Progression Of Mycosis Fungoides Research Articles

Preliminary Analysis Demonstrates Durvalumab (Anti-PD-L1) & Lenalidomide Is Superior to Single-Agent Durvalumab (anti-PD-L1) in Refractory/Advanced Cutaneous T Cell Lymphoma in a Randomized Phase 2 Trial

Introduction: Mycosis fungoides (MF) and the leukemic variant Sézary syndrome (SS), commonly referred to as cutaneous T cell lymphoma (CTCL), are characterized by clonal expansion of malignant T cells in the skin within a background of chronic inflammation. Advanced stages have an unfavorable prognosis. The skin microenvironment plays an important role in the development and progression of MF and SS. We have shown that the malignant T cells escape immune surveillance via immune checkpoint signaling such as the PD-1/PD-L1 axis. In our phase I dose-escalating study anti-PD-L1 (durvalumab) & lenalidomide demonstrated a tolerable safety profile with significant clinical activity in refractory/advanced CTCL. We initiated the randomized Phase 2 portion to compare single agent durvalumab to durvalumab combined with lenalidomide in relapsed/advanced CTCL (NCT03011814). The primary end point was objective response rate (ORR) using the global composite response (based on skin, blood, nodes, and viscera) according to consensus guidelines. Secondary end points included duration of response, progression-free survival, and toxicity. Relationships between gene expression profile, tumor-microenvironment, and antitumor activity were exploratory end points. Methods:Adult patients with histologically confirmed MF or SS, who had failed ≥2 systemic therapies were enrolled and randomized 1:1 to single agent durvalumab (1500 mg (day 1 of 28-day cycle) or durvalumab (same dose) & lenalidomide (10 mg for cycle 1, 15 mg for cycle 2, then 20 mg for subsequent cycles daily for 21 days of each 28-day cycle). The study used a “pick a winner” design based on ORR. Serial skin and blood samples were collected to assess the impact on the tumor microenvironment (TME) and anti-tumor activity. Results:A total of 23 patients were randomized and had the following characteristics (11 durvalumab vs 12 durvalumab/lenalidomide): median age 57 yrs (35-79) vs 63 yrs (32-88); stage IB, 2 (18%) vs 4 (33%); stage IIB, 4 (36%) vs 3 (25%); stage III/IV, 5 (45%) vs 5 (42%); MF, 8 (73%) vs 8 (67%); e-MF/SS, 4 (36%) vs 2 (17%); large cell transformation 3 (27%) vs 5 (42%). The median number of prior systemic treatments for both single and combo arm was 3. Global best ORR was 58% for durvalumab/ lenalidomide vs 36% for durvalumab alone.Median follow up time was 7.9 (range, 0.9-27.6) months. Analysis is ongoing. One patient died one month after discontinuation from study due to PD. No serious AEs were observed. The most common treatment-emergent adverse events (shown below for combo arm) were more frequent in the durvalumab/lenalidomide arm vs durvalumab arm and included fatigue (n=9), diarrhea (n=4), decreased platelets (n=4), leg edema (n=3), constipation (n=3), hyperglycemia (n=3), anemia (n=3), and leukopenia & neutropenia (n=3). The majority of AEs with both treatment arms were mild to moderate in severity (grade I/II, 91%; grade III, 8 %). No grade IV event except 1 neutropenia on combo arm was observed. Median cycles of treatment were 4 (range, 1-12) and 5 (range 1-7) for single and combo arms.) Five pts remain on treatment on single agent durvalumab vs 3 pts on combo arm. Molecular profiling using CIBERSORT and single cell analysis revealed distinct changes of immune cell signatures and cellular signaling interactions within the TME that occurred in each treatment arm when compared to baseline. Conclusions: This randomized phase 2 trial of durvalumab (anti-PD-L1) +/- lenalidomide evaluating anti-tumor activity demonstrated superior clinical activity of combinatorial durvalumab/lenalidomide vs single-agent durvalumab in refractory/advanced CTCL. Responses were durable and ongoing, and treatment was well tolerated. Our correlative results from sequential skin biopsies demonstrated immune signatures for enhanced anti-tumor responses on skin biopsies at baseline may be predictive of response to checkpoint blockade and yield insights into mechanisms of therapeutic resistance.

