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Prognostic Significance of Serum Copper in Patients With Cutaneous T-cell Lymphoma
Original Study
Prognostic Significance of Serum Copper in Patients With Cutaneous T-cell Lymphoma Eric C. Vonderheid,1 Andrew R. Martinez2 Abstract Greater than normal serum copper levels in a subset of patients with early mycosis fungoides lymphoma correlated with a worse prognosis compared with that of patients with normal copper levels. The reason for this association is unknown. We hypothesized that inflammatory cytokines such as interleukin-6 secreted by inflammatory cells in skin lesions might play a role in disease progression. Background: Serum copper has been reported to be increased in various cancers, including lymphoma. The purpose of the present study was to investigate the clinical and prognostic importance of serum copper levels in patients with cutaneous T-cell lymphoma (CTCL). Patients and Methods: Serum copper was measured in 60 men and 38 women with mycosis fungoides (MF) and 14 men and 3 women with erythrodermic CTCL (6 with Sézary syndrome) consecutively evaluated from July 1980 to June 1985. Results: A greater than normal copper level was present in nearly 20% of patients and was associated with an increased risk of disease progression and shortened diseasespecific survival for patients with patch or plaque phase MF, but not for those with tumor phase MF or erythrodermic CTCL. In contrast, the serum lactate dehydrogenase level and neutrophil/lymphocyte ratio were not significantly associated with prognosis in our patient cohort. Conclusion: The reason for the association between the high serum copper levels and adverse prognosis is unknown. We hypothesized that interleukin-6 is secreted primarily by non-neoplastic cells at MF skin sites, leading to release of copper by the liver. Local production of interleukin-6 at the lesion sites might conceivably also promote neoplastic cell progression by stimulation of the STAT3 pathway. Further studies on the relationship between activated tumor-associated macrophages, serum copper levels, interleukin-6, or C-reactive protein and prognosis might be informative. Clinical Lymphoma, Myeloma & Leukemia, Vol. 19, No. 4, 228-38 ª 2018 Elsevier Inc. All rights reserved. Keywords: Erythroderma, Interleukin-6, Lactate dehydrogenase, Mycosis fungoides, Neutrophil/lymphocyte ratio
Introduction Primary cutaneous T-cell lymphoma (CTCL) is a non-Hodgkin lymphoma in which neoplastic T cells present initially in the skin. The most common manifestation of CTCL is mycosis fungoides (MF), which typically presents as patches or thin plaques, often on nonesun-exposed regions, with the potential to progress to tumid plaques, nodules or tumors, and involvement of lymph nodes and visceral organs.1 In addition to this classic presentation, many clinicopathologic variants of MF have been described, which can be confused with various inflammatory dermatoses.2
1
Johns Hopkins Medical Institutes, Baltimore, MD University of Arizona, Tucson, AZ
2
Submitted: Oct 3, 2018; Revised: Nov 20, 2018; Accepted: Dec 26, 2018; Epub: Jan 2, 2019 Address for correspondence: Eric C. Vonderheid, MD, 37580 South Desert Sun Drive, Tucson, AZ 85739 E-mail contact: [email protected]
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Clinical Lymphoma, Myeloma & Leukemia April 2019
The skin lesions of early MF are characterized by small- to medium-size atypical T cells with irregular to hyperconvoluted “cerebriform” nuclei within the epidermis (epidermotropism) and a lymphohistiocytic infiltrate in the superficial dermis that might or might not contain neoplastic or other inflammatory cells.3 With disease progression to more infiltrated plaques and tumors, both the depth of the dermal infiltrate and proportion of neoplastic cells within the dermal infiltrate will increase. Also, the neoplastic cells could become larger, with vesiculated nuclei indicative of transformation to large cell lymphoma. The second most common clinical presentation of CTCL is generalized or nearly generalized diffuse erythroderma (ie, erythrodermic CTCL [E-CTCL]). In the current terminology, Sézary syndrome (SS) refers to E-CTCL with high numbers of neoplastic T cells with hyperconvoluted “cerebriform” nuclei (Sézary cells) in the blood (i.e., “leukemic” E-CTCL).4 In addition to absolute Sézary cell counts of 1.0 K/mL, several other hematologic criteria according to the flow cytometry findings have been proposed to define the blood involvement of SS.5,6 Cases of E-CTCL that lack the blood criteria of
2152-2650/$ - see frontmatter ª 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.clml.2018.12.020
SS are diagnosed as either erythrodermic MF (E-MF) if the erythroderma was preceded by typical MF or as E-CTCL, not otherwise specified (E-NOS). (Patients with MF can develop SS or have evidence of leukemic involvement without erythroderma. The terms “secondary SS” and “leukemic MF” have been used to describe these cases.) The histopathologic features of E-CTCL can be nonspecific, even for patients with actual SS, and will often be comparable to those of patch or early plaque phase MF.7,8 The prognosis of patients with CTCL depends on the magnitude of the skin tumor burden and extracutaneous involvement. In general, the prognosis of patients worsens from patch to plaque to tumor phases, according to the appearance of the most infiltrated skin lesions and the extent of involvement at the skin surface. For clinical staging using the TNBM (tumor-node-blood-metastasis) classification system recommended by the International Society for Cutaneous Lymphomas/European Organization for Research and Treatment of Cancer (ISCL/EORTC),5 the skin ratings of T1 and T2 define the presence of patches, papules, and/or plaques on < 10% or 10% of the skin surface, respectively. These ratings can be further stratified into subgroups according to the presence of patches only (T1a/T2a) or plaques with or without patch (T1b/ T2b) lesions. The T3 and T4 skin ratings define the presence of 1 nodules or tumors and erythroderma, respectively. These T ratings are used in concert with findings in the lymph nodes (N rating), visceral organs (M rating), and blood (B rating) to determine the clinical stage. Given the substantial inflammatory component in the skin lesions of MF and SS, one might expect that the production of acute phase proteins would be affected.9 Several acute phase proteins have been found to be increased in patients with MF.10 These have included ceruloplasmin, the major carrier protein for copper.10,11 The serum copper level will also be increased in inflammatory skin diseases and various cancers, including lymphoma.12-15 In the present study, we investigated the clinical significance of serum copper levels in patients with MF and E-CTCL.
Patients and Methods Laboratory studies were obtained as a part of the initial evaluation of patients referred for an evaluation of CTCL. Data were retrieved from an institutional review boardeapproved cutaneous lymphoma patient registry established for the correlation with the prognosis. The serum copper levels were measured in reference laboratories using atomic absorption spectrophotometry. The normal referent ranges were 70 to 140 mg/dL for men and 85 to 155 mg/dL for women. Ceruloplasmin was also measured for a few patients (normal range, 20-60 mg/dL). To adjust for the different laboratory methods used to measure lactate dehydrogenase (LDH), the LDH values are given as the LDH index (ie, the reported LDH values divided by the highest normal reference value). An increased LDH level was defined as 10% greater than the highest normal reference value (LDH index, 1.1) as reported by another study.16 A neutrophil/lymphocyte ratio (NLR) of 2.85 was defined as high according to another study.17 The patient population consisted of 115 patients consecutively evaluated from July 1980 to June 1985. Of the 115 patients, 98 had a diagnosis of MF (60 men and 38 women) and 17 a diagnosis of
E-CTCL (14 men and 3 women). Sixty-one of the MF patients presented with typical clinical findings. The remaining 37 patients had an atypical aspect to their presentation (evidence of poikiloderma or parakeratosis variegata - 21 patients; follicular mucinosis 5 patients; large cell transformation - 5 patients; coexisting lymphomatoid papulosis - 3 patients; unilesional MF - 2 patients; ichthyosiform MF - 1 patient). The E-CTCL group included 6 patients with SS (absolute Sézary cell count 1.0 K/mL in blood), 2 patients with E-MF (1 with large cell transformation), and 9 patients with E-NOS, according to the ISCL guidelines.4 The ISCL/EORTC clinical stage of patients with a diagnosis of MF was stage IA (n ¼ 46), IB (n ¼ 26), IIA (n ¼ 10), IIB (n ¼ 10), IVA2 (n ¼ 3), and IVB (n ¼ 3). The clinical stage of patients with E-CTCL was IIIA (n ¼ 7), IIIB (n ¼ 4), IVA1 (n ¼ 4), and IVA2 (n ¼ 2).
