1. Dermatology Aspects of Cutaneous T-cell Lymphoma
Dr. Raed Alhusayen MD, FRCPC
Division of Dermatology
Sunnybrook Health Sciences Centre
Cutaneous Lymphoma Patient Education Forum
April 14, 2012

2. Objectives
Brief description of cutaneous T-cell lymphoma (CTCL): focus on Mycosis Fungoides
The role of the dermatologist in CTCL
Treatment options for early stage disease

3. Abnormal growth of T-lymphocytes (a type of blood cells) in the skin
CTCL
Abnormal growth of T-lymphocytes (a type of blood cells) in the skin

4. CTCL

5. CTCL

6. (Majority of patients)
Skin lesions
patches of erythema and scaling
Slightly raised plaques
(Majority of patients)

7. Skin lesions
Tumors

8. Skin lesions
Erythroderma

9. Other skin presentations

10. The role of the dermatologist
Making the diagnosis:
History and physical examination
Skin biopsy(ies)
Workup (staging):
Blood work
Radiological studies (if required):CXR, US, CT
Treatment

11. Why does it take so long to diagnose MF?
On average it takes 3 years from the development of skin lesions
It is a rare disease
It mimics other common skin diseases
It could be asymptomatic limited disease
Even if suspected, the skin biopsies might not be diagnostic
Multiple biopsies over a period of time might be needed

12. Staging of Mycosis Fungoides
MF stage
Description IA
Patches & plaques < 10% BSA IB
Patches & plaques ≥ 10% BSA
IIA
Patches & plaques + ENLARGED palpable Lymph node
IIB
Tumors
IIIA
Erythroderma
IIIB
Erythroderma + Sezary cells > 5% (B1)
IVA
Sezary Syndrome
IVB
Lymph node involvement (pathology)
IVC
Metastasis

13. Staging of Mycosis Fungoides
MF stage
Description IA
Patches & plaques < 10% BSA IB
Patches & plaques ≥ 10% BSA
IIA
Patches & plaques + ENLARGED palpable Lymph node
IIB
Tumors
IIIA
Erythroderma
IIIB
Erythroderma + Sezary cells > 5% (B1)
IVA
Sezary Syndrome
IVB
Lymph node involvement (pathology)
IVC
Metastasis

14. “Rarely progresses, frequently relapses”
Treatment options
“Rarely progresses, frequently relapses”
Active observation
Topical agents:
Topical steroids: symptomatic lesions
Imiquimod (Aldara): localized lesions
Topical Retinoids (Tazarotene): localized lesions
Intralesional steroids

15. Aldara reaction

16. Phototherapy Performed at PERC
More than 500 CTCL patients (350 active)
NBUVB (3x/wk): very effective on patches and thin plaques, less toxicity
PUVA (2x/wk): thicker plaques, longer remission

17. Systemic Isotretinoin
Vitamin A derivative
Especially helpful when combined with phototherapy
Very well tolerated at low doses
Does not suppress the immune system
TERATOGENIC
Need to monitor lipid profile and liver enzymes

18. Steps to manage the itch
Bathing with lukewarm water followed by gently patting the skin dry
Using moisturizers on regularly
Topical steroids
Oral antihistamines: Benadryl, Atarax, Doxepin
Low dose oral prednisone

19. St Johns Institute of Dermatology

20. Cutaneous lymphoma team
Multidisciplinary Team: Dermatologist / Clinical Oncologist / Hematologist / NURSES
50-60 patients (6-8 new)
Overall similar treatment approach (bexarotene notable exception)
Interesting ideas:
Cutaneous lymphoma tumor board: reviewing all new cases and selected follow ups
Case manager: primary contact person for the patient
Low dose prednisone for symptom relief

23. Resources
Cutaneous Lymphoma Foundation: