Sézary Syndrome Research Articles

Prec-O1-05 - Flow-cytometry and functional evaluation of the CD39/CD73 adenosinergic immunosuppressive axis in patients with Sézary syndrome

Sézary syndrome (SS) is a primary cutaneous T-cell lymphoma characterized by measurable levels of malignant lymphocytes in the blood, and progressive impairment of the immune response. Among the mechanisms of immune modulation, adenosine can impair anti-tumor immunity, through the attenuation of protective effector cells, including T and NK cells, and by enhancing the suppressive capacity of T regulatory cells. CD39 and CD73 nucleotide-metabolizing enzymes are involved in the adenosine-generating pathway: CD39 cleaves ATP and ADP down into AMP, which is converted into adenosine by CD73. The extracellular adenosine deaminase/CD26 complex catalyzes the deamination of adenosine to inosine, thus reducing the adenosine levels. The objective of this study were: to investigate the expression of the of CD39 and CD73 nucleotide-metabolizing ectoenzymes in peripheral blood from SS patients; to define the contribution of the CD39/CD73 adenosinergic immunosuppressive pathway to tumor escape from immune response and immune dysfunctions in patients with SS. CD39 and CD73 expression analyzed in whole blood with multiparametric flow-cytometry from SS patients (n=10) and healthy donors (HD, n=11) revealed altered expression of CD39 and CD73 in SS patients compared to HD. Two subgroups of patients can be identified based on the mutually exclusive overexpression of CD39 or CD73 in CD4+ T cells. Indeed, 7 out of 10 patients had high CD39, while 3 had high CD73. CD4+T cells with high CD39 have low CD73, vice versa those with high CD73 have low CD39. To define whether CD39 and CD73 were biologically active, we compared the ability of peripheral blood CD4+T cells from SS patients and HD to hydrolyze ATP and to convert AMP into adenosine, in vitro. Briefly, CD4+ Tcells from SS/HD were seeded in 48-well plates in HBSS, pretreated or not with specific inhibitors for 1h and then incubated with exogenous (e) eATP (patients with high CD39) or eAMP (patients with high CD73) at 37°C. After 1 h incubation, analyses of the supernatant were performed with an RP-HPLC. Results indicated that CD4+ T cells from SS patients with high levels of CD39 showed an increased ability to hydrolyze ATP with increased generation of AMP compared to normal control cells. In parallel, CD4+ T cells with high levels of CD73 showed increased conversion of AMP into ADO, respect to normal control cells. The aberrant expression of CD39 and CD73 along with loss of CD26 expression in circulating Sézary cells suggest that the sequential activity of CD39 and CD73 ectoenzymes scavenges ATP and generates immunosuppressive adenosine in the tumor microenvironment contributing to tumor immune escape. The results inferred from this study are the starting point for more comprehensive studies towards the development of new therapies targeting the CD39/CD73 adenosinergic axis in order to overcome tumor immunosuppression, allowing the induction of effective anti-tumor immune response.

Tre-P-06 - Efficacy of mogamulizumab in mycosis fungoides by patient blood involvement and time to response analysis in mycosis fungoides and Sézary syndrome: a post hoc analysis of the MAVORIC study

Background: Cutaneous T-cell lymphomas (CTCL) are rare forms of non-Hodgkin lymphoma, presenting primarily in the skin. Mycosis fungoides (MF) and Sézary syndrome (SS) account for around two-thirds of all CTCL cases. MAVORIC (NCT01728805) was an open-label, phase 3 study comparing mogamulizumab (Moga) to vorinostat (Vori) in MF and SS patients (pts). Previously published post hoc MAVORIC data has shown trends to higher multicompartmental efficacy with Moga in MF and SS pts with increasing baseline blood tumour burden (Scarisbrick J, et al.