Statistical Analysis The results of the laboratory studies are presented as the mean standard error of the mean and/or the median with the range. The Fisher exact and Pearson c2 tests were used to test the 2 by 2 and R by C categorical tables, respectively. The Kruskal-Wallis test was used to compare the values of the independent samples. However, the Welch unequal variance t test using log-transformed data was also computed, and if a significant difference was found among 3 groups, the Games-Howell post hoc test was used. The Dunnett t test was used to compare the MF cohorts against the group with parapsoriasis en plaques as the inflammatory disease control group and the atypical MF cohorts against the typical MF group. The Spearman correlation coefficient (rho) was used to test for correlations between the percentages of cells. The overall and diseasespecific survival from the date of the serum copper measurements were determined using the Kaplan-Maier and Cox proportional hazards methods. The minus twice the logarithm of the maximized likelihood statistic (2 log L ) was used to compare alternative Cox models (the lower the value of 2 log L, the better the fit in the model).18 The statistical software programs used in the present study were SYSTAT10 and SPSS, version 13.0, for Windows (IBM Corp, Armonk, NY) and StatXact-3 (Cytel, Inc, Cambridge, MA).
Results General Observations The results of the clinical and laboratory studies for MF and E-CTCL are summarized in Table 1. A separate analysis showed no difference in copper levels between the typical and atypical presentations of MF (Supplemental Table 1; available in the online version). Therefore, all variants of MF were combined for the subsequent analyses. More men had a diagnosis of MF or E-CTCL compared with the women (male/female ratio, 1.8:1). Patients with MF were significantly younger with a longer duration of disease before evaluation compared with the patients with E-CTCL. The total leukocyte and absolute lymphocyte counts for patients with E-CTCL, which included 6 patients with SS, were greater than those for patients with MF. The eosinophil counts were also greater in the patients with E-CTCL. Differences in the NLR and serum copper and LDH levels are discussed in the subsequent sections.
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Prognostic Significance of Serum Copper in CTCL Table 1 Clinical and Laboratory Results for Patients With Cutaneous T-cell Lymphoma Variable
MF (n [ 98)
E-CTCL (n [ 17)
P Valuea .046
All Patients (n [ 115)
Age, y Median
56.5
67.0
Range
25-81
41-80
55.0 1.5
62.8 2.7
.018
56.1 1.4
44 (45)
11 (65)
.188
55 (48)
Male
60
14
.108
Female
38
3
White
89
15
Nonwhite
9
2
Mean SEM 60 y
57.0 25-81
Gender 74 41
Race .665
104 11
Overall duration,b y Median
7.2
3.0
Range
0.2-50.1
0.3-24.2
10.3 1.1
4.8 1.4
.003
.048
Mean SEM
.026
5.8 0.2-50.1 9.5 0.9
Duration from compatible histopathologic diagnosis,b mo Median
2.2
1.6
Range
0-308.5
0-7.6
15.3 3.8
2.1 0.5
.001 .997
Mean SEM
2.2 0-308.5 9.5 0.9
Copper, mg/dL Median
122.5
121.0
Range
68-227
86-163
Mean SEM
122.0 68-227
126.08 2.96
124.12 4.89
.733
125.79 2.61
Increased
19 (19)
3 (18)
1.0
22 (19)
SS
NA
n¼6
NA
NA
NA
NA
Median
124.5
Range
108-163
Mean SEM E-NOS
129.2 8.7 NA
Median
n¼9 117.0
Range
86-156
Mean SEM
119.8 7.3
Ceruloplasminc Median
39.6
NA
NA
NA
Range
28-66
NA
NA
NA
Mean SEM Increased
41.82 2.54
NA
NA
NA
1 (6)
NA
NA
NA
0.87
1.16
< .001
0.91
LDH indexd Median Range Mean SEM
0.42-1.80
0.82-1.79
0.90 0.03
1.25 0.07
< .001
0.96 0.03
0.42-1.80
1.10
9 (12)
8 (53)
.001
17 (19)
SS
NA
n¼4
NA
NA
Median
1.25
Range
0.82-1.54
NLRe
230
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Median
3.27
2.29
Range
0.90-12.14
0.72-12.00
Clinical Lymphoma, Myeloma & Leukemia April 2019
.042
3.14 0.72-12.14
Eric C. Vonderheid, Andrew R. Martinez Table 1 Continued Variable Mean SEM 2.85
MF (n [ 98)
E-CTCL (n [ 17)
P Valuea
All Patients (n [ 115)
3.95 0.25
3.08 0.68
.240
3.82 0.24
57 (59)
7 (41)
.196
64 (56)
.004
WBC count, /mL Median
6.5
8.3
Range
3.1-35.4
5.2-13.4
7.08 0.35
8.72 0.62
.029 .360
Mean SEM
6.7 3.1-35.4 7.32 0.32
3
Neutrophil count, /mm Median
4257
5175
Range
1944-29,028
2756-7500
4976.2 300.9
5065.1 342.7
.846
4989.5 260.6
1435
2034
.011
1508 1710.9 98.6
Mean SEM
4385 1944-29,028
Lymphocyte count, /mm3 Median Range Mean SEM
350-4752
434-6298
1546.5 79.8
2658.5 424.7
.020
350-6298
< .001
Sézary cell count, /mm3 Median
0
511
Range
0-503
0-5320
36.9 12.4
938.03 315.43
.011 < .001
Mean SEM
0 0-5320 262.20 91.10
Eosinophil count, /mm3 Median
63
276
Range
0-1292
0-1125
116.9 18.4
407.5 89.1
Mean SEM
83 0-1292
.005
160.2 22.5
Data presented as n (%), unless otherwise noted. Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: E-CTCL ¼ erythrodermic cutaneous T-cell lymphoma; E-NOS ¼ erythrodermic cutaneous T-cell lymphoma, not otherwise specified; MF ¼ mycosis fungoides; NA ¼ not applicable; NLR ¼ neutrophil/lymphocyte ratio; SEM ¼ standard error of the mean; SS ¼ Sézary syndrome; WBC ¼ white blood cell. a Differences between MF and E-CTCL groups were tested using the Mann-Whitney U test, Welch t test, and Fisher exact test. b Duration of disease from onset of symptoms or first skin specimen with findings compatible with diagnosis of CTCL to date of laboratory testing. c Ceruloplasmin measured for 18 patients with MF. d LDH value divided by the highest normal laboratory reference value; LDH levels were obtained for 90 patients with MF and 15 patients with E-CTCL. e NLR not available for 1 patient.
Serum Copper Levels The serum copper levels were increased above normal for 19 of 98 patients with MF (19%) and 3 of 17 patients with E-CTCL (18%; Table 1). The levels were significantly higher in the women than in men for both MF (P ¼ .001) and E-CTCL (P ¼ .012; Supplemental Table 2; available in the online version). However, the proportion of men and women with greater than normal reference values was nearly 20% for each group. Ceruloplasmin was increased in only 1 of 18 patients with MF (1 man with extensive patch phase MF and a copper level of 227 mg/dL) and was not measured in patients with E-CTCL. The correlation of the copper levels with the findings for the clinical parameters is presented in Table 2. For patients with MF, the serum copper level was significantly greater in those patients with tumor phase disease, a T3 skin rating, and > 50% skin involvement. The difference between patch and plaque phase MF, a T1 and T2 skin rating, and < 10% and 10% to 50% skin involvement was not statistically significant. The difference among the substages of T1a, T1b, T2a, and T2b was not quite statistically significant (P ¼ .067). Moreover, the serum copper level for patients with E-CTCL was not different from that of the MF group and approximated that of the patients with plaque phase disease.
