Interventions for mycosis fungoides
- PMID: 32632956
- PMCID: PMC7389258
- DOI: 10.1002/14651858.CD008946.pub3
Interventions for mycosis fungoides
Abstract
Background: Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma, a malignant, chronic disease initially affecting the skin. Several therapies are available, which may induce clinical remission for a time. This is an update of a Cochrane Review first published in 2012: we wanted to assess new trials, some of which investigated new interventions.
Objectives: To assess the effects of interventions for MF in all stages of the disease.
Search methods: We updated our searches of the following databases to May 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We searched 2 trials registries for additional references. For adverse event outcomes, we undertook separate searches in MEDLINE in April, July and November 2017.
Selection criteria: Randomised controlled trials (RCTs) of local or systemic interventions for MF in adults with any stage of the disease compared with either another local or systemic intervention or with placebo.
Data collection and analysis: We used standard methodological procedures expected by Cochrane. The primary outcomes were improvement in health-related quality of life as defined by participants, and common adverse effects of the treatments. Key secondary outcomes were complete response (CR), defined as complete disappearance of all clinical evidence of disease, and objective response rate (ORR), defined as proportion of patients with a partial or complete response. We used GRADE to assess the certainty of evidence and considered comparisons of psoralen plus ultraviolet A (PUVA) light treatment as most important because this is first-line treatment for MF in most guidelines.
Main results: This review includes 20 RCTs (1369 participants) covering a wide range of interventions. The following were assessed as either treatments or comparators: imiquimod, peldesine, hypericin, mechlorethamine, nitrogen mustard and intralesional injections of interferon-α (IFN-α) (topical applications); PUVA, extracorporeal photopheresis (ECP: photochemotherapy), and visible light (light applications); acitretin, bexarotene, lenalidomide, methotrexate and vorinostat (oral agents); brentuximab vedotin; denileukin diftitox; mogamulizumab; chemotherapy with cyclophosphamide, doxorubicin, etoposide, and vincristine; a combination of chemotherapy with electron beam radiation; subcutaneous injection of IFN-α; and intramuscular injections of active transfer factor (parenteral systemics). Thirteen trials used an active comparator, five were placebo-controlled, and two compared an active operator to observation only. In 14 trials, participants had MF in clinical stages IA to IIB. All participants were treated in secondary and tertiary care settings, mainly in Europe, North America or Australia. Trials recruited both men and women, with more male participants overall. Trial duration varied from four weeks to 12 months, with one longer-term study lasting more than six years. We judged 16 trials as at high risk of bias in at least one domain, most commonly performance bias (blinding of participants and investigators), attrition bias and reporting bias. None of our key comparisons measured quality of life, and the two studies that did presented no usable data. Eighteen studies reported common adverse effects of the treatments. Adverse effects ranged from mild symptoms to lethal complications depending upon the treatment type. More aggressive treatments like systemic chemotherapy generally resulted in more severe adverse effects. In the included studies, CR rates ranged from 0% to 83% (median 31%), and ORR ranged from 0% to 88% (median 47%). Five trials assessed PUVA treatment, alone or combined, summarised below. There may be little to no difference between intralesional IFN-α and PUVA compared with PUVA alone for 24 to 52 weeks in CR (risk ratio (RR) 1.07, 95% confidence interval (CI) 0.87 to 1.31; 2 trials; 122 participants; low-certainty evidence). Common adverse events and ORR were not measured. One small cross-over trial found once-monthly ECP for six months may be less effective than twice-weekly PUVA for three months, reporting CR in two of eight participants and ORR in six of eight participants after PUVA, compared with no CR or ORR after ECP (very low-certainty evidence). Some participants reported mild nausea after PUVA but no numerical data were given. One participant in the ECP group withdrew due to hypotension. However, we are unsure of the results due to very low-certainty evidence. One trial comparing bexarotene plus PUVA versus PUVA alone for up to 16 weeks reported one case of photosensitivity in the bexarotene plus PUVA group compared to none in the PUVA-alone group (87 participants; low-certainty evidence). There may be little to no difference between bexarotene plus PUVA and PUVA alone in CR (RR 1.41, 95% CI 0.71 to 2.80) and ORR (RR 0.94, 95% CI 0.61 to 1.44) (93 participants; low-certainty evidence). One trial comparing subcutaneous IFN-α injections combined with either acitretin or PUVA for up to 48 weeks or until CR indicated there may be little to no difference in the common IFN-α adverse effect of flu-like symptoms (RR 1.32, 95% CI 0.92 to 1.88; 82 participants). There may be lower CR with IFN-α and acitretin compared with IFN-α and PUVA (RR 0.54, 95% CI 0.35 to 0.84; 82 participants) (both outcomes: low-certainty evidence). This trial did not measure ORR. One trial comparing PUVA maintenance treatment to no maintenance treatment, in participants who had already had CR, did report common adverse effects. However, the distribution was not evaluable. CR and OR were not assessable. The range of treatment options meant that rare adverse effects consequently occurred in a variety of organs.
