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Cutaneous T-cell Lymphoma: Overcoming Challenges and Choosing the Best Treatment

Cutaneous T cell lymphomas are types of non-Hodgkin lymphoma that arise when infection-fighting white blood cells in the lymphatic system – called lymphocytes – become malignant and affect the skin.

Lymphomas are cancers of the lymphoid system and usually arise in lymph nodes.

However, with skin being the largest lymphoid organ in the body and our first line of defense against the outside environment, occasionally it becomes the site of lymphoma formation.

Listen in as Jasmine Zain, MD talks about T cell lymphomas,along with the best prevention and treatments.

Cutaneous T-cell Lymphoma: Overcoming Challenges and Choosing the Best Treatment
Featured Speaker:
Jasmine Zain, MD
Jasmine Zain, M.D., is one of today’s most respected physicians in the treatment of hematologic malignancies. Triple-board certified in hematology, oncology and internal medicine, Dr. Zain leads a state-of-the-art program for the treatment of T cell malignancies using novel targeted therapeutic agents, immunological approaches and stem cell transplantation. She has developed a focus in the use of epigenetic strategies for the treatment of T cell and other lymphoid malignancies. Her work has contributed to the approval process for key drugs currently in use of the treatment of T cell lymphomas.
Transcription:

Melanie Cole (Host):  For people who are diagnosed with lymphoma, City of Hope is one of the biggest and most successful treatment centers in the nation. My guest today is Dr. Jasmine Zain. She’s one of today’s most respected physicians in the treatment on hematologic malignancies, and she’s triple board certified in hematology, oncology, and internal medicine at City of Hope. Welcome to the show, Dr. Zain. Tell us a little bit about what is cutaneous T-cell lymphoma. 

Dr. Jasmine Zain (Guest):  Cutaneous T-cell lymphomas are lymphomas that arise in the skin. Lymphomas are basically malignancies or cancers that arise in lymph nodes and from lymphocytes. Skin is one of our largest lymphoid organs, and these are basically diseases or cancers of lymphocytes that reside in the skin. More commonly, lymphomas arise in lymph nodes, but this particular lymphoma actually starts in the skin and usually stays in the skin. The patients usually don’t have internal organ disease. They just have skin manifestations and rashes. 

Melanie:  What are the symptoms and manifestations of cutaneous T-cell lymphoma? 

Dr. Zain:  Most of the time, the most common presentation is a skin rash that looks very much like either an eczema or sometimes psoriasis, and the distinguishing part is that it arises usually in areas of the skin that are covered usually and are not exposed to sunlight, like the trunk, parts of the body that we usually cover, unlike some of the other rashes or sunburns that may arise in sun-exposed skin. Most of the time, that’s the usual presentation. Occasionally, patients will present with a more aggressive form of the disease, where they present with tumors or ulcers on the skin. Obviously, these lesions don’t respond to the normal treatments that we use for eczema, and ultimately, the patient ends up going to a dermatologist to have that evaluated further. These rashes basically don’t go away, and they’d continue to progress. That’s the most common presentation. 

Melanie:  Are there any known risk factors for CTCL? 

Dr. Zain:  Not that we know of. We don’t really know what causes these lymphomas. The important thing for the patients is that they should know that they didn’t get it from somewhere. Most of the time, people think of skin lesions as being infected, or they feel that they can’t touch anyone because they’ll transmit it. That’s not the case with these lymphomas. We don’t know what causes them, and we can’t transmit them to anyone else. 

Melanie:  How is it diagnosed? 

Dr. Zain:  It’s usually diagnosed with a skin biopsy. As I said, most of the time, the presentation is patients will have skin rashes that don’t get better and continue to come back, and ultimately, somebody will do a biopsy and that’s going to have characteristic findings that will help us make the diagnosis. There are ways to diagnose it under the microscope and doing special tests of the skin biopsy. That’s how it’s done.

Melanie:  Dr. Zain, is this a very quick-developing type of cancer, type of lymphoma, or is it a slow developing? What happens once it’s diagnosed, and what treatments are available at City of Hope? 

Dr. Zain:  Sure. It’s one of the indolent lymphomas. It is a slow-growing disease. And usually, the diagnosis can take up to several years. Sometimes, patients have these rashes that don’t get better. Once the diagnosis is made, they’d look back and say, “Yes, I noticed that four or five years ago.” On average, it can take that long to actually come to a dermatologist who knows about this disease. Again, these are very rare diseases, so it’s not going to be the first thing on everyone’s mind. But if the rashes don’t get better over time, somebody will think about it and do a biopsy. The diagnosis can take a while, and overall, the course of the disease remains very indolent as well. For most patients who are diagnosed with this disease, it will be something they will live with. Sometimes it doesn’t affect your life expectancy. They just have these lesions that get treated and are an annoyance. As I mentioned earlier, they don’t don’t spread to the internal organs very frequently. There are cases, about 10 percent of the time, where they become more aggressive. It’s called transformation of the disease. And when that happens, you can have patients who may have internal organ involvement and have a more aggressive course. But for the most part, it’s a very indolent course, and the treatments vary with the type of lesions you have. Most of the time, in the initial stages, these are treated with skin-directed treatments. You don’t need chemotherapy. That’s the most important message I want to give to our listeners, that you don’t need chemotherapy in the initial stages. You can treat it with topical treatments, like topical chemotherapy, or you can treat them with light therapy. There are other medicines, like retinoids that are vitamin A derivatives. They can use them, again, topically as an ointment, or even as a pill form. You don’t really need chemotherapy given through the IV till very late stages of the disease. So, most people don’t require it. 