The copper levels for 6 patients with SS, with a relatively high tumor burden, were not significantly different statistically from those of the 11 patients with non-Sézary E-CTCL (P ¼ .546). To assess the effect of extracutaneous involvement on the copper levels, a comparison was also performed between stage I-II (skin limited) and stage IV for MF and stage III (skin limited) versus stage IV for E-CTCL (Table 2). Although the copper levels were higher in the 6 patients with MF and extracutaneous involvement than in the 92 patients with MF limited to the skin, the difference was not statistically significant (P ¼ .106). Additionally, no difference was apparent between the 10 patients with E-CTCL and intracutaneous disease (8 with E-NOS and 2 with E-MF) and the 7 patients with extracutaneous disease (6 with SS and 1 with E-NOS; P ¼ .696). These results suggest that advanced CTCL with extracutaneous involvement is not a major factor in determining the copper levels in patients with MF and E-CTCL. The relationship between the phase of MF and the disease extent was investigated further. Patients with stage IV disease were excluded to negate the influence of extracutaneous disease (Supplemental Table 3; available in the online version). The copper levels were significantly higher for patients with > 50% than for those with 50% skin surface involvement for the patch
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232
LDH Indexb
Copper Levels Variable
Patients, n
Mean ± SEM
Median (Range)
Patients, n
Mean ± SEM
NLR Median (Range)
Patients, n
Mean ± SEM
Median (Range)
Gender Male
74
118.41 2.82
116.5 (68-227)
56
0.97 0.04
0.92 (0.42-1.80)
74
3.99 0.30
3.32 (0.72-12.0)
Female
41
139.12 4.67
139.0 (85-220)
34
0.93 0.05
0.90 (0.55-1.77)
40
3.51 0.39
2.89 (0.78-12.14)
< .001
< .001
.454
.353
.258
.256
104
125.10 2.85
121.0 (68-227)
80
0.92 0.03
0.89 (0.42-1.80)
104
3.90 0.26
3.19 (0.72-12.14)
11
132.36 4.76
133.0 (99-150)
10
1.23 0.94
1.18 (0.79-1.77)
11
3.15 0.44
2.90 (1.34-5.58)
.107
.151
.004
.001
.473
.555
P valuec Race White Nonwhite P value Diagnosis Patch MF
58
125.45 4.07
121.0 (68-227)
42
0.83 0.03
0.79 (0.42-1.80)
57
3.57 0.29
2.88 (1.27-10.63)
Plaque MF
26
118.04 4.57
120.0 (85-170)
23
1.03 0.06
0.98 (0.52-1.77)
26
3.95 0.49
3.32 (0.90-12.14)
Tumor MF
14
143.64 7.07
140.5 (109-198)
10
0.88 0.04
0.87 (0.66-1.09)
14
5.54 0.81
5.00 (1.34-11.13)
P value
.010
.020
.008
.001
.044
.088
Post hoc
PT, PQ versus T
SS Non-SS
PT versus PQ
NA
6
129.17 8.75
124.5 (108-163)
4
1.25 0.18
1.25 (0.82-1.54)
6
1.13 0.15
1.15 (0.72-1.71)
11
121.36 5.99
121.0 (86-156)
11
1.27 0.08
1.16 (0.93-1.79)
11
4.15 0.90
3.44 (1.13-12.00)
.458
.546
.741
.514
< .001
.004
P value MF involvement extent < 10%
50
118.06 3.78
115.0 (68-220)
34
0.86 0.03
0.85 (0.55-1.14)
49
3.48 0.27
3.09 (1.27-9.67)
10%-50%
18
128.67 6.39
122.0 (92-198)
14
0.83 0.04
0.82 (0.52-1.05)
18
4.37 0.71
3.41 (1.65-12.14)
> 50%
30
137.90 5.72
136.5 (85-227)
27
0.98 0.06
0.91 (0.42-1.80)
30
4.48 0.53
3.84 (0.90-11.13)
P value
.013
.012
.262
.360
.338
.369
Post hoc
< 10 versus > 50
NA
NA
MF IntraC
92
124.82 3.01
121.5 (68-227)
69
0.90 0.03
0.84 (0.42-1.80)
91
3.80 0.25
3.19 (0.90-12.14)
ExtraC
6
145.50 12.91
156.0 (104-174)
6
0.91 0.03
0.93 (0.81-0.99)
6
6.33 1.15
7.06 (2.64-9.89)
.098
.106
.651
.359
.018
.025
P value E-CTCL IntraC
10
121.80 6.61
122.0 (86-156)
10
1.24 0.08
1.12 (0.93-1.79)
10
4.31 0.97
3.96 (1.13-12.00)
ExtraC
7
127.43 7.59
120.0 (108-163)
5
1.29 0.16
1.50 (0.82-1.57)
7
1.33 0.23
1.22 (0.72-2.50)
0.164
0.696
0.309
0.903
.043
.006
P value
Prognostic Significance of Serum Copper in CTCL
Clinical Lymphoma, Myeloma & Leukemia April 2019
Table 2 Results of Serum Copper, Serum LDH, and NLR Stratified by Clinical Parameters of Patients With CTCLa
Table 2 Continued LDH Indexb
Copper Levels Variable
NLR
Patients, n
Mean ± SEM
Median (Range)
Patients, n
Mean ± SEM
Median (Range)
Patients, n
Mean ± SEM
Median (Range)
T skin rating 46
117.37 4.05
113.5 (68-220)
33
0.86 0.03
0.83 (0.55-1.14)
45
3.38 0.27
3.09 (1.27-9.67)
T1a
36
119.67 4.83
115.0 (68-220)
25
0.83 0.03
0.82 (0.55-1.14)
35
3.34 0.32
2.88 (1.27-9.67)
T1b
10
109.10 6.40
102.0 (89-140)
8
0.94 0.05
0.93 (0.79-1.12)
10
3.50 0.45
3.26 (1.49-5.69)
38
130.16 4.77
125.5 (85-227)
32
0.95 0.06
0.91 (0.42-1.80)
38
4.05 0.45
3.00 (0.90-12.14)
T2a
22
134.91 6.94
126.5 (90-227)
17
0.83 0.07
0.75 (0.42-1.80)
22
3.92 0.57
2.81 (1.63-10.63)
T2b
16
123.63 5.98
121.5 (85-170)
15
1.08 0.08
0.99 (0.52-1.77)
16
4.23 0.74
3.63 (0.90-12.14)
T1
T2
T3
14
143.64 7.07
140.5 (109-198)
10
0.88 0.04
0.87 (0.66-1.09)
14
5.54 0.81
5.00 (1.34-11.13)
T4
17
124.12 4.88
121.0 (86-163)
15
1.25 0.07
1.16 (0.82-1.79)
17
3.08 0.68
2.29 (0.72-12.00)
.008
.009
< .001
< .001
.045
.023
P value All T ratings Post hoc T substage Post hoc
T1 versus T3 .067 NA
T1-T3 versus T4 .098
.020 T1a versus T2b
T3 versus T4 .002
.810
.766
NA
Clinical Lymphoma, Myeloma & Leukemia April 2019
Eric C. Vonderheid, Andrew R. Martinez
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: CTCL ¼ cutaneous T-cell lymphoma; E-CTCL ¼ erythrodermic cutaneous T-cell lymphoma; ExtraC ¼ extracutaneous involvement; IntraC ¼ intracutaneous (skin only); LDH ¼ lactate dehydrogenase; MF ¼ mycosis fungoides; NA ¼ not applicable; NLR ¼ neutrophil/lymphocyte ratio; PQ ¼ plaque MF; PT ¼ patch MF; SS ¼ Sézary syndrome; SEM ¼ standard error of the mean; T ¼ tumor MF. a Details of the entire MF and E-CTCL groups and the results of patients with skin-only involvement are provided in Supplemental Tables 2 and 3, respectively (available in the online version). b LDH value divided by top normal laboratory reference value. c Differences among cohorts tested with Mann-Whitney U test (median values) and 1-way analysis of variance using the Welch t test and Games-Howell post hoc test (mean values).
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Prognostic Significance of Serum Copper in CTCL Figure 1 Median-quartile Box Plot of Serum Copper Levels for Patients With Mycosis Fungoides (MF) Limited to the Skin According to the Extent of Skin Involvement and Parapsoriasis En Plaques (PEP)
parapsoriasis en plaques. The copper levels for these patients (n ¼ 8; mean, 139.50 8.30 mg/dL; median, 138 mg/dL; range, 99-178 mg/dL) were as high as those for patients with tumor phase MF limited to the skin (n ¼ 10; mean, 139.10 7.80 mg/dL; median, 135 mg/dL; range, 110-198 mg/dL) and were perforce higher than those for patients with patch or plaque phase MF (Figure 1). These observations suggest that the inflammatory component of MF lesions influences the copper levels to a greater degree than do the neoplastic cells in the early evolution of MF.
LDH Levels
(P ¼ .035) and plaque (P ¼ .037) phases but not for the tumor phase MF (P ¼ .819; Figure 1). The difference between patch and plaque phase MF with 50% involvement and patch and plaque MF with > 50% involvement was not significant. When the T ratings were divided into subgroups using the ISCL/EORTC recommendations,5 the copper levels tended to be greater for the patch-only subgroups compared with the corresponding subgroups of the plaques with or without patches (ie, copper level for T1a > T1b and T2a > T2b; Figure 2). Furthermore, for patients with a T4 skin rating without extracutaneous involvement (1 patient with E-MF and 6 with E-NOS), the copper values were significantly lower than those with T3 (P ¼ .037) and were comparable to those with substage T2b (P ¼ .801; Table 2). Finally, we observed copper values greater than the referent value in 25% of our patients with a diagnosis of
Figure 2 Median-quartile Box Plot of Serum Copper Levels for Patients With Mycosis Fungoides Limited to the Skin According to the ISCL/EORTC Skin T Ratings
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Clinical Lymphoma, Myeloma & Leukemia April 2019
LDH was measured in 75 patients with MF (42 with patch phase, 23 with plaque phase, 10 with tumor phase) and 15 patients with E-CTCL (4 with SS, 2 with E-MF, 9 with E-NOS). Unlike the copper levels, the LDH levels were significantly higher in those with E-CTCL than in those with MF (Table 1). No difference in the LDH levels was observed for those with MF with or without extracutaneous manifestations (Table 2; P ¼ .359). Furthermore, the LDH levels for patients with noneSézary E-CTCL (median LDH index, 1.12) were nearly identical to those for patients with SS (median LDH index, 1.32; P ¼ .713). For patients with MF limited to the skin, the LDH levels did not progressively increase according to the extent of skin involvement with MF nor was the LDH higher for tumor phase MF (median LDH index, 0.85) compared with patch or plaque phase MF (median LDH index, 0.84; P ¼ .958; Supplemental Table 3; available in the online version). In addition, the correlation between the LDH levels and T ratings was somewhat different from that observed for the serum copper levels. For example, the LDH levels tended to be higher for the T substages with plaques with or without patches compared with the T substages with patches only (ie, LDH levels for T1b > T1a and T2b > T2a; Figure 3). This observation suggests that neoplastic cells might be contributing to the LDH levels to a greater degree than the copper levels in clinical early-stage MF. Finally, no correlation was found
Figure 3 Median-quartile Box Plot of Serum Lactate Dehydrogenase (LDH) Levels for Patients With Mycosis Fungoides Limited to the Skin According to the ISCL/EORTC Skin T Ratings and Parapsoriasis En Plaques (PEP)
Eric C. Vonderheid, Andrew R. Martinez between the LDH and copper levels for all patients (rho ¼ 0.081; P ¼ .448) or for MF only (rho ¼ 0.156; P ¼ .181) and E-CTCL only (rho ¼ 0.338; P ¼ .218).
Neutrophil/Lymphocyte Ratio Patients with E-CTCL had a higher total leukocyte count than patients with MF (Table 1). The difference was attributed to higher lymphocyte and eosinophil counts (and Sézary cell counts) in the ECTCL group. However, the difference in the absolute neutrophil count was not statistically significant. Thus, the NLR was significantly lower for patients with E-CTCL compared with those with MF. In addition, the NLR for patients with SS was lower (median, 1.22) than that of patients with noneSézary E-CTCL (median, 4.15; P ¼ .004; Table 2). Lymphopenia (absolute lymphocyte count < 1.0 K/mL) occurred in only 1 patient with noneSézary E-CTCL. In contrast, the NLR was 2.85 for 57 of the 97 patients with MF (59%), including 52 of 91 patients (57%) with intracutaneous MF and 5 of 6 patients (83%) with extracutaneous disease (P ¼ .396). A possible contributing factor was lymphopenia, which occurred in 23 of 98 patients (23%) with MF overall, including 20 of 92 (22%) with intracutaneous MF and 3 of 6 (50%) with extracutaneous MF (P ¼ .139). The difference in the absolute neutrophil or lymphocyte counts between those with intracutaneous MF and extracutaneous MF was not statistically significant (P ¼ .164 and P ¼ .233, respectively). In contrast, neutrophilia (> 15 K/mL) was not encountered in either cohort. Finally, for patients with MF limited to the skin, the NLR showed no significant increase with the phase of MF, extent of skin involvement, or T skin ratings (Supplemental Table 3; available in the online version). The box plot of NLR according to the ISCLEORTC T ratings is shown in Figure 4. Although the pattern was similar to that of LDH, no correlation between the NLR and LDH values was found (rho ¼ 0.056; P ¼ .646). The NLR also did not correlate with the serum copper values for all patients with MF (rho ¼ 0.041; P ¼ .682).
The other significant laboratory studies included the total leukocyte and absolute neutrophil count but not the absolute lymphocyte or eosinophil count. The presence of 6 Sézary cells/100 lymphocytes, but not the absolute Sézary cell count, was associated with a poor disease-specific prognosis, as was lymphopenia (< 1.0 K/mL). The ratio of neutrophils to lymphocytes was not significant. With the clinical stage and age entered as covariates in the Cox model, an increased serum copper level was the only laboratory study finding that remained significantly associated with both overall and disease-specific survival (Supplemental Table 4; available in the online version). This finding indicates that gender-adjusted high copper values provide prognostic information that is independent of clinical stage. When correlated with the clinical parameters that reflect disease severity (Table 3), the estimated mean survival tended to be shorter for patients with increased copper levels than for the corresponding patients with normal levels, although these differences were usually not statistically significant. Furthermore, the differences became smaller with more advanced involvement. Overall and disease-specific survival curves for all patients with MF, stratified according to normal or increased levels of serum copper, are shown in Figures 5 and 6.