Authors' conclusions: There is a lack of high-certainty evidence to support decision making in the treatment of MF. Because of substantial heterogeneity in design, missing data, small sample sizes, and low methodological quality, the comparative safety and efficacy of these interventions cannot be reliably established on the basis of the included RCTs. PUVA is commonly recommended as first-line treatment for MF, and we did not find evidence to challenge this recommendation. There was an absence of evidence to support the use of intralesional IFN-α or bexarotene in people receiving PUVA and an absence of evidence to support the use of acitretin or ECP for treating MF. Future trials should compare the safety and efficacy of treatments to PUVA, as the current standard of care, and should measure quality of life and common adverse effects.
Trial registration: ClinicalTrials.gov NCT00030589 NCT00050999 NCT01578499 NCT00630903 NCT00091208 NCT01386398 NCT01625455 NCT01738594 NCT02213861 NCT02301494 NCT02323659 NCT02448381 NCT02811783 NCT02943642 NCT02953301 NCT03011814 NCT03292406 NCT03454945 NCT03713320.
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Conflict of interest statement
Arash Valipour: I received travel expenses and accommodation for the annual German Dermatology Society Meeting 2019 from UCB Pharma, but this company is not involved in the development of drugs for mycosis fungoides. I attended a meeting called 'Inflammation campus' (a dermatology/rheumatology‐oriented medical meeting) in July 2015, which was organised by Pfizer. Pfizer paid for my travel expenses and accommodation. Manuel Jäger: nothing to declare. Peggy Wu: nothing to declare. Jochen Schmitt: I acted as a consultant for Lilly and Sanofi and received institutional grants for investigator‐initiated trials outside the submitted work from Novartis, Sanofi, ALK, and Pfizer. Charles Bunch: nothing to declare. Tobias Weberschock: nothing to declare.
Clinical referee, Prof Sean Whittaker: "I led and co‐authored the updated U.K. Cutaneous Lymphoma Group guidelines for the management of primary cutaneous lymphomas, which were published in 2018 (Gilson 2019)."
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Update of
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Interventions for mycosis fungoides.Cochrane Database Syst Rev. 2012 Sep 12;(9):CD008946. doi: 10.1002/14651858.CD008946.pub2. Cochrane Database Syst Rev. 2012. Update in: Cochrane Database Syst Rev. 2020 Jul 7;7:CD008946. doi: 10.1002/14651858.CD008946.pub3. PMID: 22972128 Updated.
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Duvic 2010 {published data only}
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- Duvic M, Martin A, Olsen EA, Fivenson D, Prince M. Efficacy of denileukin diftitox retreatment in patients with cutaneous T-cell lymphoma who relapsed after initial response. Blood 2010;116(21):2863.
Fawzi 2010 {published data only}
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Fisher 1993 {published data only}
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Heald 2003 {published data only}
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JapicCTI‐050041 {published data only}
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- JapicCTI-050041. Post-marketing clinical study of Ogamma 100 in patients with mycosis fungoides. www.clinicaltrials.jp/user/showCteDetailE.jsp?japicId=JapicCTI-050041 (first received 12 September 2005).
Kaung 1969 {published data only}
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Kujawska 2003 {published data only}
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Kuzel 2010 {published data only}
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- Kuzel T. Correlates of capillary leak syndrome (CLS) in patients with cutaneous T-cell lymphoma (CTCL) during treatment with denileukin diftitox (DD) in a placebo (PBO)-controlled phase III trial. Journal of Clinical Oncology 2010;28(15 Suppl):e18509.
Lambert 1986 {published data only}
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- Lambert D, Bousser AM, Dalac S, Godard W, Lepinoy D, Horiot JC. Mycosis fungoides and radiotherapy. Value of combined total skin electron therapy and whole-body photon therapy. Annales de Dermatologie et de Venereologie 1986;113(6-7):541–7. [PMID: ] - PubMed
Lansigan 2010 {published data only}
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- Lansigan F, Foss FM. Rate of infection and immunosuppression in two phase III studies of denileukin diftitox (DD) in cutaneous T-cell lymphoma (CTCL). Journal of Clinical Oncology 2010;28(15 Suppl):e18515.
