To investigate the prognostic value of initial characteristics including blood eosinophilia in patients with primary cutaneous T-cell lymphoma.
A retrospective inception cohort, patients included from date of diagnosis (1982-1998).
Two dermatology departments of a university hospital.
A total of 104 patients with cutaneous T-cell lymphoma, including patients with mycosis fungoides (n = 69), Sézary syndrome (n = 13), and nonepidermotropic cutaneous lymphoma (n = 22). The following variables were recorded: age, sex, diagnosis according to the European Organization for Research and Treatment of Cancer (EORTC) classification, type of skin involvement at the time of diagnosis, initial eosinophil absolute count, lactate dehydrogenase value, date of disease progression, and cause and date of death or date of last contact.
Main Outcome Measures
Time from diagnosis to disease progression and to disease-specific death.
The median follow-up was 43 months (range, 7-197 months). Estimated rates of disease progression and disease-specific death for 3 years were 19.5% (95% confidence interval [CI],11.3%-27.6%) and 9.9% (95% CI, 2.8%-13.6%), respectively. Univariable analysis of initial variables possibly influencing disease progression revealed significant prognostic value for diagnosis according to EORTC classification (hazard ratio [HR], 2.77; 95% CI, 1.04-7.41; P = .04), type of skin involvement (HR, 2.70; 95% CI, 1.00-7.25; P = .04), raised blood eosinophil absolute count (HR, 7.33; 95% CI, 2.84-18.91; P<.001), and raised serum level of lactate dehydrogenase (HR, 3.72; 95% CI, 1.58-8.78; P = .001).Concerning disease-specific death, significant prognostic indicators were diagnosis according to the EORTC classification (HR, 6.62; 95% CI, 1.68-26.12; P = .007) and a raised blood eosinophil absolute count (HR, 10.57; 95% CI, 2.28-49.0; P<.001). In multivariable analysis, only blood eosinophilia was associated with disease progression and disease-specific death.
These results strongly suggest that blood eosinophilia at baseline is a prognostic factor in patients with primary cutaneous T-cell lymphoma.
Primary cutaneous T-cell lymphomas (CTCLs) are characterized by a proliferation of T lymphocytes in the skin, most often of the CD4+ helper subtype. They comprise various entities, distinguishable on the basis of clinical, histologic, and immunophenotypic criteria, with variable prognoses, as defined by the European Organization for Research and Treatment of Cancer (EORTC) classification for primary cutaneous lymphomas1: mycosis fungoides (MF), the most common group of CTCLs, and CD30+ large T-cell lymphomas (CD30+) have an indolent clinical course; Sézary syndrome (SS) and CD30−large T-cell lymphomas (CD30−) have an aggressive clinical course; and pleomorphic small- to medium-sized CTCLs (PSMs) have a prognosis not yet well defined. Several studies, mostly focusing on the epidermotropic lymphomas of the MF and SS groups, have attempted to identify clinical, biological, histopathologic, or immunophenotypic characteristics that can predict outcome. So far, the main prognostic factors identified in this group are the type and extent of skin involvement, extracutaneous spread of the disease, initial response to treatment, histologic transformation, high serum level of lactate dehydrogenase (LDH), and the detection of a cutaneous or peripheral blood T-cell clone by polymerase chain reaction.2-14
As with other T-cell malignancies and Hodgkin disease, CTCLs are frequently associated with eosinophilia.3,13-18 In this context, eosinophilia has been related to the predominant secretion of T helper cell type 2 (TH2) eosinophilopoietic or eosinophilotactic cytokines (interleukin [IL] 3, IL-5, and sargramostim) by neoplastic cells.19-26 Since TH1 cells are likely to play a key role in the initiation and the persistence of an antitumoral response, while a predominant TH2 differentiation has been associated with a relative defect of the antitumoral and anti-infectious response,27 the hypothesis that eosinophilia might be an indicator of poor prognosis was raised. Accordingly, several studies investigating eosinophilia in Hodgkin disease found a worse relapse-free survival rate in patients with eosinophilia than in those without,28,29 despite 1 report of better overall survival;29 in a more recent study, tissue eosinophilia has been shown to be the strongest prognostic factor for poor relapse-free survival and overall survival in nodular sclerosing Hodgkin disease.30 In patients with CTCL, the relevance of blood eosinophilia has been suggested in 1 study,13 but so far, results from this early report have not prompted large-scale studies investigating this latter variable. In the present study, we retrospectively investigated the prognostic value of blood eosinophilia in a cohort of 104 patients with CTCL.
A total of 154 cases of CTCL were recorded in the hospital pathology register between January1982 and December 1998. For the present study, only patients with sufficient clinical information and follow-up were selected. For each patient, the diagnosis was based on the combination of clinical, histologic, and immunophenotypic criteria of the EORTC classification for primary cutaneous lymphomas. The study group included patients with MF, SS, and nonepidermotropic lymphoma (NEL): CD30+, CD30−, and PSM. Diagnostic criteria for SS, on which there is at present no consensus, were as follows: erythroderma, generalized lymphadenopathy, the presence of Sézary cells in skin and lymph nodes, and the presence of at least 5% circulating large Sézary cells.
The files of the included patients were retrospectively analyzed. The following variables were recorded: age at diagnosis, sex, diagnosis according to the EORTC classification, type of skin involvement at the time of diagnosis, date of disease progression, cause and date of death or date of last contact, whether there was a raised blood eosinophil absolute count (>700 × 109/L, upper limit of the 95% confidence interval [CI] of normal) and a raised serum level of LDH (>200 U/L, 10% or more above the upper limit of the normal range) at the time of diagnosis. Disease progression was defined as lymph node, visceral, or blood involvement in patients with previously more limited disease and/or histologic transformation.
For survival analysis, we considered only disease-specific death, defined as death related to CTCL or its specific treatment. Unrelated deaths (3 patients) were censored. All censored criteria were calculated from the date of diagnosis to the occurrence of an event (disease progression or disease-specific death) or last contact. Distributions over time were estimated by the Kaplan-Meier product limit method.31 The log-rank statistic32 was used to test the prognostic value of patient characteristics at the time of diagnosis for the occurrence of the event, and hazard ratios (HRs) with 95% CIs were obtained by use of univariable Cox models.33 Multivariable Cox models were used to determine independent prognostic variables.
Because of a limited number of events, no more than 2 variables were tested jointly in multivariable Cox models. Two-sided tests were computed, and P values of .05 or lower were considered significant. We used SAS software, version 8.2 (SAS Institute, Cary, NC), for our analysis.
Patients and characteristics at presentation
Of the 154 cases initially recorded, 50 were excluded for insufficient information (n = 34), diagnosis of lymphomatoid papulosis (n = 6), or a doubtful diagnosis (n = 10); thus, 104 patients were finally included: 66 men and 38 women with a median age of 56.5 years (range, 21-92 years). According to the EORTC classification, the diagnoses were 69 MF, 13 SS, and 22 NEL (7 CD30+, 4 CD30−, and 11 PSM). The main characteristics of patients and the type of skin involvement at the time of diagnosis are listed in Table 1. None of the patients with MF or NEL had evidence of extracutaneous disease at the time of diagnosis. Of the 104 patients, 24 (23%) had an increased serum level of LDH, and 28 (27%) presented with blood eosinophilia at the time of diagnosis (Table 2).
The initial treatment modality most commonly used for epidermotropic CTCL was topical mechlorethamine hydrochloride. Most patients with solitary or localized indolent NEL received radiotherapy, while patients with more generalized or aggressive NEL or epidermotropic CTCL with visceral involvement mostly received multiagent chemotherapy as first-line treatment.
The median follow-up was 43 months (range, 7-197 months). Twenty-one patients were lost to follow-up, their median follow-up being 13 months (range, 6-64 months).
The initial treatment resulted in complete clinical remission in 42 patients; 12 (28%) of them had subsequent relapse, with a median delay of 21 months (range, 4-84 months); 35 patients had partial or no remission. In 27 patients, information on the effect of initial therapy was insufficient. Estimated rates of disease progression and disease-specific death are listed in Table 3.