O-132 - Utility of T-cell immunosequencing in distinguishing mycosis fungoides progression from treatment related cutaneous adverse events

O-132 - Utility of T-cell immunosequencing in distinguishing mycosis fungoides progression from treatment related cutaneous adverse events

A Microenvironment-Related Nine-Gene Signature May Predict Survival in Mycosis Fungoides Patients at Diagnosis.

Mycosis fungoides (MF) is the most common cutaneous lymphoma characterized by an indolent course. Prognosis is stage-based but this approach does not reflect the different outcomes within stages. Considering that tumor microenvironment is known to be involved in MF pathogenesis and progression, we decided to investigate 99 MF cases by using the PanCancer Immune Profiling Panel. We identified and validated a signature of 9 genes able to predict MF survival and distinguish a high-risk group with a worse outcome from a low-risk group of cases with a better outcome. At the molecular level, low-risk vs. high-risk cases reported a global upregulation of immune genes, enriched in cytokines, and a higher density of dendritic cells and mast cells, possibly associated with a more favorable clinical course.

Dupilumab-associated mycosis fungoides: a cross-sectional study.

Treating atopic dermatitis (AD) with dupilumab, a monoclonal antibody that inhibits interleukin-4 (IL-4) and interleukin-13 (IL-13), may be associated with the progression of mycosis fungoides (MF).This study aimsto examine the associations between the length of dupilumab treatment, age and sex, and the onset of MF.An institutional data registry and literature search were used for a retrospective cross-sectional study. Only patients with a diagnosis of MF on dupilumab for the treatment of AD and eczematous dermatitis were included.The primary outcome was the length of dupilumab exposure, age, sex, and the onset of MF. Linear correlations (Pearson) and Cox regression analysis were used to assess the correlation and the risk.A total of 25 patients were included in this study. Five eligible patients were identified at our institution. In addition, a PubMed review identified an additional 20 patients. At the time of MF diagnosis, the median age was 58, with 42% female. Disease history was significant for adult-onset AD in most patients (n = 17, 65.4%) or recent flare of AD previously in remission (n = 3, 11.5%). All patients were diagnosed with MF, and one patient progressed to Sézary syndrome while on dupilumab, with an average duration of 13.5months of therapy prior to diagnosis. Tumor stage at diagnosis of MF was described in 19 of the cases and ranged from an early-stage disease (IA) to advanced disease (IV). Treatment strategies included narrow-band UVB therapy, topical corticosteroids, brentuximab, pralatrexate, and acitretin. Male gender, advanced-stage disease, and older age correlated significantly with the hazard of MF onset and a shorter time to onset during dupilumab treatment.Our results suggest a correlation between the duration of dupilumab treatment and the diagnosis of MF, the higher MF stage at diagnosis, and the shorter the duration of using dupilumab to MF onset. Furthermore, elderly male patients appeared to be more at risk as both male gender and older age correlated with a hazard of MF diagnosis. The results raise the question as to whether the patients had MF misdiagnosed as AD that was unmasked by dupilumab or if MF truly is an adverse effect of treatment with dupilumab. Close monitoring of these patients and further investigation of the relationship between dupilumab and MF can shed more light on this question .

Cell adhesion molecule 1 expression in mycosis fungoides versus parapsoriasis versus inflammatory dermatosis: an immunohistochemical comparative study.