Loescher 1984 {published data only}
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- Loescher L, Kessler J, Jones S, Meyskens F, Levine N, Sauer K. 13-Cis retinoic acid as treatment for mycosis fungoides: Clinical results of a phase II trial. Federation Proceedings 1984;43(4):3896.
Marsden 1968 {published data only}
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- Marsden CW. Fluocinolone acetonide 0.2 per cent cream--a co-operative clinical trial. British Journal of Dermatology 1968;80(9):614-7. [PMID: ] - PubMed
Moog 2008 {published data only}
NCT00054171 {published data only}
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- NCT00054171. Photodynamic therapy in treating patients with lymphoma or chronic lymphocytic leukemia. clinicaltrials.gov/ct2/show/NCT00054171 (first received 6 February 2003).
NCT00091208 {unpublished data only}
-
- NCT00091208. A phase I/II open label, multi-center study for the evaluation of Pf-3512676 (CPG 7909) in patients with stage Ib to Iva cutaneous T-Cell lymphoma. clinicaltrials.gov/ct2/show/NCT00091208 (first received 12 August 2002). [NCT00091208]
NCT01007448 {unpublished data only}
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- NCT01007448. Study evaluating two dose levels of Targretin capsules in patients with refractory cutaneous T-cell lymphoma (CTCL). clinicaltrials.gov/ct2/show/NCT01007448 (first received 4 November 2009).
NCT01187446 {unpublished data only}
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- NCT01187446. Low-dose (12 Gy) TSEBT+Vorinostat versus low-dose TSEBT monotherapy in mycosis fungoides. clinicaltrials.gov/ct2/show/NCT01187446 (first received 24 August 2010).
NCT01386398 {unpublished data only}
-
- NCT01386398. Vorinostat with or without Bortezomib in treating patients with refractory or recurrent stage IIB, stage III, or stage IV cutaneous T-Cell lymphoma. clinicaltrials.gov/ct2/show/NCT01386398 (first received 1 July 2011).
NCT01625455 {unpublished data only}
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- NCT01625455. Effect of Neurokinin-1 Receptor (NK1R) antagonism on pruritus in patients with Sezary syndrome. clinicaltrials.gov/ct2/show/NCT01625455 (first received 21 June 2012).
Neering 1972 {published data only}
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O'Neill 2013 {published data only}
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Peugeot 1995 {published data only}
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Prince 2010 {published data only}
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- Prince HM, Duvic M, Martin A, Sterry W, Assaf C, Sun Y, et al. Phase III placebo-controlled trial of denileukin diftitox for patients with cutaneous T-cell lymphoma. Journal of Clinical Oncology 2010;28(11):1870-7. [PMID: ] - PubMed
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Serri 1990 {published data only}
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References to studies awaiting assessment
Bashey 2014 {published data only}
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- Bashey S, Tavallaee M, Duvic M, Dabaja B, Talpur R, Wilson L, et al. A multicenter, open-label, randomized, phase I/II study evaluating the safety and efficacy of low-dose (12 Gy) total skin electron beam therapy (TSEBT) combined with vorinostat versus low-dose TSEBT monotherapy in patients with mycosis fungoides. Journal of Investigative Dermatology 2014;134(Suppl 1):S104. [DOI: ]
Kim 2014 {published data only}
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- Kim YH, Krathen M, Duvic M, Wong H, Porcu P, Tacastacas J, et al. A phase 1b study in cutaneous T-cell lymphoma (CTCL) with the novel topically applied skin-restricted histone deacteylase inhibitor (HDAC-i) SHP-141. Journal of Clinical Oncology 2014;32(15 Suppl):8525.
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- Kim YH, Krathen MS, Duvic M, Wong H, Porcu P, Tacastacas J, et al. Tolerability and encouraging clinical activity of SHP-141, a topical skin-restricted HDAC inhibitor, in a phase 1B study in cutaneous t-cell lymphoma. Journal of Investigative Dermatology 2014;134(Suppl 1):S93.
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- NCT01433731. Safety, pharmacodynamics (PD), pharmacokinetics (PK) study of SHP141 in 1A, 1B, or 2A cutaneous T-cell lymphoma (CTCL). clinicaltrials.gov/ct/show/NCT01433731 (first received 14 September 2011).
References to ongoing studies
NCT01738594 {published data only}
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- NCT01738594. Dose-escalation trial of carfilzomib with and without Romidepsin in cutaneous T-cell lymphoma. clinicaltrials.gov/ct2/show/NCT01738594 (first received 30 November 2012).
