.2% and 100%. Conclusion: Unilesional mycosis fungoides has a long natural history, is possibly the earliest manifestation of a malignant process, and local treatments, including local radiotherapy, result in long-term disease-free intervals and, possibly, cure. Total skin electron beam radiotherapy is not indicated for this disease entity.

CGRP is a neuropeptide that has previously been described to possess immunosuppressive activities. CGRP is released from peripheral nerves that, in the skin, are in close physical association with dendritic APC. We sought to investigate the mechanisms by which CGRP can inhibit immune responses by studying its effects on human peripheral blood mononuclear cells (PBMC). Using allogeneic monocytes as stimulator cells, CGRP could inhibit the proliferation of PBMC by 47% when CGRP was present for the duration of culture. Interestingly, when the stimulator monocytes were incubated with CGRP for 2 h prior to irradiation then washed, the observed inhibition increased to 85%, suggesting that CGRP was exerting a direct effect on the monocyte stimulator population. Finally, the recall response to tetanus toxoid (TT) by PBMC from individuals vaccinated with TT 14 d prior was inhibited by 25-50% in the presence of CGRP. Also, CGRP decreased the levels of B7.2 but not B7.1 on treated monocytes, and this inhibition could be abrogated by the addition of anti-IL-10 antibody, suggesting that the inhibition was mediated by an increase in IL-10 production. Moreover, increased IL-10 production was confirmed by ELISA. Both IL-12 p40 and IFN-gamma levels in CGRP-treated cultures were found to be decreased by approximately 30%. The decrease in IL-12 p40 levels could be reversed by addition of anti-IL-10. These data suggest that CGRP inhibits PBMC proliferation, in part, through the release of IL-10, which in turn can downregulate important co-stimulatory molecules and the cytokines IL-12 and IFN-gamma.

Cutaneous T-cell lymphoma (CTCL) is a lymphoproliferative disorder characterized by skin invasion of clonally derived malignant CD4+ lymphocytes that phenotypically resemble mature T-helper (Th) cells. Sezary syndrome (SzS) represents an advanced form of CTCL associated with generalized erythroderma and involvement of the peripheral blood by the malignant cell population. We have previously demonstrated aberrant cytokine production by peripheral blood mononuclear cells (PBMCs) in SzS characterized by increased IL-4 and deficient IL-2 and IFN-gamma production, as well as increased expression of mRNA for IL-4 and IL-5 within active skin lesions, indicating that the clonal T-cell population is likely derived from the T-helper type 2 (Th2) subset of helper T lymphocytes. Furthermore, a variety of immune abnormalities have been observed in association with SzS that have been attributed to the cytokine abnormalities. Because IL-12 is a potent inducer of IFN-gamma production and causes the activation of cytotoxic lymphocytes, we assessed the production of IL-12 by PBMCs from SzS patients, and whether IL-12 could alter the unfavorable cytokine balance typical of SzS and, thus, possibly lead to correction of immune defects. In this review, we present our data, which indicate that patients with SzS exhibit marked defects in monocyte production of IL-12 p70. Moreover, in vitro culture of PBMC from SzS patients with recombinant IL-12 leads to reconstitution of normal IFN-gamma production and markedly enhances cell-mediated cytotoxicity.