Tre-P-18 - The use of small doses of gemcitabine in the treatment of drug-resistant forms of mycosis fungoides/Sézary syndrome

Mycosis fungoides (MF) and Sézary syndrome (SS) are the most frequent cutaneous T-cell lymphomas. These tumors have a chronic progradient course. Hitherto there is no evidence of effective therapy, particularly of the late-stage of the diseases. About 30% of the patients are not effected by interferon, radiotherapy and combined treatment regimens. Patients' age (median age 62 years) limits therapy options. Several lines of previous treatment could lead to tumor resistance and higher accumulated toxicity. Thus, use of potentially effective chemotherapeutic agents in lower doses will reduce myelotoxicity and expand the cohort of patients. Gemcitabine is an effective medication in treatment of MF/SS. Its efficacy is preserved in small doses with prolonged duration of infusion and allows to decrease myelotoxicity. It was firstly discovered in therapy of solid tumors. In current study 14 patients were involved with resistant forms of MF/SS (10 patients with MF, 3 with SS, and 1 case of MF with transformation into large cell lymphoma). We used 6-hour infusion of gemcitabine at dosage of 250 mg/m². 86% of patients achieved a general response: 29% complete remission, 50% partial remission, 21% stabilization of disease, 14% (2 patients) progression. Present study showed promising results in treatment of patients with advanced stages of MF/SS which had at least two preceding lines of therapy without an effect. Common response (PR/CR) was received in high percent of cases. This treatment protocol is reproducible in elderly patients. For long-term conclusions further studies are required.

Bio-O2-05 - Epigenetic modifiers can alter telomerase expression and clonogenic capacities of Sézary cells

Sézary syndrome (SS) is an aggressive leukemic variant of cutaneous T-cell lymphomas (CTCL) for which current available treatments do not provide long-term responses. Two epigenetic-modulating agents belonging to the family of histone deacetylase inhibitors (HDACi), vorinostat and romidepsin are FDA approved for advanced stage CTCL. However, the rationale for using such therapies in SS and their biological impact are not well defined. The majority of cancer cells achieve proliferative immortality by activating or upregulating the normally silent human Telomerase Reverse Transcriptase (<i>hTERT</i>) gene. Sezary cells do not escape to this phenomenon. As the <i>hTERT</i> promoter is rich in CpG, we investigated the contribution of epigenetic mechanisms in its re-expression. We analyzed <i>hTERT</i>-promoter methylation status in CTCL cells compared to healthy cells. Nine CTCL cell lines including, five SS cell lines were experimentally investigated (HuT78, the unique commercial SS cell line and four newly developed SS cell lines from our laboratory (PMID: 33106625). Gene-specific methylation analyses revealed a common promotor hypermethylation pattern exclusively observed in tumor cells. We explored <i>hTERT</i> promoter methylation status under the pressure of a demethylating agent approved for the treatment of several hematological disorders (5-azacytidine) by comparison with clinically approved HDACi (romidespin and vorinostat). Surprisingly, romidespin, vorinostat or 5-azacytidine could each reduce <i>hTERT</i> expression level without altering the methylation status of <i>hTERT</i> promoter. To go further, we analyzed the functional effect of the aforementioned epidrugs on the clonogenic capacities of Sézary cells using the soft agar assay. Our data revealed that, besides <i>hTERT</i> downregulation, epidrugs reduced the proliferative and the tumor formation capacities in Sézary cells <i>in vitro</i>. Our first report on <i>hTERT</i> promotor methylation status in CTCL suggests that <i>hTERT</i> promotor methylation status is a hallmark of neoplastic CTCL cells. Our results also provide evidence for functional consequences of epidrugs treatments on tumor formation capacities in Sézary cells <i>in vitro</i>. Indeed, the present investigation states that Sézary cells' clonogenic capacity correlates well with <i>hTERT</i> expression level under epigenetic drugs pressure. The present findings represent a step forward towards a better understanding of the relationship between targeting epigenetic modifiers in a cell-context–dependent manner and the response generated at the cellular levels.

