Supportive Care for T-Cell Lymphomas

Erin Kopp, ACNP-BC

As part of our coverage of the 11^th Annual National Comprehensive Cancer Network (NCCN) Hematological Malignancies Congress, held September 30–October 1 in New York, we are speaking with Erin Kopp, an acute care nurse practitioner at the City of Hope Comprehensive Cancer Center in California, about the management of T-cell lymphomas. Erin will be giving the presentation, “Supportive Care in the Management of T-Cell Lymphomas”at the conference.

- Interviewed by Anna Azvolinsky 

Cancer Network: Could you define the different types of T-cell lymphomas, and are there different approaches to their management?

Erin Kopp: T-cell lymphomas are a very heterogeneous group of lymphomas. In particular, in my presentation, I will be discussing the different cutaneous or skin-based T-cell lymphomas vs the peripheral T-cell lymphomas. So in cutaneous you see mycosis fungoides about 80% to 85% of the time, and then its more aggressive leukemic-type version that is systemic in the blood, Sézary syndrome. Those are probably the two most common.

Then, when you are dealing with peripheral T-cell lymphoma, there are many different variants including anaplastic large-cell lymphoma, adult T-cell leukemia/lymphoma, and peripheral T-cell lymphoma not otherwise specified. I think what is of interest is that T-cell lymphoma does not have to originate or reside in lymph nodes-for instance, there is hepatosplenic T-cell lymphoma and NK/T-cell lymphoma. So there are so many different types of T-cell lymphoma, and the number and types of treatments correspond to those.

Cancer Network: Could you briefly define supportive care in this setting, what are the types of care that fall into this category?

Erin Kopp: When we are dealing with supportive care, it’s twofold. The disease itself causes multiple side effects, multiple symptoms that the patient will have to deal with that can significantly impact their quality of life. So supportive care in that sense is aimed at minimizing these symptoms and maximizing their quality of life. For cutaneous T-cell lymphoma, we tend to see a tremendous amount of pruritus. In addition there is a risk for infection, fatigue, skin sloughing, and erythema. So you have people who are walking around who may be disfigured by the disease by the time it gets to the tumor stage, because it can go from patches to plaques to tumors. All of these symptoms have a lasting impact on the patient. When you are dealing with peripheral T-cell lymphoma, depending on where it originates and where it manifests you can also be dealing with symptoms related to the disease such as fevers, chills, fatigue, gastrointestinal symptoms, and nausea and vomiting.

While you have treatments that are directed to cure or to induce a remission, whether it be chemotherapy or monoclonal antibodies that are directed at stopping the disease, the supportive care is going to be managing symptoms of the disease, and in addition to that, managing and minimizing the toxicities from the treatments for some very important reasons. We want to be able to minimize the toxicity so that the patient can tolerate the treatment, so that they can get the doses on a schedule that we need them to be on for the medication to be effective, and so that we can have long-term adherence to therapy, if possible. So when we are dealing with toxicities from treatment, again, you might be dealing with skin irritation from topical effects for cutaneous T-cell all the way to severe emetogenesis to tumor lysis syndrome when dealing with patients with peripheral T-cell lymphoma.

Cancer Network: What are some of the treatment options for symptom management that patients with T-cell lymphomas may require?

Erin Kopp: I would start with the cutaneous form. As I mentioned, pruritus is the number one symptom patients complain about because it can be all-consuming. And unfortunately, it’s the most difficult to treat. We have used everything from aprepitant (Emend), which is traditionally an anti-emetic therapy, topical corticosteroids, to encouraging patients to put ointments in the refrigerator-when they apply the ointment to their skin it helps to mitigate some of that pruritus. We also have used light therapy-narrow band, UVB therapy-to eliminate some of the pruritus. Some of the antidepressants, specifically doxepin, can be effective. There are multiple studies on using naloxone to try to minimize pruritus.

When we are talking about preventing infection, we recommend bleach baths. Bleach baths have been studied in children with eczema and psoriasis and have been incredibly effective in minimizing the colonization of bacteria on the skin-which is critical in someone who has skin breaks everywhere-to prevent infection. So we will recommend weekly or sometimes twice-a-week bleach baths (1/4 cup to a full cup depending on the amount of water in the bath), and the patient will sit in that for 10–15 minutes and that will help get rid of some of the colonizing bacteria.

For cutaneous T-cell lymphoma, one of the biggest things is moisturizing the skin. It may seem so simple that patients might balk at it because they have lymphoma and think, What can using a protective cleanser or moisturizer do to help me? But dry skin is more irritated skin, it’s itchier, more red, flakes more often, and it is more susceptible to infection.

That is for the general disease. One particular skin-directed therapy, nitrogen mustard topical ointment, in and of itself causes irritation of the skin. That is an expected side effect so we often have patients apply it at night, and then in the morning apply a topical corticosteroid to minimize that irritation so that the patient can continue with the treatment.

In peripheral T-cell lymphoma, nausea is one of the biggest side effects of histone deacetylase (HDAC) inhibitors like romidepsin-we find that patients have a very difficult time. The regimen we use is romidepsin once a week for 3 weeks out of 4. Patients will report that they are so nauseated that they cannot eat until day 3 or 4 days post-treatment, so we have to aggressively manage that nausea and vomiting. We often use granisetron, which tends to be effective alone, or in combination with a benzodiazepine, and we often have to plan for infusions of fluids to manage the dehydration that comes along with their inability to get adequate fluids.

With medications like brentuximab vedotin, we see a lot of neuropathy. We constantly have to assess the patient’s neuropathy, and then adjust doses as appropriate and use medications including pregabalin (Lyrica) and some of the selective serotonin–norepinephrine reuptake inhibitors that can help mitigate some of those symptoms. On top of that in peripheral T-cell lymphoma you have chemotherapy regimens that have all of the side effects that may go along with cytotoxic therapy-fatigue, pancytopenias-and we are providing supportive care with transfusions, surveillance to make sure people are not getting infections, and prophylactic antibiotics. So there are multiple approaches that are required for this patient population.

Cancer Network: You mentioned some newer agents used for the treatment of T-cell lymphomas. In general, is it mostly chemotherapies that result in toxicities requiring supportive care, or is it treatments across the board?

Erin Kopp: Unfortunately, it is across the board, and it is unique to each type of medication that we use. For instance, I will be discussing tumor lysis syndrome in my presentation, and that is quite common with monoclonal antibodies. If there is a high tumor burden with the individual patient-almost regardless of therapy-and we are aggressively treating, we can see something like tumor lysis syndrome that needs aggressive hydration and management of fluid and electrolytes and balances and management of uric acid. But you are also looking at things that we talked about with brentuximab vedotin, which is neuropathy.

When we are using lenalidomide we are looking more at risks for clots, and we are watching for pancytopenias, predominantly thrombocytopenia. We use a lot of romidepsin and lenalidomide together and when you use combination therapies you have to deal with the side effect profile from each drug. And when you look even at light therapy (if you are using narrow band UVB therapy), you don't have the risk of skin cancers in the future but you do have photosensitivity and need consistent monitoring to make sure the skin is not flaking, peeling, and to make sure that the skin is moisturized. Then if you have to deal with something like photochemotherapy (PUVA), or UVA with psoralen, you do have an increased risk of cancer in the future. So these patients, regardless of the therapy we use, do have a unique set of challenges to face and require a high level of supportive care. And even if we never treated the patients, just the diseases themselves cause so many symptoms that affect quality of life.

Cancer Network: Thank you so much for joining us today, Erin, and enjoy the conference.

Erin Kopp: Thank you.