Cell adhesion molecule 1 (CADM1) is one of the immunoglobulin super family adhesion molecules, that is proposed to contribute in the pathogenesis of various types of cutaneous T-cell lymphoma, including mycosis fungoides (MF). In this work, we decided to examine the immunohistochemical expression of CADM1 in MF specimens compared to premycotic parapsoriasis, benign inflammatory dermatosis and normal control skin specimens. 125 participants were enrolled (50 MF, 25 parapsoriasis, 25 inflammatory dermatosis, and 25 healthy controls). Patients were selected from the Outpatient Clinic of Dermatology and Venereology Department, Tanta University Hospitals. From all, 4mm punch skin biopsies were taken and examined for CADM1 immunohistochemical expression. The current study revealed statistically significant upregulation of CADM1 expression in MF specimens in comparison to parapsoriasis, inflammatory dermatosis, and normal control specimens. Additionally, there was statistically significant positive correlation between CADM1 expression and progression of TNMB staging of MF disease. Therefore, it is possible to recommend CADM1 as a beneficial diagnostic immunohistochemical marker for differentiation between early stages of MF and both the premycotic parapsoriasis and benign inflammatory dermatosis. Moreover, it may be of value in early detection of neoplastic transformation of parapsoriasis as well as in assessment of MF progression.

Tape stripped stratum corneum samples are suitable for diagnosis and comprehensive proteomic investigation in mycosis fungoides.

Mycosis Fungoides (MF) is a common cutaneous T-cell lymphoma. It can sometimes be challenging to diagnose MF using current clinico-histopathological criteria. Non-invasive molecular profiling analysis has the potential to aid the diagnosis and understanding of MF. Lesional and body site matched normal stratum corneum samples were obtained from the same MF patients (n=28) using adhesive discs, followed by proteomic analyses using data-independent acquisition mass spectrometry (DIA-MS). Differential abundance analyses and bioinformatic analyses were performed to identify differentially abundant proteins and altered biofunctions between the MF and normal stratum corneum samples. In total, 1303 proteins were identified, of which 290 proteins were significantly changed in the MF cohort compared to the normal stratum corneum. Ingenuity pathway analysis (IPA) predicted the significant inhibition of cell death of cancer cells and significant activation of immune-related activities and viral infection in the MF lesions. MF lesions were also associated with upstream regulators relating to immuno-oncologic dysfunctions. The top-250 variating proteins efficiently separated normal stratum corneum from matched MF samples. Non-invasive proteomic analysis could transform the diagnosis of MF by reducing the need for invasive biopsy. The identification of altered biological functions may serve as useful biomarkers to predict MF progression.

The Transcription Factor Twist1 Has a Significant Role in Mycosis Fungoides (MF) Cell Biology: An RNA Sequencing Study of 40 MF Cases.

The purpose of this RNA sequencing study was to investigate the biological mechanism underlying how the transcription factors (TFs) Twist1 and Zeb1 influence the prognosis of mycosis fungoides (MF). We used laser-captured microdissection to dissect malignant T-cells obtained from 40 skin biopsies from 40 MF patients with stage I-IV disease. Immunohistochemistry (IHC) was used to determinate the protein expression levels of Twist1 and Zeb1. Based on RNA sequencing, principal component analysis (PCA), differential expression (DE) analysis, ingenuity pathway analysis (IPA), and hub gene analysis were performed between the high and low Twist1 IHC expression cases. The DNA from 28 samples was used to analyze the TWIST1 promoter methylation level. In the PCA, Twist1 IHC expression seemed to classify cases into different groups. The DE analysis yielded 321 significant genes. In the IPA, 228 significant upstream regulators and 177 significant master regulators/causal networks were identified. In the hub gene analysis, 28 hub genes were found. The methylation level of TWIST1 promoter regions did not correlate with Twist1 protein expression. Zeb1 protein expression did not show any major correlation with global RNA expression in the PCA. Many of the observed genes and pathways associated with high Twist1 expression are known to be involved in immunoregulation, lymphocyte differentiation, and aggressive tumor biology. In conclusion, Twist1 might be an important regulator in the disease progression of MF.

Progression of Mycosis Fungoides After Fingolimod Treatment for Multiple Sclerosis and Targeted Next-Generation Sequencing Demonstrating Potential Links Between the Two Diseases.