Discussion The present study found higher than normal serum copper levels in nearly 20% of patients with MF or E-CTCL. Furthermore, patients with MF with hypercupremia, but not E-CTCL, were more likely to experience disease progression and shorter survival than were patients with normal copper levels. The correlation with an adverse prognosis seemed to be independent of clinical stage, which is the main determinant of prognosis for those with MF/E-CTCL. In contrast, increased serum LDH levels and a NLR of 2.85, both of which have been reported to correlate with the prognosis,17,19 did not correlate significantly with either overall or disease-specific survival in the present cohort of patients, nor was the correlation with copper values significant. The reason copper is increased in those with MF or E-CTCL is unknown. One possibility is that copper, similar to ceruloplasmin
Prognosis The prognostic importance of the clinical and laboratory variables for patients with MF were evaluated in the Cox model with patient age (< 60 and 60 years) as a covariate and any cause of death and disease-specific death as the endpoints (Supplemental Table 4; available in the online version). Patients with E-CTCL were excluded because no clinical or laboratory study findings were associated with survival, including the Sézary cell counts. Several clinical findings with known prognostic importance for patients with MF were found on univariate analysis to be significantly associated with survival. These included the phase of MF, extent of skin involvement, extracutaneous involvement, and ISCL-EORTC T ratings, and clinical stage. The 5-year overall and disease-specific survival rates were 81% and 88% for patients with normal copper levels and 58% and 65% for patients with increased copper levels, respectively. In addition, 13 of 22 patients (59%) with high copper values had experienced disease progression after the initial evaluation compared with 21 of 93 patients (23%) with normal values (P ¼ .002). In contrast, the rate of disease progression for patients with high LDH levels was not different from that of patients with normal values (P ¼ .569).
Figure 4 Median-quartile Box Plot of the Neutrophil/ Lymphocyte Ratio in the Blood of Patients With Mycosis Fungoides Limited to the Skin According to the ISCL/EORTC Skin T Ratings and Parapsoriasis En Plaques (PEP)
Clinical Lymphoma, Myeloma & Leukemia April 2019
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Prognostic Significance of Serum Copper in CTCL Table 3 Mean Overall and Disease-specific Survival for Patients With Cutaneous T-cell Lymphoma Stratified by Serum Copper Level Overall Survival ± SEM
Disease-specific Survival ± SEM
Increased CU/ Total, n (%)
Normal CU
Increased CU
P Value
All MF patients
19/98 (19)
21.94 1.53
11.06 2.94
.003
Stage I-IIB MF
16/92 (17)
22.71 1.52
12.90 3.29
.016
32.15 1.40
20.26 4.36
.002
9/58 (16)
27.89 1.47
17.60 4.00
.029
36.27 0.83
28.51 4.67
.031
Plaque phase
3/24 (13)
15.77 2.64
13.96 8.88
.811
26.09 3.12
20.65 10.50
.511
Tumor phase
4/10 (40)
3.00 1.26
1.39 0.48
.443
3.00 1.15
1.39 0.48
.443
Variable
Patch phase
a
Normal CU
Increased CU
P Valuea
31.39 1.47
18.13 4.12
.001
T1 rating
4/46 (9)
25.95 1.78
16.66 6.20
.257
35.89 1.07
28.38 6.72
.101
T2 rating
8/36 (22)
21.77 2.47
16.62 4.67
.411
30.92 2.32
25.66 5.68
.523
T3 rating
4/10 (40)
3.00 1.26
1.39 0.48
.443
3.00 1.15
1.39 0.48
.443
Stage IV MF
3/6 (50)
2.62 1.33
1.20 0.68
.277
2.96 1.69
1.27 0.15
.433
All E-CTCL patients
3/17 (18)
6.37 1.58
7.69 5.27
.469
9.83 2.16
7.69 5.27
.903
SS Non-SS
1/6 (17)
6.98 2.72
1.48
.247
8.43 2.97
1.48
.046
2/11 (18)
5.88 1.96
10.79 7.38
.274
9.38 2.27
10.79 7.38
.962
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: CU ¼ copper; E-CTCL ¼ erythrodermic cutaneous T cell lymphoma; MF ¼ mycosis fungoides; SS ¼ Sézary syndrome. a Log-rank test was used to test for differences between normal and increased CU levels in Kaplan-Meier survival curves.
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and other acute phase proteins,9 is released from the liver via stimulation with pro-inflammatory cytokines produced at the skin lesion sites of MF/E-CTCL. For example, interleukin-1 and interleukin-6 (IL-6), the most important cytokine involved in the production of most acute-phase proteins by the liver, has been demonstrated in exudates from MF lesions20 and in the blood of patients with MF and SS.21-23 If this hypothesis is correct, the source of the cytokines could be the inflammatory cell component or neoplastic T cells, or both. Regarding the neoplastic T cells as a possible source of IL-6, neoplastic cell lines are capable of secreting IL-6,24,25 and IL-6 mRNA has been demonstrated in MF tumors.26 In addition, C-reactive protein, which is particularly responsive to IL-6 stimulation, has been reported to be increased in patients with MF.10,11 One study reported an increase in mean C-reactive protein levels in tandem with the increased clinical stage of MF.10 Therefore, it is
likely that neoplastic cells provide a significant source of IL-6, especially in the advanced phases of MF. Given that macrophages are a major source of IL-6,27 the inflammatory component of MF skin lesions could provide another mechanism for the increased copper levels. Hypercupremia has been reported in patients with psoriasis and atopic dermatitis,12 and we observed higher than normal copper values in 25% of our patients with a diagnosis of parapsoriasis en plaques. We found it surprising that the copper levels in the patients with parapsoriasis en plaques were as high as those with tumor phase MF limited to the skin. In addition, although not statistically significant, the copper levels tended to be higher in patients with limited-extent patch phase MF (5 of 40 patients with 50% of the skin surface had copper levels higher than normal) compared with those with plaque phase MF (none of 15 patients with 50% of the skin surface had copper levels higher than normal). One possibility that could not be
Figure 5 Overall Survival of Patients With Mycosis Fungoides (MF) According to Serum Copper Level
Figure 6 Disease-specific Survival of Patients With Mycosis Fungoides (MF) According to Serum Copper Level
Clinical Lymphoma, Myeloma & Leukemia April 2019
Eric C. Vonderheid, Andrew R. Martinez retrospectively addressed is that topically applied corticosteroid preparations might have influenced the serum copper levels in some patients with early MF. Nevertheless, these observations suggest that the inflammatory component of MF lesions influences the copper levels to a greater degree than do the neoplastic cells at least until the tumor phase or extracutaneous involvement has developed. Another question is why the presence of hypercupremia signifies a worse prognosis independently of the clinical stage. This question was interesting considering that 2 other reported prognostic indicators for MF (ie, increased LDH16,19 and high NLR17,28) did not correlate with the prognosis in this cohort of patients, even using univariate analysis. This might be explained by a difference in the mechanism. If IL-6 regulates serum copper levels and if most IL-6 emanates from non-neoplastic cells in skin lesions of MF as theorized, perhaps patients with relatively high serum copper levels at any particular phase of disease are those in whom the neoplastic cells in the lesions contribute substantially to the total IL-6 production. Thus, the amount of IL-6 secreted by the biomass of activated neoplastic cells added to the amount secreted by non-neoplastic cells in lesional skin might yield a greater total IL-6 release in some patients and, consequently, higher than normal serum copper levels. If this hypothesis is correct, a positive correlation could be expected between the copper levels and activation of proliferation markers in skin lesions such as CD30 or Ki-67.29,30 Alternatively, it is conceivable that a higher level of IL-6 production from non-neoplastic cells in MF lesions might encourage the progression of disease in some patients. For example, IL-6 from activated tumor-associated macrophages (M2 macrophages) in situ might directly promote tumor progression via stimulation of the STAT3 pathway.31-34 These possibilities are not mutually exclusive. Finally, high IL-6 levels, as suggested by high serum copper levels, might affect overall survival by increasing the risk of coronary artery disease, as recently reported.11 However, our patients had an increased risk of progressive MF and impaired disease-specific survival. This effect became less evident for patients with advanced disease (tumor phase MF or extracutaneous involvement) and for patients with E-CTCL. Additional studies of the prognostic implications of C-reactive protein, which is more stable and easier to measure than IL-6,10 M2 macrophage markers such as CD163 and CCL18,33,35 and perhaps soluble CD25,23 would be of interest.
