Understanding TreatmentOptions in
Cutaneous Lymphoma
8
9
Cutaneous T-Cell Lymphomas
2
Figure1.
Treatment ofCTCLs Based on theNCCNGuidelines
a
a
From theNational ComprehensiveCancerNetworkGuidelines inOncology;Non-Hodgkin
Lymphomas,V3.2011.Available at:
.
b
Patientswith stage IA, IB, or IIAwhohave refractory diseasemay receive other types of treatments
aswell.
HDAC, histone deacetylase.
Skin-Directed Therapies
Topical Corticosteroids
Topical corticosteroids (sometimes referred to simply as steroids) are one of the
more established treatments forCTCL.These agents cause the immune system
to becomemore active and alsohave anti-inflammatory effects.There aremany
options in steroid treatment, andmultiple formulations are available including
creams, gels, ointments, and lotions.Withmodest efficacy,
8,9
steroids can be
particularly useful in reaching some areas of the skin that aremore difficult
to reachwith other forms of treatment, such as under the arms.They are also
helpful in alleviating symptoms of itching.However, steroids are associatedwith
several side effects such as thinning of the skin (atrophy), stretchmarks/striae
(irregular areas of skin that look like bands, stripes, or lines), acne/pimples, and
hair growth,which should be consideredwhen evaluating this option.Although
theymay be used independently, steroids are frequently used in combination
with other treatments.
Topical Chemotherapy
Alkylating agents are a class of chemotherapy that act by chemically
modifyingDNA andpreventing cancer cells from growing.Mechlorethamine
(Mustargen® andValchlor™), commonly known as nitrogenmustard, and
carmustine (BiCNU®) are examples of these.They have beenmixed into
solution or compounded into ointments and used topically to treatCTCL.
10-
12
Recently, a gel form ofmechlorethamine (Valchlor™) has become available
for treatment ofCTCL.During the course of topical chemotherapy,
patients sometimes experience redness, irritation, and/or allergy (dermatitis),
development of fine, dilated blood vessels (telangiectasias), or darkening of the
skin (hyperpigmentation) in the treated area.Dermatitis andhyperpigmentation
may cause physicians andpatients to choose another treatment when the
affected area is visual, such as the face.
Imiquimod
Topical imiquimod (Aldara®) is a cream that works by stimulating the release
of interferon and cytokines,whichhave anti-tumoral effects.
13
While the
exactmechanism behind the anti-tumoral response is still unclear, imiquimod
is thought to stimulate dendritic cells,which leads to immune activation.
Although large clinical trials are needed, there ismounting evidence from
clinical practice that imiquimodhas activity againstCTCL. Inmost cases
reported todate, imiquimodwas used for patientswhohad failed at least
one other topical therapy, suggesting imiquimodmay be beneficial indisease
forwhich the initial treatment has stoppedworking (resistant or refractory
disease).
14,15
One current limitation is that this cream is distributed in small
packets,making it difficult to use over larger areas of the body.
Retinoids
Retinoids are another, newer class of agents that are available as topical or
oral formulations,which include bexarotene (Targretin®) and tazarotene gel
(Tazorac®).These vitaminA-derived agents regulate awide range of biological
processes, including cell growth anddeath.
16
Retinoids have been shown to be
effective at killing cancer cells and inhibit the ability of cancer cells tomove into
the skin,whichhelpswith itching and redness.
17
Topical bexarotene is approved
by theUSFood andDrugAdministration (FDA) for the treatment of Stage
1A and 1BCTCL inpatientswhohave not responded to or tolerated other
Stage IA IB IIA IIB IIIA IIIB IVA IVB
Skin-DirectedTherapies
b
• Ointments, creams, or lotions
• Phototherapy
• Radiation
Systemic/NovelTherapies
• Extracorporeal photopheresis
• Retinoids
• HDAC inhibitors
• Interferon
• Denileukindiftitox
• Single-agent/multiagent chemotherapy
• Monoclonal antibodies
StemCellTransplant
ClinicalTrials