Tre-P-12 - Psoriasis-like eruption and arthritis secondary to mogamulizumab in a patient with Sézary syndrome

Mogamulizumab is an anti-CC chemokine receptor 4 (CCR4) monoclonal antibody that has been approved for the treatment of adult patients with relapsed or refractory mycosis fungoides (MF) or Sézary syndrome (SS) who have been treated with at least 1 prior line of therapy. We present the case of a 76-year-old woman diagnosed with SS refractory to all prior lines of therapies, who presented a prolonged response to Mogamulizumab in the peripheral blood, skin, and lymph nodes. However, after almost 1 year of treatment, the patient developed psoriasis-like patches (confirmed by histology), and arthritis mainly in the shoulder girdle, hip and cervical region diagnosed by MRI and ultrasonography as a polymyalgia rheumatica-like. After consensus between hematologists, dermatologists and rheumatologists, the patient was treated with low-dose prednisone (5–10 mg) daily and mogamulizumab was tapered (dose widening to every two months), with great control of side effects and maintenance of complete response of her SS (skin, peripheral blood, and lymph nodes) until now. Mogamulizumab has been shown to be an effective and well tolerated therapy for patients with relapsed and refractory MF/SS with excellent activity in the circulating component of the disease. Common adverse events include infusion reactions and drug eruptions and increase of the risk of immune-mediated complications such as autoimmune disease and acute graft-versus-host disease following transplantation. However, we still must be aware of new drug eruptions and side effects that require prompt diagnosis and treatment.

A weakly supervised deep learning approach for label-free imaging flow-cytometry-based blood diagnostics

SummaryThe application of machine learning approaches to imaging flow cytometry (IFC) data has the potential to transform the diagnosis of hematological diseases. However, the need for manually labeled single-cell images for machine learning model training has severely limited its clinical application. To address this, we present iCellCnn, a weakly supervised deep learning approach for label-free IFC-based blood diagnostics. We demonstrate the capability of iCellCnn to achieve diagnosis of Sézary syndrome (SS) from patient samples on the basis of bright-field IFC images of T cells obtained after fluorescence-activated cell sorting of human peripheral blood mononuclear cell specimens. With a sample size of four healthy donors and five SS patients, iCellCnn achieved a 100% classification accuracy. As iCellCnn is not restricted to the diagnosis of SS, we expect such weakly supervised approaches to tap the diagnostic potential of IFC by providing automatic data-driven diagnosis of diseases with so-far unknown morphological manifestations.

Tre-O1-04 - Assessment of skin involvement in cutaneous T-cell lymphoma using convolutional neural networks

<h3>Introduction:</h3> Mycosis fungoides (MF) and Sézary syndrome (SS) are the most common types of cutaneous T-cell lymphomas (CTCL). The assessment of skin involvement is critical for the correct TNMB classification, however, prone to intra- and interobserver variability. The aim of this project was an automated identification of skin lesions with artificial intelligence on clinical images of CTCL patients to reduce subjectivity in the evaluation of skin lesions. <h3>Materials and methods:</h3> The analysis included two datasets. The first set included 50 standard photographic clinical images of three CTCL patients with multilocular disease. These images were manually segmented by a dermatologist to obtain binary masks used as ground truth. The second set included 50 lesional images with a calibration marker of 15 patients retrieved with mobile devices (iPhone, iPad) and manually marked for lesional areas on the device. For both cohorts, all images were split with a ratio of 80:20 into training and validation set and analyzed using a convolutional neural network (CNN) created in cooperation by the imito AG, Zürich, the department of informatics of the University Hospital and Institute of Medical Informatics at Luebeck University. <h3>Results:</h3> Overall, 15 CTCL patients (11 M, 4 F; M:F 2.75), median age seventy (41-80 years) were included. 13 patients were diagnosed with MF, stages IA (3), IB (5), IIB (4), IIIA (1) and two patients with SS. The median mSWAT was 8 (ranges 1–85). Due to the large image size, all images were split into smaller pixel sizes, so that the final image set included 931 images for the standard photographs and 1123 images in the mobile device cohort. The CNN was created as a UNet and trained with a Google OpenImages dataset. Several analyses were performed and the finally used variant chosen based on the test accuracy (F-score and Jaccard index). Within the first set of images, lesional areas were correctly identified in 79.8% and non-lesional in 89.2%, compared to 19.8% and 96.8% in the second set. The lesional areas were digitally calculated in the second set. <h3>Conclusion:</h3> The image classification in the first set was considered very convincing. However, the discrepancy between the results of the analysis of the first and second set appear striking with a much better classification and correct identification of lesional areas in the first set. Both approaches were based on trained algorithms as explained. Therefore, we presume that the inferior recognition in the mobile cohort is most likely due to a less exact mark-up of the lesions on the device and the restriction that only one lesion could be marked as a lesion. Overall, we consider that the standardized assessment of cutaneous involvement in CTCL may be helpful in the evaluation of skin lesions in daily practice and in clinical trials. With further development, an automated full-body skin lesion recognition and calculation of involved areas might be feasible.

