Clinical outcomes in a cohort of patients with cutaneous T-cell lymphoma and COVID-19 (2022)

To the Editor: Patients with malignancies are at risk of poor outcomes from COVID-19.1Zhang H. Han H. He T. et al.Clinical characteristics and outcomes of COVID-19-infected cancer patients: a systematic review and meta-analysis.J Natl Cancer Inst. 2021; 113: 371-380Crossref PubMed Scopus (78) Google Scholar In particular, the death rate of patients with hematologic malignancies is reported to be 14% within 1 month of COVID-19 diagnosis.2Kuderer N.M. Choueiri T.K. Shah D.P. et al.Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study.Lancet. 2020; 395: 1907-1918Abstract Full Text Full Text PDF PubMed Scopus (914) Google Scholar It remains unclear whether patients with cutaneous lymphomas are at comparable risk. One study reported that patients with cutaneous lymphomas infected with SARS-CoV-2 have the same susceptibility and outcomes as those without cutaneous lymphomas infected with SARS-CoV-2.3Elmasry M.F. Youssef R. Elbendary A. Helmy K. Abdelkader H.A. Cutaneous lymphomas and COVID-19: what is known so far?.Dermatol Ther. 2021; 34e14463Crossref Scopus (4) Google Scholar However, advanced age and long-term immunosuppressive therapy may place patients with cutaneous lymphomas at risk of life-threatening complications.4Zic J.A. Ai W. Akilov O.E. et al.United States cutaneous lymphoma consortium recommendations for treatment of cutaneous lymphomas during the COVID-19 pandemic.J Am Acad Dermatol. 2020; 83: 703-704Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 5Sánchez-Velázquez A. Bauer-Alonso A. Estrach T. et al.Patients with primary cutaneous lymphoma are at risk for severe COVID-19. Data from the Spanish primary cutaneous lymphoma registry.J Eur Acad Dermatol Venereol. 2021; 35: e624-e626https://doi.org/10.1111/jdv.17430Crossref PubMed Scopus (2) Google Scholar We aimed to assess the impact of COVID-19 on patients with primary cutaneous T-cell lymphomas (CTCLs) at our institution. Our study was conducted with the approval of the institutional review board at the University of Michigan. We retrospectively reviewed patient records for individuals diagnosed with CTCL at Michigan Medicine from 2010 to 2022. Patients deceased before February 1, 2020, were excluded. In our cohort of 384 patients with cutaneous lymphoma seen in our health system since January 1, 2010, we identified 24 patients with CTCL who tested positive for COVID-19. To understand the risk factors for patients who tested positive for COVID-19, we performed a retrospective analysis of lymphoma-related disease history. A summary of the patient demographics and CTCL history at the time of COVID-19 infection is provided in Table I. Our cohort includes 13 men and 12 women with a median age of 57.08 years (range, 18-88 years). Diagnoses ranged from lymphomatoid papulosis to mycosis fungoides with large cell transformation, leukemic involvement, or erythroderma (Sezary syndrome). The majority of cases were patients with stage IA or IB disease (13 cases, 52%). A smaller subset had stage II-IV disease (Table II). Seven cases (28%) were being treated with systemic approaches.Table IClinical summary of CTCL patients with COVID-19DemographicsNumber of cases (%)Sex Male13 (52.0) Female12 (48.0)Age, y, median (range)57.08 (18-88)Race/ethnicity White20 (80.0) Black3 (12.0) Hispanic1 (4.0) Not specified1 (4.0)Diagnosis MF, NOS7 (28.0) Folliculotropic MF3 (12.0) MF-LCT2 (8.0) MF with leukemic involvement1 (4.0) Sezary syndrome2 (8.0) CD4+ lymphoproliferative disorder2 (8.0) Hypopigmented MF2 (8.0) MF with LyP2 (8.0) CTCL-NOS1 (4.0) Syringotropic MF1 (4.0) LyP2 (8.0) Duration of disease, mo, mean (range)55 (1-156)Stage at COVID-19 diagnosis IA/B13 (52.0) IIA/B3 (12.0) III-IV3 (12.0) LyP2 (8.0) Quiescent3 (12.0) Unavailable1 (4.0)LCT, Large cell transformation; LyP, lymphomatoid papulosis; MF, mycosis fungoides; NOS, not otherwise specified. Open table in a new tab Table IIDemographics, CTCL disease history, and COVID-19 related outcomesCaseAgeSexEthnicityDiagnosisStageLymphoma treatmentDuration of disease (mo)ComorbiditiesCOVID-19 vaccination historyHospitalization for COVID-19Complication from COVID-19Status after COVID-19176MWhiteMF, NOSIATriamcinolone43Hypertension, obesity3 