Prognostic variables for disease progression
Univariable analysis of initial variables possibly influencing disease progression revealed that diagnosis according to EORTC classification (SS vs MF), type of skin involvement (erythroderma vs patches), raised blood eosinophil absolute count, and a raised serum level of LDH at the time of diagnosis were significant prognostic factors (Table 4). The prognostic influence of eosinophilia is presented in the Figure 1. In multivariable analysis, only eosinophilia at the time of diagnosis was associated with disease progression.
Prognostic variables for disease-specific death
Concerning disease-specific death, the diagnosis according to the EORTC classification and a raised blood eosinophil absolute count at the time of diagnosis were statistically significant prognostic factors in univariable analysis (Table 5). In multivariable analysis, only eosinophilia at the time of diagnosis was associated with disease-specific death.
Prognostic analysis in the mf and ss groups
We further restricted the prognostic analysis to the epidermotropic MF and SS groups and found the same prognostic variables as in the whole group. Univariable analysis of initial variables possibly influencing disease progression revealed the following significant prognostic factors: diagnosis according to the EORTC classification (SS vs MF) (HR, 2.80; 95% CI, 1.05-7.48; P = .03); type of skin involvement (erythroderma vs patches) (HR, 2.91; 95% CI, 1.05-8.03; P = .04); raised blood eosinophil absolute count (HR, 7.31; 95% CI, 2.60-20.55; P<.001); and a raised serum level of LDH at the time of diagnosis (HR, 3.65; 95% CI, 1.44-9.27; P = .004). In multivariable analysis, only eosinophilia at the time of diagnosis was associated with disease progression.
In univariable analysis, significant predictive factors for disease-specific death were diagnosis according to the EORTC classification (HR, 7.30; 95% CI, 1.74-30.59; P = .001) and a raised blood eosinophil absolute count at the time of diagnosis (HR, 7.77; 95% CI, 1.65-36.6; P = .002). In multivariable analysis, only eosinophilia at the time of diagnosis was associated with disease-specific death.
In the present study, the prognostic value of the main initial characteristics of 104 patients with primary CTCL was investigated. Our results confirmed that diagnosis according to the EORTC classification, type of skin involvement, and increased LDH values are important prognostic factors in univariable analysis in patients with CTCL. In multivariable analysis, only blood eosinophilia at diagnosis was an independent prognostic factor for disease progression and disease-specific death in these patients. Direct comparison with previous prognostic studies is not feasible because these studies did not include eosinophilia in their analyses.2,3,6,7,10,13,14
Our study population was similar to most studies in age and male-female ratio.5,10,34 The estimated disease-specific death rate was also similar to that reported in the more recent studies.6,10,34,35
In our patients, primary CTCL was associated with blood eosinophilia in up to 20% of cases, comparable with previous reports.3,13,14 As in other types of lymphomas, it is presumed that in this context eosinophilia is due to the secretion of cytokines of the TH2 pattern by neoplasic cells.19-26 Indeed, it has been shown that patients with advanced CTCL exhibit a depressed cell-mediated immunity and that lymphocytes from these patients are deficient in IL-2 and interferon γ production while showing an increased production of IL-4, IL-5, and IL-10.36-42 On the other hand, the TH1 signal observed in the early stages of the disease is interpreted to indicate either normal trafficking lymphocytes or a tumor-infiltrating host response with a predominance of TH1 cytokines.37,39,41
In view of these notions, one might hypothesize that eosinophilia in patients with CTCL would correlate with the increased tumor burden and lead to excessive IL-5 production. However, since only eosinophilia at baseline was investigated in the present retrospective analysis, this latter hypothesis must be tested in further prospective, large-scale studies; changes in blood eosinophilia with clinical evolution or after treatment as well as tissue eosinophilia remain to be investigated. Such research might help to identify subgroups of patients who might benefit from immunotherapeutic approaches such as interleukin 12, interleukin 2, and interferon gamma, which are likely to correct the abnormal cytokine production observed in CTCL.25,43-47 However, our results strongly suggest that blood eosinophilia at baseline should now be considered a prognostic factor of poor outcome in patients with CTCL.
Correspondence: Emmanuelle Tancrède-Bohin, MD, Policlinique de Dermatologie, Hôpital Saint-Louis, Assistance Publique, Hôpitaux de Paris 1, avenue Claude Vellefaux, 75475 Paris CEDEX 10, France (email@example.com).