Hist-O-06 - Image-guided lymph node core-needle biopsy predicts survival in mycosis fungoides and Sézary syndrome

<h3>Background:</h3> The prognosis of Sézary syndrome (SS) and mycosis fungoides (MF) depends on lymph node (LN) involvement. The usefulness of LN image-guided core-needle biopsies (CNBs), instead of surgical sampling, has been poorly evaluated. <h3>Objectives:</h3> To determine the prognostic value of LN CNB in MF/SS. <h3>Methods:</h3> A retrospective search was conducted to identify all LN biopsy specimens of MF/SS between 2008 and 2019. Biopsies were staged according to the International Society for Cutaneous Lymphomas/European Organisation for Research and Treatment of Cancer (ISCL/EORTC) criteria. We performed immunolabelling and determined the tumour clone frequency (TCF) by high-throughput sequencing of the T-cell receptor beta locus. <h3>Results:</h3> We included 119 consecutive biopsies from 100 patients, 45 with MF and 55 with SS. N1, N2 and N3 stages were diagnosed in 34 (29%), 26 (22%) and 59 (49%) cases, respectively. The TCF, Ki67 index, and percentage of cells positive for thymocyte selection-associated high mobility group box protein (TOX), programmed cell death protein 1 (PD1), killer cell immunoglobulin-like receptor 3DL2 (KIR3DL2) and cluster of differentiation (CD)30 were all positively correlated with the N stage. Median overall survival (OS) for N1/N2 vs. N3 patients was 42 months (range 26–not reached) vs. 14 months (range 5–30), respectively (p<0.001). In univariate analyses, an age >75 years, LN short-axis diameter >15 mm, N3 stage, presence of large-cell transformation, TOX >60%, PD1 >25%, Ki67 >30%, KIR3DL2 >15%, CD30 >10% and TCF >25% were identified as adverse prognostic factors. In multivariate analyses, only an age >75 years and Ki67 index >30% were associated with reduced OS. We developed a new prognostic index associating the N stage and the Ki67 index, which better discriminates N3 patients with poor prognosis. <h3>Conclusions:</h3> CNB allows an objective assessment of the LN involvement in MF/SS, relevant for staging and prognosis.

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

Bio-O1-06 - Exploring the role of the skin microenvironment in cutaneous T-cell lymphoma using single cell RNA-sequencing

Background: Mycosis fungoides (MF) and Sézary syndrome (SS) are the most frequent epidermotropic cutaneous T-cell lymphomas (CTCL), both originating from CD4+ lymphocytes. There is no curative treatment for these orphan diseases, healing is rare and 25% may progress to higher stage disease. Although the malignant and reactive lymphocytes were studied extensively, little is known about the role of the dermal-epidermal microenvironment in MF and SS. The group of Hodak et al proposed an important role of dermal fibroblasts, but our knowledge on other dermal components is poor.

Tre-P-13 - Mogamulizumab in a patient with Sézary syndrome and severe atopic dermatitis

Introduction: The chemokine receptor type 4 (CCR4) is involved in both Sézary syndrome (SS) and atopic dermatitis (AD) pathophysiology. Mogamulizumab (Moga), an anti-CCR4 monoclonal antibody, is labeled for the treatment of SS. We describe a patient for whom Moga had a benefit in both SS and AD.