dosesNoN/ALiving235MWhiteMF, NOSIATriamcinolone36Asthma, smoking history0 dosesNoN/ALiving358FWhiteMF, NOSIAClobetasol121Hypertension, obesity, smoking history3 dosesNoN/ALiving467FWhiteMF, NOSIABetamethasone, UV-B phototherapyUnknown (>20 years)None2 dosesYesPneumonia, ARDSLiving558FBlackCTCL, NOS1ABetamethasone, psoralen–UV-A with methoxsalen35Hypertension, obesity, smoking history0 doses∗Infection before vaccine availability.NoN/ALiving650FWhiteMF-LyPIATriamcinolone26None0 dosesNoN/ALiving718MWhiteMF -LyPIAUV-B phototherapy, desoximetasone26None0 doses∗Infection before vaccine availability.NoN/ALiving863FBlackHypopigmented MFIATriamcinolone74Hypertension, smoking history0 doses∗Infection before vaccine availability.NoN/ALiving974FWhiteMF, NOSIBTriamcinolone46Asthma, smoking history0 doses∗Infection before vaccine availability.NoN/ALiving1044MHispanicMF, NOSIBTriamcinolone, hydrocortisone, fluocinolone, Vitamin D, prednisone, methotrexate48Hypertension, obesity, smoking history1 doseYesN/ALiving1125MN/AHypopigmented MFIBNatural sunlight therapy, Triamcinolone48None0 dosesNoN/ALiving1265FWhiteFolliculotropic MFIBTargretin, Triamcinolone72Hypertension0 doses∗Infection before vaccine availability.NoN/ALiving1373MWhiteFolliculotropic MFIBClobetasol, triamcinolone, UV-B phototherapy, mupirocin40Smoking history1 doseNoN/ALiving1478FWhiteMF with leukemic involvementIBMogamulizumab, betamethasone, triamcinolone89Hypertension0 doses∗Infection before vaccine availability.NoN/ALiving1549MBlackFolliculotropic MFIIBTargretin, urea, fluocinonide, triamcinolone23Smoking history3 dosesNoN/ALiving1627FWhiteMF-LCTIIBPralatrexate, clobetasol, triamcinolone, UV-B phototherapy6None0 dosesNoN/ALiving1757FWhiteMF-LCTIIBMogamulizumab, doxycycline, clobetasol, radiation72Obesity, smoking history2 dosesNoN/ALiving1873MWhiteSezary syndromeIVMogamulizumab, clobetasol, triamcinolone11Hypertension2 dosesYesReadmission for deliriumLiving1988MWhiteMF, NOSIVA1Doxycycline, clobetasol, hydroxyzine, ibrutinib53Waldenstrom's macroglobulinemia0 doses∗Infection before vaccine availability.YesPneumoniaDeceased2074MWhiteSezary syndromeIVECP, triamcinolone1COPD, smoking history3 dosesNoECP treatment delayLiving2174FWhiteSyringotropic MFQuiescentObservation141Smoking history0 dosesNoNoneLiving2227MWhiteLyPN/AClobetasol28None2 dosesNoNoneLiving2366FWhiteLyPN/AObservation156Smoking history0 doses∗Infection before vaccine availability.NoNoneLiving2453MWhiteCD4 Lymphoproliferative diseaseQuiescentObservation52Diabetes mellitus, kidney transplant, hypertension, obesity2 dosesNoNoneLiving2555MWhiteCD4 Lymphoproliferative diseaseQuiescentObservation73Obesity0 dosesNoNoneLivingARDS, Acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; ECP, extracorporeal photopheresis; F, female; LCT, large cell transformation; LyP, lymphomatoid papulosis; M, male; MF, mycosis fungoides; NOS, not otherwise specified.∗ Infection before vaccine availability. Open table in a new tab LCT, Large cell transformation; LyP, lymphomatoid papulosis; MF, mycosis fungoides; NOS, not otherwise specified. ARDS, Acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; ECP, extracorporeal photopheresis; F, female; LCT, large cell transformation; LyP, lymphomatoid papulosis; M, male; MF, mycosis fungoides; NOS, not otherwise specified. Individual cases are described in Table II. Of note, 4 patients were hospitalized because of COVID-19, including 2 of the 3 patients with advanced disease (stage III-IV). One of these patients died because of complications from COVID-19 (case 19). The other patient with advanced disease (case 20) experienced an extracorporeal photopheresis treatment delay because of symptoms and visitation policies, suggesting that COVID-19 infection may have indirect effects on CTCL outcomes. Our retrospective analysis suggests that patients with CTCL, particularly those with advanced disease, are at risk of severe COVID-19. Our study has several limitations, including its small sample size and retrospective design. Given a multitude of factors, including barriers to testing and asymptomatic infections, it is likely that our findings are skewed toward severe disease. Nonetheless, our findings emphasize the importance of risk-reduction counseling for at-risk patient populations, including those with CTCLs. None disclosed.