PURPOSE One of the unique characteristics of cutaneous T-cell lymphoma (CTCL) is its ability to undergo cytologic transformation in which the malignant T cells develop the morphologic appearance of a large-cell lymphoma. Reported to occur in up to 20% of advanced cases, large-cell transformation (LCT) is associated with an aggressive clinical course. Little is known about the risk factors or the molecular mechanisms of LCT. Before current immunohistochemical and molecular techniques, it was not possible to determine if LCT represented changes of the initial neoplastic T-cell clone or, in fact, was a distinct second malignancy. The goal of this study was to define the clonal evolution of LCT in CTCL. PATIENTS AND METHODS Polymerase chain reaction (PCR) amplification of T-cell receptor-beta (TCR-beta) gene rearrangements and immunohistochemistry with monoclonal antibodies to TCR-V beta regions were used as markers of T-cell clonality to analyze the skin and peripheral blood of a patient with CTCL and LCT. RESULTS We first detected the presence of minimal residual disease (MRD) in a CTCL patient with a complete clinical response to biologic response modifiers (BRMs). When clinical relapse occurred and demonstrated LCT, TCR-beta-PCR and in situ immunohistochemistry with a specific TCR-V beta monoclonal antibody identified a single neoplastic T-cell clone that expressed the identical TCR as the original clone. CONCLUSION Our results confirm a common clonal origin for CTCL and LCT. We also provide evidence of MRD in CTCL by molecular analysis, implying that residual malignant cells maintain a potential for clinical relapse and possibly LCT. The role of MRD detection remains to be defined in the clinical assessment of CTCL. LCT in CTCL provides a unique model to investigate the molecular events that underlie terminal-stage tumor progression.

Presumably because of its potent immunomodulatory activity, the use of interferon has led to the development of autoimmune disease in susceptible individuals. Because psoriasis is considered to be, in part, an autoimmune phenomenon, it is plausible that interferon may influence disease activity. We describe the development of psoriatic plaques in two patients without a history of this disease while they were receiving interferon alfa and extracorporeal photochemotherapy for erythrodermic cutaneous T-cell lymphoma. Paradoxically, in both patients the erythroderma resolved with subsequent de novo onset of psoriasis. This clinical sequence provides support for disparate immune mechanisms in the pathogenesis of these disorders, both of which are typified by lymphoid infiltrates. A review of the literature reveals that all forms of interferons have been associated with the exacerbation of psoriatic plaques, but that only interferon alfa has induced de novo development of psoriasis.

The majority of cutaneous T-cell lymphomas (CTCLs) consist of clonal proliferations of skin-trafficking T cells that are usually CD4+/CD45RO+/CCR4+/CLA+/CD26-. The malignant T cells frequently exhibit a Th2 cytokine profile with up-regulation of glutamate acetyltransferase 3 (GATA-3), enhanced

The growth of our knowledge in T-cell biology, in particular the molecular biology of the T-cell receptor (TCR), has provided a means to molecularly characterize lymphoproliferative diseases of the skin based on the presence or absence of a clonal population of T lymphocytes. TCR gene rearrangement studies, by Southern blot analysis, have aided the investigative dermatologist in gaining insights into the pathogenesis and clonal evolution of lymphoproliferative skin diseases. In addition, the application of TCR gene rearrangement studies as a diagnostic aid in the evaluation of lymphoproliferative skin diseases has been introduced into clinical dermatology. Despite its enormous research value, TCR gene rearrangement studies presently have limited applications as an independent diagnostic tool. However, as our knowledge and experience grows and as the application of new techniques provides us with greater detection sensitivity and specificity, the diagnostic utility of TCR gene rearrangement studies will be enhanced.

8047 Background: CTCL is a rare form of non-Hodgkin's lymphoma that usually manifests in the skin, blood, and lymph nodes (LN)/viscera in later stages. Previous studies primarily focused on skin as...

Background: This original cohort of patients with erythrodermic cutaneous T-cell lymphoma (CTCL) was reported to have clinical improvement with photopheresis during the 12 months of the original study. No long-term follow-up data have been available to examine the impact of this therapy on the disease. Objective: Our purpose was to provide long-term follow-up on the original 29 erythrodermic CTCL patients treated with photopheresis and to compare these results with historical controls. Methods: Files of patients from the original photopheresis study centers were reviewed and their current status was documented. Results: The median survival of the treated patients was 60.33 months from the date of diagnosis and 47.9 months from the date of the start of photopheresis therapy. A complete remission has been maintained in four of the six patients who achieved complete responses in the original study. The best responses were seen in patients with a lower CD4/CD8 ratio in the peripheral blood at the start of therapy. Conclusion: Photopheresis can influence the natural history of erythrodermic CTCL by inducing remissions and prolonging survival with minimal toxicity.