Article Tools CASE REPORTS Article Tools OPTIONS & TOOLS Export Citation Track Citation Add To Favorites Rights & Permissions COMPANION ARTICLES No companion articles ARTICLE CITATION DOI: 10.1200/PO.22.00501 JCO Precision Oncology no. 7 (2023) e2200501. Published online February 1, 2023. PMID: 36724412 Progression of Mycosis Fungoides After Fingolimod Treatment for Multiple Sclerosis and Targeted Next-Generation Sequencing Demonstrating Potential Links Between the Two Diseases Saisindhu Narala , MD, MAS1,2xSaisindhu NaralaSearch for articles by this author; Yonglu Che, MD, PhD2xYonglu CheSearch for articles by this author; Atif Saleem , DO1xAtif SaleemSearch for articles by this author; Christopher B. Lock , MBBS, PhD3xChristopher B. LockSearch for articles by this author; Youn H. Kim , MD2xYoun H. KimSearch for articles by this author; and Kerri E. Rieger , MD, PhD1,2xKerri E. RiegerSearch for articles by this author Show More 1Department of Pathology, Stanford University School of Medicine, Stanford, CA2Department of Dermatology, Stanford University School of Medicine, Stanford, CA3Division of Neuroimmunology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA https://doi.org/10.1200/PO.22.00501 First Page Full Text PDF Figures and Tables © 2023 by American Society of Clinical OncologySUPPORTSupported in part by the Haas Family Foundation (Y.H.K.).AUTHOR CONTRIBUTIONSConception and design: Saisindhu Narala, Youn H. Kim, Kerri E. RiegerProvision of study materials or patients: Youn H. KimCollection and assembly of data: Saisindhu Narala, Yonglu Che, Atif Saleem, Christopher B. Lock, Youn H. Kim, Kerri E. RiegerData analysis and interpretation: Saisindhu Narala, Yonglu Che, Youn H. Kim, Kerri E. RiegerManuscript writing: All authorsFinal approval of manuscript: All authorsAccountable for all aspects of the work: All authorsAUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTERESTThe following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/po/author-center.Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).Christopher B. LockEmployment: NeoTxStock and Other Ownership Interests: NeoTXHonoraria: TG TherapeuticsConsulting or Advisory Role: TG Therapeutics, Diagnose EarlySpeakers' Bureau: Bristol-Myers Squibb/MedarexTravel, Accommodations, Expenses: GenentechYoun H. KimConsulting or Advisory Role: Kyowa Hakko Kirin, Innate Pharma, Corvus Pharmaceuticals, Galderma, Crispr TherapeuticsResearch Funding: Eisai (Inst), Kyowa Hakko Kirin (Inst), Innate Pharma (Inst), Elorac Pharmaceuticals (Inst), Crispr Therapeutics (Inst), Corvus Pharmaceuticals (Inst)Patents, Royalties, Other Intellectual Property: Royalty for Chapters in UpToDateTravel, Accommodations, Expenses: Innate PharmaKerri E. RiegerConsulting or Advisory Role: Kyowa Kirin International, PfizerNo other potential conflicts of interest were reported.

Immunohistochemical research of CADM 1 in mycosis fungoides

Background: Mycosis fungoides (MF) is the most prevalent form of cutaneous lymphoma, characterised by clonal proliferation of atypical CD4+ T-lymphocytes.Objectives: The goal of this research is to investigate CADM1 antibody expression in skin lesions of MFby immunohistochemistry, to throw a light on its possible role in etiology and worsening of this type of cutaneous lymphoma.Patients and methods: This research was carried out on 20 cases with various stages of mycosis fungoides, specimens were selected from the Outpatient Clinic of Dermatology and Venereology Department, Tanta University Hospitals. 4mm punch skin biopsies were taken and were examined by H&E and CADM1 antibodies.Results: There was statistically significant upregulation of CADM1 expression in MF specimens with statically significant positive correlation between CADM1 expression and progression of mycosis fungoides.Conclusion: CADM1 may be useful as a potential diagnostic marker for mycosis fungoides. Moreover, CADM1 may be of value in assessment of mycosis fungoides progression.