Accepted for publication September 24, 2003.
This work was presented in part at the annual meeting of the French Society of Dermatology, Journées Dermatologiques de Paris;December 6-9, 2000; Paris, France.
et al. EORTC classification for primary cutaneous lymphomas: a proposal from the Cutaneous Lymphoma Study Group of the European Organization for Research and Treatment of Cancer Blood.
1997;90354- 371PubMedGoogle Scholar
RT Prognostic factors in erythrodermic mycosis fungoides and the Sézary syndrome Arch Dermatol.
1995;1311003- 1008PubMedGoogle ScholarCrossref
AR Prognostic factors and evaluation of mycosis fungoides and Sézary syndrome J Am Acad Dermatol.
1997;3758- 67PubMedGoogle ScholarCrossref
et al. Prognostic significance of a polymerase chain reaction-detectable dominant T-lymphocyte clone in cutaneous lesions of patients with mycosis fungoides Blood.
1998;923376- 3380PubMedGoogle Scholar
RT Clinical charactristics and long-term outcome of patients with generalized patch and/or plaque (T2) mycosis fungoides Arch Dermatol.
1999;13526- 32PubMedGoogle Scholar
A Prognosis in cutaneous T-cell lymphoma by skin stage: long-term survival in 489 patients J Am Acad Dermatol.
1999;40418- 425PubMedGoogle ScholarCrossref
R Prognostic factor analysis in mycosis fungoides/Sézary syndrome J Am Acad Dermatol.
1999;40914- 924PubMedGoogle ScholarCrossref
et al. Transformation of mycosis fungoides: clinicopathological and prognostic features of 45 cases Blood.
2000;952212- 2218PubMedGoogle Scholar
SJ Detection of a peripheral blood T-cell clone is an independant prognostic marker in mycosis fungoides J Invest Dermatol.
2000;114117- 121PubMedGoogle ScholarCrossref
CWvan Voorst Vader
et al. Mycosis fungoides: disease evolution and prognosis of 309 Dutch patients Arch Dermatol.
2000;136504- 510PubMedGoogle ScholarCrossref
et al. Prognostic significance of tumor burden in the blood of patients with erythrodermic primary cutaneous T cell lymphomas Blood.
2001;97624- 630PubMedGoogle ScholarCrossref
KD Quantifying skin disease burden in mycosis fungoides-type cutaneous T-cell lymphoma: the severity-weighted assessment tool (SWAT) Arch Dermatol.
2002;13842- 48PubMedGoogle Scholar
et al. Histopathologic staging at initial diagnosis of mycosis fungoides and the Sézary syndrome: definition of three distinctive prognostic groups Ann Intern Med.
1988;109372- 382PubMedGoogle ScholarCrossref
JM Prognostic clinicopathologic factors in cutaneous T-cell lymphoma Arch Dermatol.
1991;1271511- 1516PubMedGoogle ScholarCrossref
Jvan der Does
A The association of eosinohilia with lymphoblastic leukemia or lymphoma: a study of seven patients Br J Haematol.
1980;45523- 534PubMedGoogle ScholarCrossref
L Detection of interleukin-5 messenger RNA in Reed-Sternberg cells of Hodgkin's disease with eosinophilia Blood.
1990;7513- 15PubMedGoogle Scholar
et al. Role of granulocyte-macrophage colony-stimulating factor, interleukin-3 and interleukin-5 in the eosinophilia associated with T cell lymphoma Br J Haematol.
1993;83359- 364PubMedGoogle ScholarCrossref
LJ Sézary syndrome with elevated serum IgE and hypereosinophilia: role of dysregulated cytokine production J Allergy Clin Immunol.
1993;92123- 131PubMedGoogle ScholarCrossref
et al. CD3-CD4+ cells with a Th2-like pattern of cytokine production in the peripheral blood of a patient with cutaneous T cell lymphoma Leukemia.
1997;111983- 1985PubMedGoogle ScholarCrossref
et al. Eosinophilia associated with adult T cell leukemia: role of interleukin-5 and granulocyte-macrophage colony-stimulating factor Am J Hematol.