Sezary syndrome (SzS), the leukemic stage of cutaneous T-cell lymphoma (CTCL), is typically a CD4+ T-cell lympho-proliferative disease characterized by numerous immunologic abnormalities, including decreased T-cell responses to antigens and mitogens, decreased natural killer and lymphocyte-activated killer cell activities, eosinophilia, and increased levels of immunoglobulins, particularly IgE and IgA. Because this constellation of abnormalities is reminiscent of the pleiotropic in vitro activities of IL-4 and IL-5, we examined the possibility that malignant T cells in SzS may be producing increased amounts of IL-4 with a concomitant decrease in IL-2 and IFN-gamma production. Such a cytokine secretion pattern would be similar to that produced by murine Th2 cells. Serum IL-4 enzyme-linked immunosorbent assay measurements revealed that 33% of SzS patients (n = 21) had levels of IL-4 significantly higher (mean, 7.2 pg/ml; range, 0-48, p less than 0.05) than normal controls (mean, 1.59; range, 0-3.1). Although the majority of tested patients had elevated serum IgE, no direct correlation between serum IL-4 levels and serum IgE levels was observed. Peripheral blood mononuclear cells (PBMC) isolated from SzS patients and stimulated with phytohemagglutinin (PHA) produced significantly higher levels of interleukin (IL)-4 and significantly lower levels of IL-2 and interferon (IFN)-gamma than did PBMC from normal controls (p less than 0.02, p less than 0.05, and p less than 0.02, respectively). PBMC from SzS patients in remission produced IL-4 and IL-2 levels similar to that of the normal controls. To determine if IFN-gamma could inhibit the increased IL-4 production by PHA-stimulated PBMC from SzS patients, IFN-gamma was added to culture at 0, 24, or 48 h prior to the addition of PHA. Significant decreases in IL-4 production were seen only in cultures incubated with IFN-gamma for 24 and 48 h prior to the addition of PHA. IL-2 levels were not affected by IFN-gamma incubation. The increased IL-4 and decreased IL-2 and IFN-gamma production by PBMC from SzS patients suggests that Sezary cells have a cytokine profile similar to murine Th2 cells. Moreover, this cytokine secretion pattern may play an integral role in the immunopathogenesis of advanced CTCL. The results also suggest that IFN-gamma be a useful component in the spectrum of therapeutic approaches to SzS.