NCT02213861 {published data only}
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- Duvic M, Kim YH, LeBoeuf NR, Porcu P, Hastings J, Bassuner J, et al. A phase 2 randomized study of SHAPE Gel (SHP-141) in patients with early-stage cutaneous T-cell lymphoma: Interim results. Journal of Clinical Oncology 2016;34(15 Suppl):7562. [DOI: 10.1200/JCO.2016.34] - DOI
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- NCT02213861. Efficacy, safety and tolerability study of SHAPE in IA, IB or IIA cutaneous T-cell lymphoma. clinicaltrials.gov/ct2/show/NCT02213861 (first received 12 August 2014).
NCT02301494 {published data only}
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- NCT02301494. Effectiveness of imiquimod topical cream in early stage cutaneous T-cell lymphoma (CTCL). clinicaltrials.gov/ct2/show/NCT02301494 (first received 26 November 2014).
NCT02323659 {published data only}
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- NCT02323659. Comparison of methotrexate versus interferon-alfa 2b in patients with primary cutaneous T-cell lymphomas. clinicaltrials.gov/ct2/show/NCT02323659 (first received 23 December 2014).
NCT02448381 {published data only}
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- NCT02448381. FLASH [Fluorescent Light Activated Synthetic Hypericin] clinical study: topical SGX301 (synthetic hypericin) for the treatment of cutaneous T-cell lymphoma (mycosis fungoides). clinicaltrials.gov/ct2/show/NCT02448381 (first received 19 May 2015).
NCT02811783 {published data only}
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- NCT02811783. Naloxone hydrochloride study for relief of pruritus in patients with MF or SS forms of CTCL. clinicaltrials.gov/ct2/show/NCT02811783 (first received 23 June 2016).
NCT02943642 {published data only}
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- NCT02943642. Safety and effectiveness of A-dmDT390-bisFv(UCHT1) fusion protein in subjects with mycosis fungoides (Resimmune®). clinicaltrials.gov/ct2/show/NCT02943642 (first received 25 October 2016).
NCT02953301 {published data only}
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- NCT02953301. Resminostat for maintenance treatment of patients with advanced stage mycosis fungoides (MF) or Sézary syndrome (SS) (RESMAIN). clinicaltrials.gov/ct2/show/NCT02953301 (first received 2 November 2016).
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- Stadler R, Scarisbrick J, Knobler R, Quaglino P, Borgmann M, Orlovius M, et al. A multicentre, double blind, randomised, placebo controlled, Phase II trial to evaluate Resminostat for maintenance treatment of patients with advanced stage (Stage IIB-IVB) mycosis fungoides (MF) or Sezary Syndrome (SS) that have achieved disease control with systemic therapy-the RESMAIN Study. Journal of the European Academy of Dermatology and Venereology 2017;31(Suppl 3):50.
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- Stadler R, Scarisbrick J, Knobler R, Quaglino P, Borgmann M, Orlovius M, et al. A multicentre, double blind, randomised, placebo-controlled, Phase II trial to evaluate Resminostat for maintenance treatment of patients with advanced stage (Stage IIB-IVB) mycosis fungoides (MF) or Sezary Syndrome (SS) that have achieved disease control with systemic therapy: The RESMAIN Study. Journal der Deutschen Dermatologischen Gesellschaft [Journal of the German Society of Dermatology] 2017;15(Suppl 3):74–5. [DOI: 10.1111/ddg.13300] - DOI
NCT03011814 {published data only}
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- NCT03011814. Durvalumab with or without lenalidomide in treating patients with relapsed or refractory cutaneous or peripheral T cell lymphoma. clinicaltrials.gov/ct2/show/NCT03011814 (first received 5 January 2017).
NCT03292406 {published data only}
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- NCT03292406. A safety, efficacy and pharmacokinetics study of CD11301 for the treatment of cutaneous T-cell lymphoma (CTCL) (CTCL). clinicaltrials.gov/ct2/show/NCT03292406 (first received 25 September 2017).
NCT03454945 {published data only}
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- NCT03454945. Efficacy of doxycycline in the treatment of early stages of mycosis fungoides: A randomized controlled trial. clinicaltrials.gov/ct2/show/NCT03454945 (first received 6 March 2018).
NCT03713320 {published data only}
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- NCT03713320. SOLAR: A phase 2, randomized, open-label, parallel-group, active comparator, multi-center study to investigate the efficacy and safety of cobomarsen (MRG-106) in subjects with cutaneous T-cell lymphoma (CTCL), mycosis fungoides (MF) subtype. clinicaltrials.gov/ct2/show/NCT03713320 (first received 17 October 2018).
UMIN000029537 {published data only}
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