Abstract A40: Evaluation of the tumor microenvironment in mycosis fungoides using the PanCancer IO 360™ assay and nCounter® platform

Abstract BACKGROUND: Alterations in the tumor microenvironment (TME) can result in a “T-cell inflamed” TME, which is characterized by activation of the PD1/PD-L1 pathway, immunosuppression, and production of anergic, “exhausted” CD8(+)-T-cells. Similar alterations in the TME of Mycosis Fungoides (MF) have been linked to disease progression. However, the relationship between progression and the TME in MF remains incompletely understood. We aimed to further study the TME in MF using the PanCancer IO 360™ 750-gene expression panel and nCounter® platform (Nanostring; Seattle, WA). DESIGN: Clinical and laboratory data from the electronic medical record were reviewed in combination with microscopic review of biopsies from 27 patients to confirm diagnosis of MF and assign samples as “low-grade” (patch/plaque; n=8) or “high-grade” (tumor/large cell transformation, n=19). Patients were also classified as having “limited stage” (TNMB1 <1B, n=8) or “advanced stage” (TNMB1 >1B, n=19) disease. All patients received prior, heterogenous treatment, but no patients received prior anti-PD1 therapy. RNA was extracted from formalin-fixed, paraffin-embedded (FFPE), punch biopsy sections and analyzed per manufacturer’s instructions. Gene expression scores (log2) and a “tissue inflammation score” (TIS) were calculated for each sample. A TIS of >5 has been associated with the presence of a “T-cell inflamed” microenvironment. Samples scores were compared by histologic group and disease stage as described above. RESULTS: Twenty-nine of 30 samples had sufficient RNA integrity for analysis. TIS was >5 in 26/30 samples (median, 7.6; range, 4.3-9.3). No significant differences in TIS were identified between low-grade/limited-stage and high-grade/advanced-stage samples. High-grade samples had significantly increased expression of PD1 and higher amounts of exhausted CD8(+)-cells than low-grade samples (p= 0.015, 0.027). Low-grade samples showed significantly higher expression of ARG1, B7-H3, and genes associated with tissue hypoxia. Expression of genes associated with tumor proliferation was higher in high-grade lesions (p= 0.0019). Limited stage samples showed higher levels of endothelial cells, mast cells, and T-regulatory cells (p=0.033, 0.024, 0.004,) than advanced stage samples. Proliferation, PD1, and exhausted CD8 scores trended higher in advanced stage disease but did not reach statistical significance. CONCLUSION: Our findings indicate that the IO 360™ panel provides comprehensive analysis of the TME in MF. Most samples showed a TIS of >5, suggesting a T-cell inflamed TME in MF. Increased PD1 and exhausted CD8(+) cells were found in high-grade lesions, supporting a role for this pathway in progression. Increased expression of factors associated with angiogenesis (endothelial cells, ARG1) and immunosuppression (B7-H3, tissue hypoxia, mast cells, T-regulatory cells) suggest these mechanisms may play a role in early stages of disease. These findings highlight the complex and dynamic nature of the TME during MF progression, and the need for further study. Citation Format: Stanton Miller, Akshat Patel, Kiran A Kumar, Farrukh Awan, Heather W Goff, Travis Vandergriff, Marisa Juntilla, Franklin Fuda, Weina Chen, Jesse M Jaso. Evaluation of the tumor microenvironment in mycosis fungoides using the PanCancer IO 360™ assay and nCounter® platform [abstract]. In: Proceedings of the Third AACR International Meeting: Advances in Malignant Lymphoma: Maximizing the Basic-Translational Interface for Clinical Application; 2022 Jun 23-26; Boston, MA. Philadelphia (PA): AACR; Blood Cancer Discov 2022;3(5_Suppl):Abstract nr A40.

The role of NLRP1 and NLRP3 inflammasomes in the etiopathogeneses of pityriasis lichenoides chronica and mycosis fungoides: an immunohistochemical study.