Bio-O1-02 - Deciphering discrepancies in cutaneous lymphomas genetics

In several instances, our group has reported opposite findings to others when analyzing the genetic features of primary cutaneous T-cell or B-cell lymphomas (CTCL or CBCL). This was especially the case for the absence of NAV3 rearrangements in CTCL, the low rate of BCL2 or MYC rearrangement in primary cutaneous follicle center lymphomas (CFCL) or primary cutaneous large B-cell lymphomas, leg-type (CLBCL, LT), respectively. Here, we review bias accounting for such discrepancies. Primary cutaneous lymphoma usually present with characteristic clinical and pathological features which serve as universal criteria for initial diagnosis and treatment. When required, extensive staging including CT scan, blood analysis and for some groups bone marrow staging, is mandatory to eliminate a secondary CTCL or CBCL. Early spreading may change the initial diagnosis and a long-term follow-up is also necessary to determine the risk for extracutaneous involvement. Non-uniform inclusion criteria and follow-up time may contribute to discrepancies, especially for studies claiming for a high rate of BCL2 rearrangement in CBCL. Most CBCL or CTCL usually display an indolent course except for aggressive subtypes arising de novo such as Sézary syndrome (SS), tumor or transformed mycosis fungoides (T-MF) or CLBCL-LT. Borderline cases between indolent and aggressive cutaneous lymphomas exist and may be called for example as leukemic CTCL or CBCL, not-otherwise specified (NOS) leading to heterogeneous terminology between centers. Moreover, aggressive CL are rare occurring mainly in adults or elderly that limits therapeutic options and comparison of small groups in retrospective series. The distribution of diagnosis between the three main primary CBCL including marginal-zone lymphoma (MZL), CFCL and CLBCL, LT has considerably evolved and its heterogeneity between centers may also hamper uniform findings. Our proposal to classify large CBCL according to germinal center or non-germinal center origin has so far not been validated by others while in systemic lymphomas genomic profiling appears mandatory to identify patients with impaired prognosis. In the most frequent cutaneous lymphomas, no highly recurrent genetic mutation is commonly used for diagnosis purpose. Some genetic lesion such as CCND1 rearrangement in mantle cell lymphoma can serve a positive criteria of secondary skin involvement. Alternatively, exceptional primary anaplastic large cell lymphoma (ALCL) bear ALK rearrangement preventing to use such criteria as a hallmark of secondary skin ALCL. BCL2 rearrangement in primary CFCL contributes to identify patients at risk for extracutaneous spreading. Most reports found negative data for NAV3 rearrangement in CTCL that may not be a primary oncogenic driver but a secondary event. Interestingly, MYC rearrangement or double-hits may have a low impact on prognosis in CBCL while they are usually associated with impaired prognosis in systemic or nodal lymphomas. Alternatively, some highly recurrent mutation such as those of MYD88 in CLBCL, LT should be routinely assessed. While clinical presentation will remain a basis for CL diagnosis and treatment, it is now time to integrate molecular profiling in research studies or clinical trials to standardize diagnosis and to identify patients which will exhibit therapeutic resistance to conventional first-line treatment.

Bio-P-11 - Sézary syndrome shows whole genome duplication as a late event in tumor evolution

Sézary syndrome (SS) is an aggressive form of cutaneous T-cell lymphoma with a diverse set of mutated genes. Using previously published datasets, we reanalyzed the copy number landscape of SS and detected whole genome amplifications in 20% of all SS samples. Furthermore, we determined the molecular time of copy number occurrence and could show that single chromosome amplifications are extremely early events in the tumorigenesis. Contrastingly, whole genome duplications are extremely late events. Taken together, our results provide initial cornerstones for building a model of SS tumorigenesis based solely on genomic data.

Prec-O2-03 - PD1 in Sézary syndrome: a repressor of cell survival sometimes lost during progression, but a new target using depleting antibodies?

Introduction: PD1 is known to be expressed by tumor cells from Sézary syndrome (SS). In a mouse model of T-cell lymphoma (ITK-SYK), it has been shown that PD1 may be a haplo-insufficient tumor suppressor and one of the PDCD1 alleles is often deleted in cutaneous T-cell lymphomas. In some T-cell lymphomas, anti-PD1 immunotherapy appears to worsen the disease, but depleting targeting of PD1 has never been studied so far.