2683 Poster Board II-659 Background: Responses to romidepsin, a novel pan-HDAC inhibitor, have been observed in patients (pts) with cutaneous T-cell lymphoma (CTCL) in 2 phase 2 studies. One of these studies, the pivotal study was a phase 2, single-arm, open-label study that enrolled 96 pts with CTCL (Stages IB–IVA) at 33 European and US sites. The objective response rate (ORR) was 34% including 6 complete clinical responses (CCR) in all treated pts. Responses (including CCRs) were seen across all stages of disease with a 42% ORR in stage ≥IIB. The median duration of response (DOR) was 14.9 months (mo). The safety profile was characterized principally by mild (grade 1 and 2) gastrointestinal disturbances, hematologic toxicities, clinical chemistry abnormalities and asthenic conditions [Kim, et al. Blood (ASH Abstracts), Nov 2008; 112: 263]. This report summarizes the analysis of 37 pts in the study with blood involvement (Sezary cells >5% circulating lymphocytes at baseline). Methods: Pts who failed ≥1 prior systemic therapy, had adequate organ function, and ECOG PS 0 or 1 were eligible. Exclusions included significant cardiovascular abnormality or treatment with QTc-prolonging or CYP3A4-inhibiting drugs. Pts received romidepsin 14 mg/m2 as a 4-hr IV infusion on days 1, 8, and 15 every 28 days for up to 6 cycles (extended for stable disease [SD] or response). Response was measured with a quantitative composite which included skin involvement [severity-weighted assessment tool (SWAT) or erythroderma scale], lymph node involvement (CT or MRI scans), and blood involvement (circulating Sezary cells assessed by flow cytometry). Pruritus was assessed by visual analog scale (VAS). Pts with baseline VAS ≥30mm were included in pruritus analysis. Results: Of the 37 pts with >5% circulating Sezary cells, 27 (73%) met the definition of evaluable (received ≥2 cycles of romidepsin) for efficacy. 8 of these 27 pts with blood involvement had a greater blood tumor burden (Sezary cell counts >1000 cells/mm3 and/or Sezary cells >20% of lymphocytes). Mean age was 57±13 yrs and median number of prior systemic therapies was 6 (range 1–14) for all pts. 17 (46%) pts received prior bexarotene and 5 (14%) received prior denileukin diftitox. Response (by composite assessment) and pruritus relief data for the evaluable pts are included in the [table][1]. Pts who achieved a response had a rapid, dramatic and durable reduction in Sezary cell counts. ORR was 32% by composite assessment in all pts including 2 CCRs. 5 pts who responded had received bexarotene (including 1 CCR) and 2 had received both denileukin diftitox and bexarotene. The median DOR (for pts with a response by composite assessment) has not been reached; the maximum DOR was 19.8 months. 12 of 27 evaluable pts had erythroderma; 5 of these pts had ≥50% response in skin (4=partial response [PR], 1=SD by composite assessment). 16 of the 37 as-treated pts had erythroderma; 6 of these pts had '50% response in skin (4=PR, 2=SD by composite assessment). | | Evaluable Pts Lower blood tumor burden N=27 | Evaluable Pts Higher blood tumor burden N=8 | |:---------------------------------------------------------------- | ------------------------------------------- | ------------------------------------------- | | Confirmed ORR | 41% | 50% | | CCR, n (%) | 2 (7%) | | | PR, n (%) | 9 (33%) | 4 (50%) | | Median DOR (months) (range) | NE (1.6+-19.8+ months) | NE (5.6+ - 8.5+ months) | | Relief of pruritus[a][2], n (%) Relief of severe pruritus, n (%) | 9/19 (47%) 4/9 (44%) | 3/6 (50%) 3/5 (60%) | * NE, not estimable * [↵][3] a relief = ≥ 30mm decrease on 100mm VAS or score of 0 for 2 consecutive cycles The safety profile in this subset of 37 pts is similar to the overall safety profile of romidepsin in this study and the overall safety profile of romidepsin. No unusual drug-related adverse events were observed. Conclusions: This study shows clinical benefit associated with romidepsin treatment in a heavily pre-treated group of pts with CTCL with blood involvement. Additional treatment options are needed for these pts. The ORR (32%) in all pts in this group was comparable with the ORR in the entire study (34%). Toxicities associated with romidepsin were tolerable and manageable. The new drug application for the use of romidepsin in CTCL is under review at the FDA. Disclosures: Robak: F Hoffmann-La Roche: Honoraria. McCulloch: Gloucester Pharmaceuticals: Consultancy. Whittaker: Gloucester Pharmaceuticals: Research Funding. [1]: #T1 [2]: #fn-2 [3]: #xref-fn-2-1