Conclusion Patients with patch/plaque phase MF and higher than normal serum copper levels were more likely to experience disease progression and have a shorter mean survival than were patients with normal levels. In contrast, the LDH levels and NLR did not identify patients at risk of progression. We hypothesized that IL-6 and other inflammatory cytokines released primarily by non-neoplastic cells at the lesion sites might be stimulating copper release from the liver and also promoting neoplastic cell progression in situ.
Clinical Practice Points To the best of our knowledge, the present study is the first to
show that patients with patch or plaque phase MF and increased serum copper levels are prone to disease progression and, hence, a worse prognosis than patients with normal levels.
Additional studies are required to understand the role that non-
neoplastic cells might be playing in promoting disease progression.
Disclosure The authors have stated that they have no conflicts of interest.
Supplemental Data Supplemental tables accompanying this article can be found in the online version at https://doi.org/10.1016/j.clml.2018.12.020.
References 1. Pimpinelli N, Olsen EA, Santucci M, et al, International Society for Cutaneous Lymphoma. Defining early mycosis fungoides. J Am Acad Dermatol 2005; 53: 1053-63. 2. Willemze R. Mycosis fungoides variants-clinicopathologic features, differential diagnosis, and treatment. Semin Cutan Med Surg 2018; 37:11-7. 3. Burg G, Kempf W, Cozzio A, et al. WHO/EORTC classification of cutaneous lymphomas 2005: histological and molecular aspects. J Cutan Pathol 2005; 32:647-74. 4. Vonderheid EC, Bernengo MG, Burg G, et al, ISCL. Update on erythrodermic cutaneous T-cell lymphoma: report of the International Society for Cutaneous Lymphomas. J Am Acad Dermatol 2002; 46:95-106. 5. Olsen E, Vonderheid E, Pimpinelli N, et al, ISCL/EORTC. Revisions to the staging and classification of mycosis fungoides and Sézary syndrome: a proposal of the International Society for Cutaneous Lymphomas (ISCL) and the cutaneous lymphoma task force of the European Organization of Research and Treatment of Cancer (EORTC). Blood 2007; 110:1713-22. 6. Scarisbrick JJ, Hodak E, Bagot M, et al. Blood classification and blood response criteria in mycosis fungoides and Sézary syndrome using flow cytometry: recommendations from the EORTC cutaneous lymphoma task force. Eur J Cancer 2018; 93:47-56. 7. Sentis HJ, Willemze R, Scheffer E. Histopathologic studies in Sézary syndrome and erythrodermic mycosis fungoides: a comparison with benign forms of erythroderma. J Am Acad Dermatol 1986; 15:1217-26. 8. Trotter MJ, Whittaker SJ, Orchard GE, Smith NP. Cutaneous histopathology of Sézary syndrome: a study of 41 cases with a proven circulating T-cell clone. J Cutan Pathol 1997; 24:286-91. 9. Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation. N Engl J Med 1999; 340:448-55. 10. Pawlaczyk M, Sobieska M. A correlation between acute phase proteins and cytokines in patients suffering from mycosis fungoides. Acta Dermatovenerol Alp Pannonica Adriat 2006; 15:107-12. 11. Cengiz FP, Emiroglu N. Evaluation of cardiovascular disease risk factors in patients with mycosis fungoides. An Bras Dermatol 2015; 90:36-40. 12. Tasaki M, Hanada K, Hashimoto I. Analyses of serum copper and zinc levels and copper/zinc ratios in skin diseases. J Dermatol 1993; 20:21-4. 13. Shah I, Lewkow LM, Khilanani U. Correlation of hypercupremia with other acute phase reactants in malignant lymphoma. Cancer 1983; 51:851-4. 14. Zowczak M, Iskra M, Torli nski L, Cofta S. Analysis of serum copper and zinc concentrations in cancer patients. Biol Trace Elem Res 2001; 82:1-8. 15. Kaiafa GD, Saouli Z, Diamantidis MD, et al. Copper levels in patients with hematological malignancies. Eur J Intern Med 2012; 23:738-41. 16. Diamandidou E, Colome M, Fayad L, Duvic M, Kurzrock R. Prognostic factor analysis in mycosis fungoides/Sézary syndrome. J Am Acad Dermatol 1999; 40(6 Pt 1):914-24. 17. Cengiz FP, Emiroglu N, Ozkaya DB, Bahali AG, Su O, Onsun N. Prognostic evaluation of neutrophil/lymphocyte ratio in patients with mycosis fungoides. Ann Clin Lab Sci 2017; 47:25-8. 18. Collett D. Modelling Survival Data in Medical Research. London, UK: Chapman & Hall; 1997. 19. Talpur R, Singh L, Daulat S, et al. Long-term outcomes of 1,263 patients with mycosis fungoides and Sézary syndrome from 1982 to 2009. Clin Cancer Res 2012; 18:5051-60. 20. Lawlor F, Smith NP, Camp RD, et al. Skin exudate levels of interleukin 6, interleukin 1 and other cytokines in mycosis fungoides. Br J Dermatol 1990; 123:297-304. 21. Hassel JC, Meier R, Joller-Jemelka H, Burg G, Dummer R. Serological immunomarkers in cutaneous T cell lymphoma. Dermatology 2004; 209:296-300. 22. Toruniowa B, Krasowska D, Kozioł M, Ksiazek A, Pietrzak A. Serum levels of IL-6 in mycosis fungoides, psoriasis, and lichen planus. Ann N Y Acad Sci 1995; 762:432-4. 23. Kadin ME, Pavlov IY, Delgado JC, Vonderheid EC. High soluble CD30, CD25, and IL-6 may identify patients with worse survival in CD30þ cutaneous lymphomas and early mycosis fungoides. J Invest Dermatol 2012; 132(3 Pt 1):703-10. 24. Nielsen M, Nissen MH, Gerwien J, et al. Spontaneous interleukin-5 production in cutaneous T-cell lymphoma lines is mediated by constitutively activated Stat3. Blood 2002; 99:973-7. 25. Lauenborg B, Christensen L, Ralfkiaer U, et al. Malignant T cells express lymphotoxin a and drive endothelial activation in cutaneous T cell lymphoma. Oncotarget 2015; 6:15235-49.
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31. Sommer VH, Clemmensen OJ, Nielsen O, et al. In vivo activation of STAT3 in cutaneous T-cell lymphoma: evidence for an antiapoptotic function of STAT3. Leukemia 2004; 18:1288-95. 32. Yu H, Pardoll D, Jove R. STATs in cancer inflammation and immunity: a leading role for STAT3. Nat Rev Cancer 2009; 9:798-809. 33. Sugaya M, Miyagaki T, Ohmatsu H, et al. Association of the numbers of CD163(þ) cells in lesional skin and serum levels of soluble CD163 with disease progression of cutaneous T cell lymphoma. J Dermatol Sci 2012; 68:45-51. 34. Wu X, Schulte BC, Zhou Y, et al. Depletion of M2-like tumor-associated macrophages delays cutaneous T-cell lymphoma development in vivo. J Invest Dermatol 2014; 134:2814-22. 35. Miyagaki T, Sugaya M, Suga H, et al. Increased CCL18 expression in patients with cutaneous T-cell lymphoma: association with disease severity and prognosis. J Eur Acad Dermatol Venereol 2013; 27:e60-7.
