UKCLG Guidelines for Primary Cutaneous Lymphomas

Transcription

1 UKCLG Guidelines for Primary Cutaneous Lymphomas Sean Whi:aker Di Gilson Fiona Child Julia Scarisbrick Tim Illidge Eileen Parry Katy Rezvani Claire Dearden and Stephen Morris

2 Diagnosis, staging, prognosis & treatment Clinical outcomes (mswat & global score) Trial endpoints NICE IOG model NHSE CRG service specificaron

3 CL-App

4

5 Clinical Pathway for Cutaneous Lymphomas Adapted from NICE IOG for skin cancers including melanoma Category Specialist MDT Supra- network MDT Low risk (IA- IIA) MF Required OpRonal Intermediate risk (IA- IIA) MF Required EssenRal Stage III erythrodermic MF/SS Required EssenRal High risk (IIB/IV) MF/SS Required EssenRal pccd30+lymphoproliferarve disorders OpRonal OpRonal CTCL variants Required EssenRal CBCL OpRonal OpRonal

6 AJCC Clinical Staging for MF/SS Stage T N M B IA ,1 IB ,1 IIA 1,2 1,2 0 0,1 IIB ,1 IIIA IIIB IVA IVA IVB Adapted from Olsen et al 2007

7 MulRvariate Factors Adverse factor HR 95% CI p-value Early Male > 60 years Plaques Folliculotropic <0.001 < N1/Nx <0.001 Late Male > 60 years B1/B2 N2/N <0.001 Visceral (M1) Mul$variate factors iden$fied in Agar et al JCO Benton et al EJC 2013

8 Cutaneous Lymphoma PrognosRc Index (CLIPi): Overall Survival Risk Group No of Risk Factors N (%) OS 5yr (%) OS 10yr ( %) I Low (45.6) Early II Intermediate 2 330(31.2) III High (23.2) I Low (29.9) Late II Intermediate 2 178(40.0) III High (30.1) Benton et al 2013 EJC

9 Cutaneous Lymphoma PrognosRc Index (CLIPi): Overall Survival Early stage model Late stage model Survival Time (years) Survival Time (years) Risk group Low Intermediate High Risk group Low Intermediate High Benton et al EJC 2013

10 Treatment Algorithm for MF/SS Prognos;c group (stage) 1 st line 2 nd line Experimental Low risk (IA- IIA) Expectant or SDT SDT Intermediate risk (IA- IIA) SDT; PUVA+IFN; PUVA +Bex; TSEBT; Stage III erythrodermic High risk (IIB/IV) MTX; ECP/IFN/Bex combinarons; Trials; Radiotherapy (including TSEBT); Chemotherapy; Trials; HDACi; Ontak; Trials; Alemtuzumab; Chemo; TSEBT; HDACi; Ontak; Trials; HDACi; Ontak; Trials; PalliaRve therapy; RicAlloSCT RicAlloSCT SDT - skin directed therapy: Topical therapy; Phototherapy (TLO1/PUVA); Radiotherapy; TSEBT total skin electron beam therapy; IFN alpha interferon; Bex bexarotene; HDACi histonedeacetylase inhibitors (vorinostat/romidepsin)* ECP extracorporeal photopheresis; MTX methotrexate; Ontak DenileukindifiRtox RicAlloSCT reduced intensity condironed allogeneic stem cell transplant;

11 Treatment Algorithm for Primary Cutaneous CD30+ LymphoproliferaRve disorders Disease 1 st line 2 nd line Exp Lymphomatoid papulosis Expectant; SDT; Radiotherapy MTX; IFN; AnaplasRc large cell lymphoma Surgical excision; Radiotherapy; MTX CHOP Brentuximab SDT - skin directed therapy: Topical therapy; Phototherapy (TLO1/PUVA); Radiotherapy; IFN alpha interferon; MTX methotrexate; Surgical excision solitary lesions

12 Treatment Algorithm for CTCL Variants Disease 1 st line 2 nd line Exp SPTCL Prednisolone; Radiotherapy CHOP Epidermotropic CD8+ CTCL Small medium pleomorphic CTCL Chemotherapy; TSEBT Surgical excision; Radiotherapy RicAlloSCT TSEBT total skin electron beam therapy; RicAlloSCT reduced intensity condironed allogeneic stem cell transplant;

13 Staging System Non MF/SS Adapted from Kim et al 2007

14 Treatment Algorithm for CBCL Prognos;c group (stage) 1 st line 2 nd line pcfcl/pcmzl Localised T1- T2b Excision; Expectant; RT RT; Intralesional Rituximab; Extensive T2c- T3 Chlorambucil; Rituximab; CVP- R or CHOP- R; Advanced N1-3 or M1 CVP- R or CHOP- R; RT; High dose chemo/auto SCT; pcdlbcl - leg CHOP- R 3-6 cycles +/- RT BSC; RT; High dose chemo/auto SCT pcdlbcl other including AnaplasRc/Pleomorphic T cell/hisrocyte rich and Intravascular Large B cell lymphoma CHOP- R RT as palliaron High dose chemo and Auto SCT RT: Local skin Radiotherapy; CHOP- R: Cyclophosphomide Doxorubicin VincrisRne Prednisolone Rituximab; Auto SCT: Autologous Stem cell transplant

15 UK CTCL Trial OpRons KKP- 010 Phase III study: AnR- CCR4 (KW- 0761) vs Vorinostat in refractory stage IB- IV MF/SS - 1 prior systemic agent; No LCT; (Endpoint - PFS) C25001 Phase III study: SGN- 35 vs physicians choice of MTX or BEX in CD30+ (>10%) MF stage IB- IV and primary cutaneous CD30+ ALCL (Endpoint - ORR) SGN Open label study: SGN- 35 in parents on physicians choice in C25001 who progress (treatment opron protocol)

16 Future Needs NCIN Audit CRG SpecificaRon UKCLG Clinical Outcomes UKCLG Clinical Trials in CTCL