Background: Responses to romidepsin, a novel pan-HDAC inhibitor, have been observed in patients (pts) with cutaneous T-cell Lymphoma (CTCL). This Phase 2B, singlearm, open-label registration study enrolled pts with CTCL (Stages IB–IVA) at 33 European and US sites. Pts with histologically confirmed CTCL who failed ≥1 prior systemic therapy, had adequate organ function, and ECOG PS 0 or 1 were eligible. Exclusions included significant cardiovascular abnormality or treatment with QTc-prolonging or CYP3A4-inhibiting drugs. Pts received romidepsin 14 mg/m2 as a 4-hr IV infusion on days 1, 8, and 15 every 28 days for up to 6 cycles (extended for stable disease or response). Aim: The primary endpoint was the response rate among evaluable pts, measured by a combination of a weighted scoring instrument to determine skin involvement (SWAT), imaging, and circulating Sézary cells (as applicable). Results: 96 pts were enrolled and received romidepsin (as-treated); 72 (75%) were evaluable (≥2 cycles) for efficacy. Enrollment is complete, 4 pts with confirmed PR continue to receive romidepsin on extended treatment, 5 pts off-treatment are being followed. Mean age of all pts was 57±12 yrs, and median time since diagnosis was 3 yrs (range 500 msec. Conclusions: This study shows clinical benefit associated with romidepsin use in treatment-refractory CTCL, with pts achieving durable response and relief from pruritus. Toxicities associated with romidepsin were tolerable and manageable. Evaluable Pts N=72 As-treated Pts N=96 a stable disease for ≥90 days b relief = ≥ 30mm decrease on 100mm VAS or score of 0 for 2 consecutive cycles Confirmed ORR 42% 34% PR, n (%) 24 (33%) 27 (28%) CCR, n (%) 6 (8%) 6 (6%) SD90a, n (%) 26 (36%) 28 (29%) Overall disease control (CCR+PR+SD90) 56 (78%) 61 (64%) Median time (mo) to response (range) 1.9 (0.9–4.8) 1.9 (0.9–4.8) Median time (mo) to disease progression (range) 9.0 (2.7–21.7) 8.3 (0–21.7) Confirmed OR in stage ≥ IIB, n (%) 23/48 (48%) 26/68 (38%) Relief of pruritusb, n (%) 25/52 (48%) NA Relief of severe pruritus, n (%) 16/29 (55%) NA

Excerpt The extracorporeal exposure of pathogenic peripheral blood leukocytes to the natural compound 8-methoxypsoralen (8-MOP) and ultraviolet A radiation has provided great benefit in certain adv...

Background: Romidepsin is a bicyclic peptide that inhibits Class I and II HDACs. Piekarz et al noted responses to romidepsin in CTCL (ASCO, 2004). This pivotal phase II study sought to confirm the activity. Methods: This single arm, open label study enrolled CTCL (Stages 1B–1VA), including MF and Sézary syndrome (SS) patients (pts) from ∼40 sites in Europe, Russia, Ukraine, Georgia and the US. Pts with biopsy-proven CTCL (centrally reviewed) who failed ≥1 prior systemic therapy received romidepsin at 14 mg/m2 as a 4-hour IV infusion on Days 1, 8, and 15 q 28 days for up to 6 cycles but could continue if deriving benefit. Eligibility criteria included adequate organ function and ECOG PS ≤ 1. Exclusions included significant CV abnormality or treatment with QTc-prolonging or CYP3A4-inhibiting drugs. The primary endpoint is response rate measured by a combination of imaging, circulating malignant T-cell counts and a weighted scoring instrument to determine skin involvement (confirmed by photography). Target accrual of 64 evaluable pts (i.e. received 2 courses) has been reached and the study will close. Results: 92 pts were eligible with 68 evaluable for efficacy per protocol. Responses in evaluable pts are 1 CR, 3 CCRs, 20 PRs, 40 SD and 4 PD for an ORR of 35% (duration 2–21 months). Of pts who received ≥1 dose, the ORR is 26% (24/92) but includes 5 too early to be assessed. Median time to response is 8 weeks (range 4 – 20). Responses by stage at entry in evaluable pts, as available: Stage IB-IIA 7/23 (30%); Stage IIB-IVA 15/37 (41%). In pts with pruritus at baseline i.e. score of ≥ 30 mm on a 100 mm visual analogue scale (VAS), relief of ≥ 30 mm from baseline or a VAS score of 0 (no itching) for at least 2 cycles, was seen in 18/38 pts (47%). In those pts with severe pruritus (VAS score ≥70 mm), 14/24 (58%) experienced relief of itching. Adverse event (AE) data are available for 75 pts. AEs were reported in 54/75 (72%) of dosed pts but Grade (G) 3/4 events in only 12/75 (16%). Most frequent AEs are nausea/vomiting (G2) fatigue (G2/3), myelosuppression (G2/3), and asymptomatic ECG changes (transient mild QTc prolongation and nonspecific ST-T wave abnormalities). Thirteen pts withdrew due to AEs but there were no treatment-related deaths although 4 pts died of PD and 1 from right ventricular failure. Serious AEs considered possibly, probably or likely related to treatment were reported in 12 pts. Of these, 8 had ≥G3 events: tumor lysis, cardiac tamponade, sepsis, constipation, oral candidiasis, dermatitis, hyperglycemia/vomiting/nausea and bradyarrhythmia/atrial fibrillation. Conclusions: This study confirms the efficacy of romidepsin in treatment-refractory CTCL including relief of pruritus and an encouraging response rate with 4 CCR (1 pathology-confirmed). The low rate of discontinuation due to AEs and prolonged treatment duration of some patients illustrate that toxicity has been manageable.