Eric C. Vonderheid, Andrew R. Martinez Supplemental Table 1 Serum Copper Levels With Clinically Typical and Atypical Expression of MF Copper (mg/dL) Diagnostic Group Typical MF
P Valuea
Increased/Total, n/N (%)
Median (Range)
Mean ± SEM
10/61 (16)
120.0 (68-220)
123.07 3.58
2/15 (13)
115.0 (86-157)
117.00 5.53
.986
1/6 (17)
132.0 (104-180)
135.17 10.56
.851
b
Atypical MF
MF with poikiloderma MF with PKV MF with LCL
3/5 (60)
151.0 (104-174)
141.40 13.63
.658
MF with LyP
0/3 (0)
125.0 (123-139)
129.00 5.03
.995
MF with FM
2/5 (40)
123.0 (109-202)
146.00 17.89
.495
Abbreviations: FM ¼ follicular mucinosis; LCL ¼ large cell lymphoma; MF ¼ mycosis fungoides; PKV ¼ parakeratosis variegata; LyP ¼ lymphomatoid papulosis; SEM ¼ standard error of the mean. a Atypical MF groups compared with the typical MF group as a control using Dunnett’s t test. b Atypical expression of MF included patients with evidence of poikiloderma, PKV, FM, LyP, and transformation to LCL.
Clinical Lymphoma, Myeloma & Leukemia April 2019
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Prognostic Significance of Serum Copper in CTCL Supplemental Table 2 Clinical and Laboratory Results for Patients With Cutaneous T-cell Lymphoma Stratified by Gender MF Variable
Men (n [ 60)
E-CTCL
Women (n [ 38)
P Value .094
Men (n [ 14)
Women (n [ 3)
P Value .377
Age, y Median
60
55
68
55
Range
60 (25-81)
55 (25-78)
41-80
54-67
57.13 1.85
51.50 2.50
63.71 3.19
58.67 4.18
10 (71%)
1 (33%)
3.2
3.02
Mean SEM 60 y
31 (52%)
13 (34%)
Overall duration,a y Median Range Mean SEM
6.3
7.6
.810
0.2-50.1
0.4-40.4
0.3-24.2
0.34-3.68
10.58 1.45
9.96 1.50
5.28 1.66
2.35 1.02
.529
Duration from first compatible histopathologic diagnosis,a mo Median
2.4
2.2
1.1
2.07
Range
0-308.5
0-131.4
0-7.6
1.64-5.58
16.22 5.57
13.85 4.41
1.89 0.58
3.10 1.25
Mean SEM
.726
.208
Copper Median
115.0
136.0
Range
68-227
85-220
118.60 3.36
137.89 4.98
Mean SEM Increased
11 (18%)
.001
118.5
156.0
86-150
145-163
117.57 4.01
154.67 5.24
1 (7%)
2 (67%)
.830
1.24
0.93
1.00-1.79
0.82-1.50
.691
1.30 0.08
1.08 0.21
7 (58%)
1 (33%)
.242
2.40
1.09
0.72-12.00
0.78-3.05
.250
3.39 0.79
154.67 5.24
6 (43%)
1 (33%)
.858
1962
5978.0
.001
8 (21%)
.012 .001
LDH indexb Median Range Mean SEM 1.10
0.85
0.90
0.42-1.80
0.55-1.77
0.89 0.03
0.92 0.05
5 (11%)
4 (13%)
3.38
2.9
.149 .397
NLR Median Range Mean SEM 2.85
c
1.27-11.13
0.9-12.1
4.13 0.32
3.66 0.41c
37 (62%)
20 (54%)
.166 .269
Lymphocyte count, /mm3 Median Range Mean SEM
1485
1374
.131
462-4292
350-4752
434-4482
1364-6298
1499.1 89.9
1621.5 149.8
.562
2254 338
4547 1594
.310
63
63
.531
346
186
.344
0-1125
0-488
.674
446.64 102.55
224.67 142.19
Eosinophil count, /mm3 Median Range Mean SEM
0-760
0-1292
114.9 19.0
120.22 37.45
.943
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: E-CTCL ¼ erythrodermic cutaneous T-cell lymphoma; LDH ¼ lactate dehydrogenase; MF ¼ mycosis fungoides; NLR ¼ neutrophil/lymphocyte ratio; SEM ¼ standard error of the mean. a Duration of disease from onset of symptoms or first skin specimen with findings compatible with a diagnosis of CTCL to the date of laboratory testing. b LDH value divided by highest normal laboratory reference value; LDH obtained for 44 men and 31 women with MF and 12 men with E-CTCL. c NLR not available for 1 patient.
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Clinical Lymphoma, Myeloma & Leukemia April 2019
Supplemental Table 3 Results of Serum Copper, Serum LDH, and NLR Stratified by Clinical Parameters of Patients With Cutaneous T-cell Lymphoma and Involvement Limited to Skin (Stage IV Excluded) LDH Indexa
Copper Variable
NLR
Patients, n
Mean
Median (Range)
Patients, n
Mean
Median (Range)
Patients, n
Mean
Median (Range)
Patch MF
58
125.45
121.0 (28-227)
42
0.83
0.79 (0.42-1.80)
57
3.57
2.88 (1.27-10.63)
Plaque MF
24
117.33
120.0 (85-170)
21
1.04
0.95 (0.52-1.77)
24
3.90
3.32 (0.90-12.14)
Tumor MF
10
139.10
135.0 (110-198)
6
0.87
0.85 (0.66-1.09)
10
4.85
3.99 (1.34-11.13)
Diagnosis
P valueb
.045
Post hoc
.087
.023
PQ versus T
.002
.348
PT versus PQ
.291
NA
Extent of skin involvement (MF only) < 10%
50
118.06
115.0 (68-220)
34
0.86
0.85 (0.55-1.14)
49
3.48
3.09 (1.27-9.67)
10%-50%
17
126.00
121.0 (92-198)
13
0.82
0.80 (0.52-1.05)
17
4.17
3.33 (1.65-12.14)
50%
67
120.08
116.0 (68-220)
47
0.85
0.83 (0.52-1.14)
66
3.66
3.14 (1.27-12.14)
> 50%
25
137.52
134.0 (85-227)
22
1.00
0.91 (0.42-1.80)
25
4.17
3.37 (0.90-11.13)
P value
.028
.020
.279
.392
.643
NA
.718
NA
T rating T1
Clinical Lymphoma, Myeloma & Leukemia April 2019
46
117.37
113.5 (68-220)
33
0.86
0.83 (0.55-1.14)
45
3.38
3.09 (1.27-9.67)
T1a
36
119.67
115.0 (68-220)
25
0.83
0.82 (0.55-1.14)
35
3.34
2.88 (1.27-9.67)
T1b
10
109.10
102.0 (89-140)
8
0.94
0.93 (0.79-1.12)
10
3.45
3.26 (1.49-5.69)
36
130.36
125.5 (85-227)
30
0.95
0.87 (0.42-1.80)
36
4.03
3.00 (0.90-12.14)
T2a
22
134.91
126.5 (90-227)
17
0.83
0.75 (0.42-1.80)
22
3.92
2.81 (1.63-10.63)
T2b
14
123.21
121.5 (85-170)
13
1.10
1.04 (0.52-1.77)
14
4.19
3.63 (0.90-12.14)
T3
10
139.10
135.0 (110-198)
6
0.87
0.85 (0.66-1.09)
10
4.85
3.99 (1.34-11.13)
T4
10
121.80
122.0 (86-156)
10
1.24
1.12 (0.93-1.79)
10
4.31
3.96 (1.13-12.00)
T2
P value (all T) Post hoc T substage Post hoc
.036 T1 versus T3 .069 NA
.041
.001
.002
.535
T1-T3 versus T4
NA
.029
0.849
T1a, T2a versus T2b
NA
- 238.e3
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: LDH ¼ lactate dehydrogenase; MF ¼ mycosis fungoides; NA ¼ not applicable; NLR ¼ neutrophil/lymphocyte ratio; PQ ¼ plaque MF; PT ¼ patch MF; T ¼ tumor MF. a Differences among cohorts tested using the Mann-Whitney U test (median values) and 1-way analysis of variance using the Welch t test and Games-Howell post hoc test (mean values). b LDH value divided by the highest normal laboratory reference value.