Tre-O2-02 - Understanding relative survival outcomes for patients with cutaneous T-cell lymphoma (CTCL) subtypes mycosis fungoides and Sézary syndrome treated with mogamulizumab or vorinostat: combining Australian real-world evidence and MAVORIC phase 3 trial data

Background: In Europe, it is estimated that the annual incidence of cutaneous T-cell lymphoma (CTCL) is approximately 52 new cases per million, affecting around 240 people per million at any one time [1]. Mycosis fungoides (MF) and Sézary syndrome (SS) are rare, debilitating, and potentially life-threatening subtypes of CTCL [2,3]. A recent systematic review and meta-analysis of 16,953 patients globally found that MF and SS represented 62% and 3% of CTCLs, respectively [4]. In the phase 3 MAVORIC trial, mogamulizumab (KW-0761, Poteligeo®)* showed significant improvements over vorinostat in terms of progression-free survival, overall response, and patient-reported quality-of-life [5].

Qol-P-04 - Health-related quality of life effect of mogamulizumab by patient blood involvement

Background: Cutaneous T-cell lymphomas (CTCL) are a rare group of non-Hodgkin lymphomas that present in skin. The most studied subtypes, mycosis fungoides (MF) and Sézary syndrome (SS), together represent around two-thirds of all cases. MF/SS disease staging is multi-compartmental utilising a modified TNMB classification. Leukemic involvement in MF/SS has previously been found to be an independent prognostic factor affecting overall survival, disease-specific survival and increasing risk of disease progression (Agar 2010, Am Soc J Clin Oncol), although further research is ongoing.

Tre-P-04 - Characterization and outcomes in patients with mogamulizumab-associated skin reactions in the MAVORIC trial

Background: MAVORIC, a phase 3, randomized trial, evaluated mogamulizumab (Moga) safety and efficacy vs vorinostat (Vori) in patients (pts) with relapsed/refractory mycosis fungoides (MF) or Sézary syndrome (SS) (NCT01728805). Moga-associated rash (MAR) was the second most common TEAE in the Moga treatment arm and most common TEAE leading to treatment discontinuation (7% discontinuation rate, 13/184). Grade 1–2 and 3 drug rashes (DR) occurred in 20% (36/184) and 4% (8/184) of Moga pts, respectively.

Tre-O2-11 - Phase II trial of atezolizumab (anti-PD-L1) in the treatment of stage IIb–IVB mycosis fungoides/Sézary syndrome patients relapsed/refractory after a previous systemic treatment (PARCT)

Treatment of advanced mycosis fungoides (MF) and Sézary syndrome (SS) remains a clinical challenge. Atezolizumab blocks a protein called PD-L1 (programmed death-ligand 1) from binding to its receptor found on the surface of immune cells and tumor cells. It helps to restore the immune activity of the body against the cancer. Atezolizumab is already used to treat adults with a range of solid tumors including cancer that affects the bladder and the urinary system, called urothelial carcinoma, and a cancer that affects the lungs, called non-small cell lung cancer.

Tre-P-09 - Mogalizumab-induced granulomatous eruption of the scalp: a distinct entity associated with clinical response?

Mogamulizumab is an anti-CC chemokine receptor 4 (CCR4) monoclonal antibody, recently approved for the treatment for cutaneous T cell lymphomas (CTCL): mycosis fungoides (MF) and Sézary syndrome (SS). Mogamulizumab has been associated with a variety of cutaneous adverse events. Here we report 6 cases of patients presenting similar eruptions on the scalp, diagnosed as mogamulizumab induced skin side effect. Among 25 patients treated with mogamulizumab for CTCL in two referral centers, we observed 6 patients presenting with similar skin plaques on the scalp and alopecia.

Tre-P-07 - Patient characteristics of long-term responders to mogamulizumab: results from the MAVORIC study

Background: The MAVORIC phase 3, randomized trial, compared safety and efficacy of mogamulizumab (Moga) with vorinostat (Vori) in patients (pts) with relapsed/refractory mycosis fungoides (MF) or Sézary syndrome (SS). Among Moga-treated pts, global overall response rate (ORR) was 28% (52/186), with median duration of response (DOR) of 14.1 months (mo). This analysis assessed the clinical and demographic characteristics of MAVORIC cohorts with varying ORR durations.