CPG 7909 belongs to a new class of chemically defined CpG immunomodulators that target dendritic cell TLR9 receptors inducing IL-12, IFN-gamma, and NK cell function. The rate and durability of response to CPG 7909 was investigated in refractory patients with recurrent or advanced CTCL, who had failed one or more systemic therapies. Dose escalation with weekly sc dosing of patients at 0.08, 0.16, 0.24, or 0.28 mg/kg (3 patients/cohort) for 24 weeks is nearing completion. Additional patients continue to receive treatment at 0.32 (4 patients) or 0.36 mg/kg (12 patients). Clinical response, monitored by Composite Assessment of Index Lesion Disease Severity (CA) and Physician’s Global Assessment of Clinical Condition, has been documented. Of 28 patients enrolled, 7 (25%) have achieved objective clinical response, 5 with partial response (PR) and 2 with complete response (CR). Eleven patients have maintained stable disease (SD), while 10 have had progressive disease (PD). Eight patients have completed 24 weeks of treatment (5 SD, 2 PR, 1 CR) with 12–16 weeks of response while on study. Six patients (3 SD, 2 PR,1 CR) are currently ongoing in the study. Three patients (2 PR, 1 SD) continue to receive long term CPG 7909 at 0.12 mg/kg (58 total doses), 0.28 mg/kg (34 total doses) or 0.32 mg/kg (29 total doses) in a follow on protocol. Responses have been maintained up to 46 weeks. Weekly doses up to 0.36 mg/kg have been well tolerated. Most reported adverse events have been of CTC grade 1 or 2. The most common are dose-related local injection site reactions (erythema, induration, edema, inflammation and pain) and mild or moderate flu-like symptoms (fatigue, rigors, fever, arthralgia). Four patients had CTC grade 3 drug related AEs: one decreased lymphocyte count (0.08 mg/kg), one increased gamma glutamyl transferase (0.16 mg/kg), one decreased absolute polys (0.36 mg/kg) and one fatigue (0.36 mg/kg). Enrollment in the phase II portion of the study is ongoing and compares results of patients randomized to receive either 10 mg or 25 mg sc weekly for 24 weeks (equating to effective doses seen in dose escalation). Clinical Response with CPG 7909 - 16 M, 12 F Dose N Disease Stage CR PR SD PD 0.36 mg/kg 12 IB (7), IIB, III (3), IVA 0 2 6 4 0.32 mg/kg 4 IIA, IIB, IVA (2) 1 0 1 2 0.28 mg/kg 3 IB (2), III 0 1 2 0 0.24 mg/kg 3 IB, IIB (2) 0 1 1 1 0.16 mg/kg 3 IB (2), IIA 1 1 1 0 0.08 mg/kg 3 IB (2), IVA 0 0 0 3 28 7% 18% 39% 36%

