Cutaneous T cell lymphomas

EDITOR, - We were disappointed by the slightly negative emphasis of Paul A Bunn Jr's editorial on cutaneous T cell lymphomas.1 Understanding of the whole range of cutaneous T cell lymphomas and their management has progressed considerably in recent years, and it is now clear that there are many variants of primary cutaneous T cell lymphoma with differences in clinical behaviour and prognosis.

We disagree with Bunn's comment that “systematic dissemination is an early feature of all types of lymphomas.” In the experience of our skin tumour unit many cases of unequivocal mycosis fungoides have a benign course, and only the minority rapidly progress to systemic disease. Most patients can be maintained on photochemotherapy (treatment with psoralens and ultraviolet A) for long periods and do not need topical nitrogen mustard. The challenge is to try to determine which of the patients who present with early stage disease are likely to have an unfavourable prognosis.

We applaud Bunn's desire for increased numbers of controlled clinical trials. The European Organisation for Research and Treatment of Cancer's Cutaneous Lymphoma Project Group, of which there are histopathological and clinical sections, has been active in the past few years. A register of cutaneous lymphomas has been set up, and data from over 20 European centres are being accumulated long term. Every clinician who contributes cases has access to the computerised data from other centres. The group is already carrying out clinical trials in mycosis fungoides, an example being a study of whether alfa-2a interferon can prolong remission that has been induced by other modalities such as psoralens and ultraviolet A. In our unit most patients with mycosis fungoides of patch and plaque stage find that their symptoms are well controlled with a combination of photochemotherapy and orthovoltage radiotherapy to individual thick cutaneous lesions.

Finally, we were disappointed that Bunn did not mention photopheresis. Since the original paper reporting encouraging results in a multicentre study was published2 there has been wide experience in Europe with this technique. Although the results from many centres are not as good as those originally reported, clearly photopheresis has a useful role in the management of some forms of cutaneous T cell lymphoma, particularly erythrodermic cutaneous T cell lymphoma and the Sezary syndrome.^3,4 These variants of cutaneous T cell lymphoma can be particularly aggressive, and there is no reliably effective alternative treatment.

The recent founding of the International Society for the Study of Cutaneous Lymphomas, which has a large proportion of members from Europe, should permit important research and carefully controlled clinical trials in this challenging group of disorders.