Melanie:  What about creams and ointments? Do you use that as the skin around it get dry? Is there any itching with that rash? 

Dr. Zain:  There is a lot of itching with the rash, and that’s really the most difficult symptoms sometimes to treat. We recommend a lot of different skin care methods for patients. We tell them to keep the skin moist and hydrated. Patients who have scaly rashes, we recommend that they take baths with things like chlorhexidine to try to help release the scales from the skin. Whirlpool therapy has been used, again, with patients who have extensive lesions on their body. There are many skin-directed treatments that can be used in the treatment of this disease, and that’s why it is very important to entail the help of a dermatologist in taking care of these patients. It’s best taken care of when there is collaboration between dermatology and oncology, where you can have skin-directed care and skin-directed therapy being suggested or managed by the dermatologist and the oncologist at the same time. At City of Hope, we are planning to have a multidisciplinary clinic for cutaneous T-cell lymphomas, probably starting within the next four to six weeks because we are having a well-renowned dermatologist join our group as well who is an expert in CTCL. When she arrives in November 1—I believe it’s her start date—we are going to have excellent care options at City of Hope for our patients. 

Melanie:  Tell us about new advances or what’s new in CTCL research. What’s on the horizon for it? 

Dr. Zain:  Sure. CTCL has been one of those diseases where we had nothing for several years. We had the standard treatments in light therapy. And then, over the last five to six years, there have been multiple advances. There have been at least two new medications approved for the treatment of CTCL, and we participated in those trials that led to these approvals. One of them is something called vorinostat. It’s an oral pill agent. It’s not chemotherapy. It’s a biologic agent. Then there is another drug called romidepsin, which has been approved for the treatment of CTCL. Again, it’s a non-chemotherapy agent. Patients could tolerate it very well. It’s given intravenously, though. Then, there are many new drugs. There is an agent called Adcetris. It’s an antibody directed to CD30 expressed from some of these cells, and that’s also currently in clinical trials for the treatment of CTCL, and the results are very positive. At City of Hope, we are looking at ways to treat these agents with immunotherapy by modifying our immune system to attack the cancer cells using specific T-cells that would be designed to attack the cancer cell. They are called CAR T-cells, and currently, CAR T-cells are in clinical trials for B-cell malignancies. But T-cell malignancies is the next thing, and City of Hope is the pioneer in this area. We have scientists at City of Hope that are looking at mechanistic pathways that go wrong in patients who have cutaneous T-cell lymphoma so we can target those pathways and provide the drug or the agent that can correct that genetic pathway. Dr. John Chen is one of the leading pioneers, molecular biologists/pathologists at City of Hope who are looking into that, and we’re planning clinical trials with novel agents that will target these pathways. And we have several of those that are currently in the planning stages. We hope to have some very exciting, new, targeted agents that can be used in these patients, particularly those patients with advanced disease, and these will hopefully have fewer side effects, and we can avoid chemotherapy in these patients completely. That’s our goal. 

Melanie:  Dr. Zain, in just the last minute, why should people come to City of Hope for their T-cell cutaneous lymphoma care? 

Dr. Zain:  One of the reasons is going to be, as I mentioned, the multidisciplinary cutaneous T-cell lymphoma approach. We have world-renowned experts in dermatology and pathology who are going to be a part of this team. We are going to have a team approach to the treatment of these patients. They will get excellent advice and care about their skin as well as systemic treatments that need to be given either by mouth or intravenously to treat the extensive disease. We have innovative research going on here, so they will have access to new clinical trials that are not available at other places. As I mentioned, one of the problems is that there is delay in diagnosis because people don’t think about it or don’t think about this diagnosis. This is the place to be because we have pathologists who are experts in this condition, and they can really just confirm the diagnosis. Even the subtype, they may have within a very short period of time. I think the patients can get an excellent care, and if distance is an issue, we can work with their local dermatologist and local oncologist to advise them about how to proceed with these patients and their care as well. So, I think the multidisciplinary approach and the availability of new, innovative treatments are the two things that will make City of Hope unique. 

Melanie:  Thank you so much. Great information. You’re listening to City of Hope Radio. For more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.