Mucormycosis classically affects patients who are immunocompromised or debilitated, including those with diabetes, malignant neoplasm, renal failure, and neutropenia. 1 Despite the opportunistic nature of mucormycosis infection, there are few cases of cutaneous manifestations of the infection reported in patients with the acquired immunodeficiency syndrome (AIDS). 2-5 We describe a patient with AIDS, neutropenia, and iron overload who developed primary cutaneous mucormycosis. In addition, the patient had recently undergone intralesional chemotherapy and radiation treatments on his face for Kaposi sarcoma. Report of a Case. A 41-year-old white man with AIDS manifested by a CD4 cell count below 10×10 9 /L and a medical history that included disseminated Kaposi sarcoma, cytomegalovirus retinitis, recurrent herpes simplex infection, anemia, and adrenal insufficiency was admitted to the hospital with acute onset of right-sided facial pain and swelling. His facial Kaposi sarcoma had been treated previously with intralesional doxorubicin hydrochloride and radiation. On

Background: Advances in our understanding of the molecular genetics of lymphocyte antigen receptors (B-cell immunoglobulin and T-cell antigen receptor), have led to the application of molecular biologic techniques to molecularly characterize lymphocytic infiltrates of the skin. Molecular diagnosis refers to the application of these techniques as a diagnostic aid in the clinicopathologic evaluation of cutaneous lymphocytic infiltrates. Observation: Molecular studies have clinical application in the determination of lineage and detection of retroviruses in cutaneous lymphoid neoplasms, distinguishing between lymphoproliferative and reactive infiltrates, and staging and monitoring response to therapy in cutaneous T-cell lymphoma. Southern blot analysis of immunoglobulin and T-cell antigen receptor gene rearrangements may fail to aid the clinician in establishing a diagnosis of a cutaneous malignancy due to the limits of detection sensitivity in minimally infiltrated lesions (eg, parapsoriasis and patch-stage mycosis fungoides) or the still uncertain prognostic significance of clonality in benign cutaneous diseases (eg, follicular mucinosis, pityriasis lichenoides et varioliformis acuta, lymphomatoid papulosis, and cutaneous lymphoid hyperplasia). Conclusions: Molecular studies have enormous research value, providing new means to explore the pathogenesis and clonal evolution of lymphoproliferative skin diseases. Presently, however, they have limited applications as an independent diagnostic tool. As our understanding of the clinical and biologic significance of the molecular detection of clonal lymphocyte populations in the skin expands and as the application of polymerase chain reaction amplification provides us with greater detection sensitivity and specificity, the clinical utility of molecular diagnosis of lymphocytic infiltrates of the skin will be enhanced. (Arch Dermatol.1993;129:1491-1500)

Among the clinical entities felt to result from biologically active agents produced by neoplasms is the proliferative skin disorder of Leser-Trelat. This syndrome is characterized by the rapid emergence of multiple seborrheic keratoses in association with an internal malignancy. Though traditionally associated with adenocarcinomas of the stomach, hematopoietic malignancies are the second most recorded neoplasm to be linked with the sign of Leser-Trelat. 1 Moreover, there have been several specific cases in patients with mycosis fungoides and Sezary syndrome. 2-4 In this report, we document an additional case of multiple seborrheic keratoses paralleling the evolution of Sezary syndrome and its response to a new combination treatment with interferon alfa and extracorporeal photopheresis. 5 Our observation of the resolution of the sign of Leser-Trelat in concert with the induction of a complete remission of the cutaneous T-cell lymphoma, which is documented at the clinical and molecular level, is discussed. Report of