Therapies

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TREATMENT

The Center of Excellence for Cutaneous Lymphoma focuses its goal on achieving a treatment plan for each patient that causes a rapid remission of the disease (chemotherapy, TSEB) and to maintain the patient in a stable condition for a long time.

The Special Dermatology Lymphoma Clinic can provide the following specialized treatments to patients with rare cutaneous lymphomas:

Phototherapy

  • UVB Narrow Band Therapies: These types of treatments are used to treat fine lesions (patches and / or thin plaques) and are similar to PUVA (psoralen plus UVA) except that UVB rays do not penetrate the skin as deep as UVA rays and are used without a photosensitizer.
  • PUVA (psoralen plus UVA): This type of cancer treatment uses a psoralen skin sensitizer (taken by mouth) and exposure to ultraviolet (UV) light to kill cancer cells. Treatment is usually given two to three times a week for a few months and less often thereafter. Maintenance treatment is usually continued for one or more years.
  • Radiation (local and entire surface of the skin)
  • Electromagnetic radiation-conventional radiation: the treatment penetrates the skin and reaches the areas inside the body. Electron beam therapy can be applied to the entire surface of the skin or to a local area, without affecting the internal organs. The radiation dose can be reduced to reduce side effects whether the patient is receiving topical or total electron beam skin treatment. Topical radiotherapy is useful for patients who have localized skin tumors or those who have had a poor response to treatment. Tumors often heal after treatment and dead tissue resolves, reducing the risk of infection. Total skin electron beam therapy is suitable for patients with extensive thick plaques with or without skin tumors. Some patients appear to have worsening skin tumors after this type of treatment. Radiation therapy, local or whole skin, is effective at low doses in MF / SS, so it is important that higher doses are avoided. Radiation therapy can be used alone, in combination or sequentially with other skin or systemic treatments. As with phototherapy, radiation increases the risk of skin damage and the risks and benefits in patients with extensive photopathology and a history of multiple UV-related skin cancers should be discussed.

The local treatment

Topical corticosteroids: This type of medication is used to relieve red, swollen and inflamed skin. It also has anti-proliferative activity (it can stop the growth or proliferation of new cells or tissues) and can kill cancer T cells in CTCL. Topical corticosteroids may be prescribed in cream, lotion, foam, gel or ointment. Long-term use of topical corticosteroids can have adverse effects such as skin atrophy. This risk increases with the potential of each topical corticosteroid.

Topical chemotherapy: Nitrogen mustard (mechloroethamine HCl, Valchlor gel®) is an FDA approved drug for the topical treatment of stage IA and IB dermal T-cell mycosis fungoides in patients who have received prior skin therapy. Carmustine (BCNU) is another drug for CTCL therapy. Both agents can be administered as a composite ointment. These ointments are applied daily either to affected areas of the skin or to all skin surfaces. Sometimes, these topical medications can cause skin irritation or an allergic reaction. Thus, a patient must be especially careful when applying the ointments to sensitive areas of the skin such as the face or facial folds. NEVER apply ointments on the skin of the genitals.

Retinoids-topical retinoids: This category includes bexarotene (Targretin®) and tazarotene (Avage®, Tazorac®), which are vitamin A-related drugs. They work by causing cancer cells to die faster and boost immune system reactions. Bexarotene is available as a gel applied to the skin (gel formulation) and as a systemic oral treatment. Topical retinoids often cause skin irritation.

Systematic treatment (affecting the whole body)

  • Biological or immunological therapies: These are milder forms of systemic therapies that aim to encourage cancer cells to die faster (facilitate apoptosis) or to strengthen the patient’s immune system to fight cancer cells. Examples include oral retinoids such as bexarotene (Targretin®), interferons, extracorporeal photopheresis (ECP) and targeted antibody therapies. The side effects of these biological therapies are generally reversible and easily manageable. The profile of side effects depends on the specific factor.
  • Oral bexarotene is FDA approved for CTCL when at least one previous systemic treatment has not worked.
  • Interferon a
  • Extracorporeal photopheresis (ECP) is an FDA approved treatment for CTCL and is only available at selected centers that offer this treatment. In this procedure, blood is removed through the patient’s vein. White blood cells, which include circulating CTCL cells, are isolated and treated with a liquid form of psoralen, which sensitizes the cells to UVA light. UVA rays irradiate cells, and this, along with the drug, damages the DNA of CTCL cells. The cells then return to the patient through a vein. The process damages cancer T cells and helps the body’s immune response. This process must be repeated several times to achieve the full result. ECP is most effective in patients with blood involvement such as SS.
  • Chemotherapy: Conventional chemotherapy kills cancer cells that are rapidly multiplying. These treatments can also affect healthy multiplying cells, so careful monitoring of blood counts and other laboratory test results is required. Chemotherapy can be given as a single agent or in combination with multiple agents. Conventional chemotherapy is not able to cure advanced cutaneous lymphoma and studies using chemotherapy in combination with radiation therapy in patients with early stages of the disease have not been very successful. Thus, chemotherapy in patients with early stages of the disease should be avoided. However, single-agent chemotherapies have been selected that have been shown to benefit patients with highly aggressive disease (particularly large cell transformation) or patients whose disease does not respond to milder systemic treatments.

Some effective systemic chemotherapy for patients with aggressive skin disease and / or involvement of the lymph nodes or other organs or for those with SS is as follows:

  • Methotrexate agents, which are involved in the growth of tumor cells
  • Gemcitabine (Gemzar®), pentostatin (Nipent®): are purine analogues that interfere with tumor growth.
  • Liposomal doxorubicin (Doxil®): a DNA-binding chemotherapy.
  • Chlorambucil (Leukeran®), cyclophosphamide (Cytoxan®): alkylating agents, which inhibit the growth of cancer cells.
  • Etoposide (VP-16, VePesid®, Etopophos®), temozolomide (Temodar®) -antineoplastic, which interferes with the growth of cancer cells

Targeted therapies

They target a specific – molecule in the cancer cell that kills the cancer cells and  not the healthy cells.