Mycosis fungoides (MF) is the most common subtype of primary cutaneous T cell lymphomas, whereas pityriasis lichenoides chronica (PLC) is a chronic inflammatory skin disorder. The inflammasome is a part of the natural immune system which has a multimeric structure consisting of the receptor, adaptor and effector protein that show specificity for various ligands or activators. After the activation of the inflammasome complex, caspase 1 becomes activated which subsequently triggers interleukin-18 (IL-18) and interleukin-1β (IL-1β) production. In our study we aimed to examine the roles of nucleotide-binding oligomerization domain-like receptor containing pyrin domain 1 (NLRP1) and nucleotide-binding oligomerization domain-like receptor containing pyrin domain (NLRP3) inflammasomes in the etiopathogeneses of PLC and MF. NLRP1, NLRP3, caspase 1, IL-18 and IL-1β levels were examined and compared immunohistochemically in the skin biopsies belonging to 16 control patients; 16 PLC cases, 12 cases with stage 1 MF and 12 cases with other stages of MF (stage 2-4). In the paired comparisons of NLRP1, stage 2-4 MF group and PLC group were shown to have increased levels of NLRP1 expression compared to the control group. IL-1β was also expressed at statistically significantly higher levels in each of the stage 1 MF, stage 2-4 MF and PLC groups compared to the control group. In the paired comparisons of caspase 1 and IL-18, it was found that stage 1 MF, stage 2-4 MF and PLC groups had increased levels of expression compared to the control group. Our findings suggest that the NLRP1 inflammasome pathway might play a role in the etiopathogenesis and progression of PLC and MF.

MicroRNAs and their signaling pathway in mycosis fungoides.

Background:Oncogenic microRNAs, a kind of stable epigenetic inhibitors, often deregulated in Mycosis fungoides (MF) which affect the skin and tend to transform and spread.Results:Previous studies investigating the de-expression of microRNA in MF patients skin biopsies identified that they were not only regulated by signaling pathway, but also regulated other signaling pathway. Furthermore, studies have elucidated the molecular mechanisms of the STAT signaling pathway that can promote a great diversity of miRNA expression via cytokine binding receptors, activating Janus kinase-3 and STAT proteins. But some non-STAT signaling pathway with mircoRNA de-expression in MF was incomplete.Conclusion:Taken together, these studies demonstrate that microRNA may be used as the prognosis, progression and diagnose of MF, as they can not only control MF cell proliferation, but also induce MF cell apoptosis.

Mycosis fungoides in pediatric population: comprehensive review on epidemiology, clinical presentation, and management.

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma. However, it is rare in pediatric population. Most of the cases of pediatric MF present with hypopigmented patches and/or various other forms, which may often mimic common childhood dermatoses, thereby causing a delay in the diagnosis. There are no established treatment guidelines for pediatric MF. As the progression of childhood MF is extremely rare and it has an indolent course, it is usually diagnosed at an early stage (IA, IB, IIA), and hence phototherapy with a response rate of >80% is a well-established effective treatment in children. However, as recurrences are frequently seen on stopping the therapies, a maintenance regimen and long-term follow-up is equally important. This article reviews the epidemiological factors, clinical presentations, diagnosis, and various treatment modalities used in pediatric MF. We analyzed and compared the data of almost 616 childhood MF cases from various studies undertaken from 1988 to 2021.

The use of interferon-α2a as monotherapy in stage IB patients with mycosis fungoides: A retrospective chart review of patient outcomes.

The aim of this study was to evaluate the response to IFN-α2a treatment as monotherapy in stage IB patients with mycosis fungoides (MF) in second-line therapy. Twenty-five patients with recurrent or persistent MF were included in the study. The diagnosis of MF was established according to clinical and histopathological signs. Clinical staging was made using TNMB classification. IFN-α2a as monotherapy was used as treatment. IFN-α2a was administered at a dose of 3 x 106 units thrice a week subcutaneously as initially described. According to clinical tolerance, the dose was increased every 4 weeks to 6 - 9 x 106 units. IFN-α2a was used more frequently for at least 3months after complete remission. Treatment success was evaluated with Clinical Response (disappearance of all clinical evidence= Complete Remission [CR], ≥50% decrease in extent or severity=Partial Remission [PR], unresponsiveness to treatment=Stable Disease [SD], progression of MF = Progressive Disease [PD]). The average age was 51.3± 9.1. CR and PR were achieved in 11 (44%) and 12 (48%) patients, respectively. PD was observed in two (8%) patients. CR was accomplished at 16.1± 9.8 weeks. Recurrences were mostly observed within 1year (10.4± 7.7months). The recurrence rate was 45.4%. The mean duration of CR was 33.3± 7.9months. Side effects were seen in 36% of the patients (18.2% in CR). The most common side effect was fatigue (12%). The patients received 11 different types of treatment before IFN-α2a treatment. The most frequent therapy prior to IFN-α2a treatment was narrow-band ultraviolet-B (NB-UVB) phototherapy (15 [60%] patients). CR can be achieved in a relatively short period of time in patients receiving IFN-α2a in MF. The duration of CR is reasonable. The side effects of IFN-α2a are acceptable. Therefore, IFN-α2a as monotherapy is a good option in stage IB second-line MF therapy.