1998;59242- 245PubMedGoogle ScholarCrossref
G Sézary syndrome, T-helper 2 cytokines and accessory factor-1 (AF-1) Leuk Lymphoma.
1998;28515- 522PubMedGoogle Scholar
et al. Increased interleukin 5 production in eosinophilic Sézary syndrome: regulation by interferon alfa and interleukin 12 J Am Acad Dermatol.
2001;4428- 32PubMedGoogle ScholarCrossref
et al. Spontaneous interleukin-5 production in cutaneous T-cell lymphoma lines is mediated by constitutively activated stat3 Blood.
2002;99973- 977PubMedGoogle ScholarCrossref
B Infiltration of eosinophils in Hodgkin's disease involved lymph nodes predicts prognosis Hematol Oncol.
1993;11187- 193PubMedGoogle ScholarCrossref
R Blood eosinophilia in Hodgkin's disease: a follow-up of 25 cases in Venezuela Cancer.
1992;691248- 1253PubMedGoogle ScholarCrossref
et al. Tissue eosinophilia correlates strongly with poor prognosis in nodular sclerosing Hodgkin's disease, allowing for known prognostic factors Blood.
2000;951207- 1213PubMedGoogle Scholar
P Non parametric estimation from incomplete observations J Am Stat Assoc.
1958;53457- 481Google ScholarCrossref
J Asymptotically efficient rank invariant test procedures J R Stat Soc.
1972;135185- 206Google Scholar
D Regression models and life tables (with discussion) J R Stat Soc.
1972;34187- 220Google Scholar
JF The changing survival of patients with mycosis fungoides: a population-based assesment of trends in the United-states Cancer.
1999;85208- 212PubMedGoogle ScholarCrossref
AH Aberrant cytokine production by Sézary syndrome patients: cytokine secretion pattern resembles murine Th2 cells J Invest Dermatol.
1992;9990- 94PubMedGoogle ScholarCrossref
ST The immunopathogenesis of cutaneous T-cell lymphoma: abnormal cytokine production by Sézary T cells Arch Dermatol.
1993;129486- 489PubMedGoogle ScholarCrossref
BJ Mycosis fungoides exhibits a Th1-type cell-mediated cytokine profile whereas Sézary syndrome expresses a Th2-type profile J Invest Dermatol.
1994;10329- 33PubMedGoogle ScholarCrossref
et al. Th2 cytokine mRNA expression in skin in cutaneous T-cell lymphoma J Invest Dermatol.
1994;103669- 673PubMedGoogle ScholarCrossref
et al. Sézary syndrome T-cell clones display T-helper 2 cytokines and express the accessory factor-1 (interferon-gamma receptor beta-chain) Blood.
1996;881383- 1389PubMedGoogle Scholar
et al. Cutaneous T-cell lymphoma reactive CD4+ cytotoxic T lymphocyte clones display a Th1 cytokine profile and use a Fas-independent pathway for specific tumor cell lysis J Invest Dermatol.
2000;11574- 80PubMedGoogle ScholarCrossref
T Interleukin 4 and interferon-γ expression of the dermal infiltrate in patients with erythroderma and mycosis fungoides: an immuno-histochemical study J Cutan Pathol.
2000;27429- 435PubMedGoogle ScholarCrossref
PA Interferon in the treatment of cutaneous T-cell lymphoma Hematol Oncol Clin North Am.
1995;91089- 1107PubMedGoogle Scholar
et al. Il-12 reverses cytokine and immune abnormalities in Sézary syndrome J Immunol.
1995;1541491- 1498PubMedGoogle Scholar
et al. High-dose recombinant interleukin-2 in advanced cutaneous T-cell lymphoma Arch Dermatol.
1995;131574- 579PubMedGoogle ScholarCrossref
et al. Interleukin-12 therapy of cutaneous T-cell lymphoma induces lesion regression and cytotoxic T-cell responses Blood.
1999;94902- 908PubMedGoogle Scholar
et al. Synergistic enhancement of cell-mediated immunity by interleukin-12 plus interleukin-2: basis for therapy of cutaneous T cell lymphoma J Invest Dermatol.
2002;118366- 371PubMedGoogle ScholarCrossref