Progression of undiagnosed cutaneous lymphoma after anti–tumor necrosis factor-alpha therapy

Abstract

Our findings suggest that the disease of most of the identified patients was misdiagnosed as psoriasis or eczema; therefore, a comprehensive morphologic and molecular review of skin biopsy specimens and peripheral blood samples should be considered before initiation of anti-TNF-α therapy in patients with poorly defined dermatitis or atypical presentations of psoriasis.

Mycosis fungoides after treatment with tumor necrosis factor‐alpha inhibitors for psoriasis: progression or onset?

“…Acknowledging the possible coexistence and/or progression of both diseases, several authors recommend performing a skin biopsy for patients with presumed psoriasis before introducing systemic therapy, especially when presenting with poorly defined lesions or atypical presentations . None of our cases had histological confirmation of psoriasis before starting etanercept treatment.…”

“…Tumor necrosis factor (TNF)‐α inhibitors are widely used to treat a myriad of inflammatory dermatoses, on‐and‐off label, due to their proven clinical benefit . However, their potent immunosuppressive effect can cause serious side effects including the development of skin cancer.…”

“…However, their potent immunosuppressive effect can cause serious side effects including the development of skin cancer. Although the effect of chronic use of immunosuppressants, including TNF‐α inhibitors, on the incidence of cutaneous T‐cell lymphomas (CTCL) remains controversial, approximately 35 cases of CTCL arising after anti‐TNF‐α therapy have been reported in the English literature . We present two cases of mycosis fungoides (MF) diagnosed after exposure to etanercept for the treatment of psoriasis.…”

“…The link between psoriasis, MF, and anti‐TNF‐α agents remains elusive . The pathogenesis of both psoriasis and MF is strictly related to the abnormal function of skin‐homing T‐cells, specifically Th1 and Th17 populations; and several studies have identified an increased relative risk for lymphomas, including CTCLs, in psoriatic patients . The explanation underlying these results may lie on the chronic lymphocyte‐driven inflammatory state of psoriasis plus the use of immunosuppressive therapies, such as anti‐TNF‐α agents, helping select a malignant T‐cell clone, provoking the development of CTCL …”

“…Given the considerable clinical and histological overlap that early‐stage MF has with other inflammatory dermatoses including psoriasis, misdiagnosis has been recognized as a factor that may account for the higher risk of CTCLs seen in psoriatic patients . However, Donigan et al .…”