Clinical Response to Anti-CD47 Immunotherapy Is Associated with Rapid Reduction of Exhausted Bystander CD4+ BTLA+ T Cells in Tumor Microenvironment of Mycosis Fungoides.

Simple SummaryThe identification of the events that accompany cancer progression is essential for developing new therapies. We have used mycosis fungoides, the most common type of cutaneous lymphoma, as a model for our study. We have shown that cancer progression is accompanied by the expansion of exhausted immune cells around malignant cells. Those exhausted cells prevent immune activation, blocking cancer clearance by the immune system. Furthermore, we have demonstrated that novel anti-CD47 immunotherapy with mycosis fungoides leads to the reduction of exhausted T cells accompanied by the expansion of NK and CD8+ T cells. These therapeutic benefits of CD47 blockade were further facilitated by interferon-α, which stimulates cytotoxic cells. Thus, we showed that CD47 might serve as an effective therapeutic target in treating mycosis fungoides.Cancer progression in mycosis fungoides, the most common form of cutaneous T-cell lymphoma, occurs in a predictable, sequential pattern that starts from patches and that evolves to plaques and later to tumors. Therefore, unlocking the relationship between the microarchitecture of mycosis fungoides and the clinical counterparts of that microstructure represents important steps for the design of targeted therapies. Using multispectral fluorescent imaging, we show that the progression of mycosis fungoides from plaque to tumor parallels the cutaneous expansion of the malignant CD4+ T cells that express TOX. The density of exhausted BTLA+ CD4+ T cells around malignant CD4+TOX+ cells was higher in tumors than it was in plaques, suggesting that undesired safeguards are in place within the tumor microenvironment that prevent immune activation and subsequent cancer eradication. Overriding the CD47 checkpoint with an intralesional SIRPαFc fusion decoy receptor induced the resolution of mycosis fungoides in patients that paralleled an amplified expansion of NK and CD8+ T cells in addition to a reduction of the exhausted BTLA+ CD4+ T cells that were engaged in promiscuous intercellular interactions. These therapeutic benefits of the CD47 blockade were further unleashed by adjuvant interferon-α, which stimulates cytotoxic cells, underscoring the importance of an inflamed microenvironment in facilitating the response to immunotherapy. Collectively, these findings support CD47 as a therapeutic target in treating mycosis fungoides and demonstrate a synergistic role of interferon-α in exploiting these clinical benefits.

Transcriptomic changes during stage progression of mycosis fungoides: from translational analyses to their potential clinical implications.

Linked Article: Xiao et al. Br J Dermatol 2022; 186:520–531.

Transcriptomic changes during stage progression of mycosis fungoides.

