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Diffuse Erythema Predicts Complete Remission of Skin Disease With Alemtuzumab in Leukemic Cutaneous T-Cell Lymphoma

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Key Points

  • Presentation with diffuse erythema without plaques or tumors was associated with complete and enduring clearance of skin disease.
  • Clinical presentation was a more accurate predictor of response than measurement of malignant T cells.

As reported in a research letter in JAMA Dermatology, Watanabe et al found that diffuse erythema at presentation in patients with leukemic T-cell lymphoma was associated with better response to low-dose alemtuzumab (Campath) compared with patients presenting with preexisting plaques or tumors.

Response According to Clinical Presentation

In the study, 23 patients with peripheral blood disease received low-dose alemtuzumab at 10 mg subcutaneously 3 times a week. All had clearance of peripheral blood disease. Among the 17 presenting with diffuse erythema without superimposed plaques or tumors, 13 had complete remission of skin disease after alemtuzumab treatment and the remaining 4 had residual or emergent skin disease that was controlled with skin-directed therapy alone.

Of the six patients presenting with discrete patches, plaques, or tumors with or without background diffuse erythema, none had complete remission with alemtuzumab. One of these patients had a full response to electron-beam therapy and five had recurrent or progressive disease, including two with subsequent large cell transformation.

Response According to Proportion of Malignant T Cells

Measurement of the proportion of malignant T cells in blood with the CCR7-positive/L-selectin–positive central memory cell (TCM) phenotype in 19 patients showed that 8 of 10 with > 80% TCM had complete remission of skin disease on alemtuzumab alone and 2 had complete response after subsequent skin-directed therapy. Complete remission on alemtuzumab alone occurred in only three of nine with < 80% TCM, with six having persistent or progressive disease. Measurement of the proportion of malignant TCM in skin in 12 patients showed complete response with alemtuzumab alone in 4 of 6 with > 80% TCM, with 1 having clearance after skin-directed therapy and 1 having progressive disease.

As noted by the investigators, although all patients treated with alemtuzumab had clearance of peripheral blood disease, only those presenting with diffuse erythema without superimposed plaques or tumors also had complete and long-lasting clearance of skin disease. They stated, “Initial clinical presentation was more predictive of response than was complex cellular phenotyping of T cells from blood and skin. In other words, the eyes of a well-trained dermatologist were more powerful than a comprehensive translational research program in identifying complete responders to [low-dose alemtuzumab] therapy.”

They concluded, “Based on our clinical and scientific findings, we recommend the use of [low-dose alemtuzumab] with or without adjuvant skin-directed therapy in patients with diffuse cutaneous erythema, but we caution against its use in patients with preexisting plaques and/or tumors.”

Rachael A. Clark, MD, PhD, of Brigham and Women’s Hospital, is the corresponding author for the JAMA Dermatology article.

The study was supported in part by an award from the Leukemia & Lymphoma Society, grants from the National Institutes of Health, a charitable contribution from Edward P. Lawrence, Esq, and an award from the Damon Runyon Cancer Research Foundation. For full disclosures of the study authors, visit archderm.jamanetwork.com.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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