Mycosis fungoides (MF) is the most common cutaneous T-cell lymphoma, which in the early patch/plaque stages runs an indolent course. However, ~25% of patients with MF develop skin tumours, a hallmark of progression to the advanced stage, which is associated with high mortality. The mechanisms involved in stage progression are poorly elucidated. We sought to address the hypothesis of MF cell trafficking between skin lesions by comparing transcriptomic profiles of skin samples in different clinical stages of MF. We performed whole-transcriptome and whole-exome sequencing of malignant MF cells from skin biopsies obtained by laser-capture microdissection. We compared three types of MF lesions: early-stage plaques (ESP, n=12) as well as plaques and tumours from patients in late-stage disease [late-stage plaques (LSP, n=10) and tumours (TMR, n=15)]. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were used to determine pathway changes specific for different lesions which were linked to the recurrent somatic mutations overrepresented in MF tumours. The key upregulated pathways during stage progression were those related to cell proliferation and survival (MEK/ERK, Akt-mTOR), T helper cell (Th)2/Th9 signalling [interleukin (IL)4, STAT3, STAT5, STAT6], meiomitosis (CT45A1, CT45A3, STAG3, GTSF1, REC8) and DNA repair (PARP1, MYCN, OGG1). Principal coordinate clustering of the transcriptome revealed extensive gene expression differences between early (ESP) and advanced-stage lesions (LSP and TMR). LSP and TMR showed remarkable similarities at the level of the transcriptome, which we interpreted as evidence of cell percolation between lesions via haematogenous self-seeding. Stage progression in MF is associated with Th2/Th9 polarization of malignant cells, activation of proliferation, survival, as well as increased genomic instability. Global transcriptomic changes in multiple lesions may be caused by haematogenous cell percolation between discrete skin lesions.

Gene Expression Profiling of Mycosis Fungoides in Early and Tumor Stage-A Proof-of-Concept Study Using Laser Capture/Single Cell Microdissection and NanoString Analysis.

A subset of patients with mycosis fungoides (MF) progress to the tumor stage, which correlates with a worse clinical outcome. The molecular events driving this progression are not well-understood. To identify the key molecular drivers, we performed gene expression profiling (GEP) using NanoString. Ten formalin-fixed/paraffin-embedded skin biopsies from six patients (six non-tumor and four tumor MF) were included; non-tumor and tumor samples were available in three patients. Laser capture/single cell microdissection of epidermotropic MF cells was used for non-tumor cases. We found that the RNA extracted from 700–800 single cells was consistently sufficient for GEP, provided that multiplexed target enrichment amplification was used. An un-supervised/hierarchical analysis revealed clustering of non-tumor and tumor cases. Many of the most upregulated or downregulated genes are implicated in the PI3K, RAS, cell cycle/apoptosis and MAPK pathways. Two of the targets, HMGA1 and PTPN11 (encodes SHP2), were validated using immunohistochemistry. HMGA1 was positive in six out of six non-tumor MF samples and negative in five out of five tumor MF samples. An opposite pattern was seen with SHP2. Our study has provided a proof-of-concept that single-cell microdissection/GEP can be applied to archival tissues. Some of our identified gene targets might be key drivers of the disease progression of MF.

Potential role of tumor-associated macrophages and CD163/CD68 ratio in mycosis fungoides and Sézary syndrome in correlation with serum sCD163 and CCL22.

Currently, there are no curative treatment options for mycosis fungoides (MF) and Sézary syndrome (SS) other than stem cell transplant. Understanding the interplay between tumor cells and tumor microenvironment could aid in the development of new therapies. Tumor-associated macrophages (TAMs) mostly have M2 phenotype that promotes tumor progression. This study investigated CD68+ and CD163+ TAMs as well as CD163/CD68 ratio in skin lesions from different stages of MF, large-plaque parapsoriasis, and SS. Moreover, we analyzed serum levels of sCD163 and CCL22 in correlation with TAMs count and CD163/CD68 ratio. CD68+ and CD163+ TAMs count significantly increased as the disease progressed. CD163/CD68 ratio was highest at MF tumor stage and SS indicating M2 polarization with disease progression. Significant positive correlations were detected between serum levels of sCD163 and CCL22 and CD68+ and CD163+ TAMs count and CD163/CD68 ratio. We concluded that TAMs play an important role in MF progression. High CD163/CD68 ratio in tumor stage MF and SS indicates M2 polarization of TAMs with tumor progression. CD163/CD68 ratio should be considered in assessing TAMs rather than total TAMs count. Also, sCD163 and CCL22 serum levels reflect M2 load and thus could be used as markers to assess disease progression.

Bio-O1-05 - Nanostring analysis of mycosis fungoides offers clues to better understand MF pathogenesis and progression

Bio-O1-05 - Nanostring analysis of mycosis fungoides offers clues to better understand MF pathogenesis and progression