.478
Eric C. Vonderheid, Andrew R. Martinez
< 10% versus 50%
Post hoc
Prognostic Significance of Serum Copper in CTCL Supplemental Table 4 Results of Univariate and Multivariate Analysis in Cox Proportional Hazards Model of Various Clinical and Laboratory Parameters for Patients with Mycosis Fungoides All-cause Death Parameter Male versus female White versus nonwhite Phase of MF Extent of involvement ISCL/EORTC T rating ISCL/EORTC stage Substage MF only Intra- versus extracutaneous disease Increased LDHc WBC count ANC ALC Lymphopenia (< 1.0 K/mL) Neutrophilia (> 8.0 K/mL) AEC Sézary cell < 6% or 6% Absolute Sézary cell count NLR NLR < 2 versus 2 NLR < 2.85 versus 2.85 Serum copper Increased copper Ceruloplasmin
MF-related Death
Univariatea
Multivariateb
Univariatea
Multivariateb
.612 .687 < .001 .039 < .001 < .001 .063 < .001
NS NS .084 .943 e e NS NS
.077 .059 < .001 .007 < .001 < .001 .006 < .001
NS NS .075 .675 e e NS NS
.465 .002 < .001 .882 .464 .084 .465 .435 .265 .302 .058 .090 .022 .061 .646
NS .001 .001 NS NS NS NS NS NS NS NS NS .041 .076 NS
.355 .015 .006 .826 .047 .756 .473 .029 .121 .246 .774 .163 .001 .002 .529
.106 .121 .170 NS .269 NS NS .162 NS .297 .754 .877 .008 .022 NS
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: AEC ¼ absolute eosinophil count; ALC ¼ absolute lymphocyte count; ANC ¼ absolute neutrophil count; ISCL/EORTC ¼ International Society for Cutaneous Lymphomas/European Organization for Research and Treatment of Cancer; LDH ¼ lactate dehydrogenase; MF ¼ mycosis fungoides; NLR ¼ neutrophil/lymphocyte ratio; NS ¼ not significant; WBC ¼ white blood cell. a Univariate P values with age < 60 and 60 years as covariate for all deaths. b Multivariate P values analyzed with age < 60 and 60 years and ISCL/EORTC clinical stage as covariates. c LDH index 1.1.
238.e4
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Clinical Lymphoma, Myeloma & Leukemia April 2019
Prognostic Significance of Serum Copper in Patients With Cutaneous T-cell Lymphoma Eric C. Vonderheid,1 Andrew R. Martinez2 Abstract Greater than normal serum copper levels in a subset of patients with early mycosis fungoides lymphoma correlated with a worse prognosis compared with that of patients with normal copper levels. The reason for this association is unknown. We hypothesized that inflammatory cytokines such as interleukin-6 secreted by inflammatory cells in skin lesions might play a role in disease progression. Background: Serum copper has been reported to be increased in various cancers, including lymphoma. The purpose of the present study was to investigate the clinical and prognostic importance of serum copper levels in patients with cutaneous T-cell lymphoma (CTCL). Patients and Methods: Serum copper was measured in 60 men and 38 women with mycosis fungoides (MF) and 14 men and 3 women with erythrodermic CTCL (6 with Sézary syndrome) consecutively evaluated from July 1980 to June 1985. Results: A greater than normal copper level was present in nearly 20% of patients and was associated with an increased risk of disease progression and shortened diseasespecific survival for patients with patch or plaque phase MF, but not for those with tumor phase MF or erythrodermic CTCL. In contrast, the serum lactate dehydrogenase level and neutrophil/lymphocyte ratio were not significantly associated with prognosis in our patient cohort. Conclusion: The reason for the association between the high serum copper levels and adverse prognosis is unknown. We hypothesized that interleukin-6 is secreted primarily by non-neoplastic cells at MF skin sites, leading to release of copper by the liver. Local production of interleukin-6 at the lesion sites might conceivably also promote neoplastic cell progression by stimulation of the STAT3 pathway. Further studies on the relationship between activated tumor-associated macrophages, serum copper levels, interleukin-6, or C-reactive protein and prognosis might be informative. Clinical Lymphoma, Myeloma & Leukemia, Vol. 19, No. 4, 228-38 ª 2018 Elsevier Inc. All rights reserved. Keywords: Erythroderma, Interleukin-6, Lactate dehydrogenase, Mycosis fungoides, Neutrophil/lymphocyte ratio
Introduction Primary cutaneous T-cell lymphoma (CTCL) is a non-Hodgkin lymphoma in which neoplastic T cells present initially in the skin. The most common manifestation of CTCL is mycosis fungoides (MF), which typically presents as patches or thin plaques, often on nonesun-exposed regions, with the potential to progress to tumid plaques, nodules or tumors, and involvement of lymph nodes and visceral organs.1 In addition to this classic presentation, many clinicopathologic variants of MF have been described, which can be confused with various inflammatory dermatoses.2
1
Johns Hopkins Medical Institutes, Baltimore, MD University of Arizona, Tucson, AZ
2
Submitted: Oct 3, 2018; Revised: Nov 20, 2018; Accepted: Dec 26, 2018; Epub: Jan 2, 2019 Address for correspondence: Eric C. Vonderheid, MD, 37580 South Desert Sun Drive, Tucson, AZ 85739 E-mail contact: [email protected]
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Clinical Lymphoma, Myeloma & Leukemia April 2019
The skin lesions of early MF are characterized by small- to medium-size atypical T cells with irregular to hyperconvoluted “cerebriform” nuclei within the epidermis (epidermotropism) and a lymphohistiocytic infiltrate in the superficial dermis that might or might not contain neoplastic or other inflammatory cells.3 With disease progression to more infiltrated plaques and tumors, both the depth of the dermal infiltrate and proportion of neoplastic cells within the dermal infiltrate will increase. Also, the neoplastic cells could become larger, with vesiculated nuclei indicative of transformation to large cell lymphoma. The second most common clinical presentation of CTCL is generalized or nearly generalized diffuse erythroderma (ie, erythrodermic CTCL [E-CTCL]). In the current terminology, Sézary syndrome (SS) refers to E-CTCL with high numbers of neoplastic T cells with hyperconvoluted “cerebriform” nuclei (Sézary cells) in the blood (i.e., “leukemic” E-CTCL).4 In addition to absolute Sézary cell counts of 1.0 K/mL, several other hematologic criteria according to the flow cytometry findings have been proposed to define the blood involvement of SS.5,6 Cases of E-CTCL that lack the blood criteria of
2152-2650/$ - see frontmatter ª 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.clml.2018.12.020
SS are diagnosed as either erythrodermic MF (E-MF) if the erythroderma was preceded by typical MF or as E-CTCL, not otherwise specified (E-NOS). (Patients with MF can develop SS or have evidence of leukemic involvement without erythroderma. The terms “secondary SS” and “leukemic MF” have been used to describe these cases.) The histopathologic features of E-CTCL can be nonspecific, even for patients with actual SS, and will often be comparable to those of patch or early plaque phase MF.7,8 The prognosis of patients with CTCL depends on the magnitude of the skin tumor burden and extracutaneous involvement. In general, the prognosis of patients worsens from patch to plaque to tumor phases, according to the appearance of the most infiltrated skin lesions and the extent of involvement at the skin surface. For clinical staging using the TNBM (tumor-node-blood-metastasis) classification system recommended by the International Society for Cutaneous Lymphomas/European Organization for Research and Treatment of Cancer (ISCL/EORTC),5 the skin ratings of T1 and T2 define the presence of patches, papules, and/or plaques on < 10% or 10% of the skin surface, respectively. These ratings can be further stratified into subgroups according to the presence of patches only (T1a/T2a) or plaques with or without patch (T1b/ T2b) lesions. The T3 and T4 skin ratings define the presence of 1 nodules or tumors and erythroderma, respectively. These T ratings are used in concert with findings in the lymph nodes (N rating), visceral organs (M rating), and blood (B rating) to determine the clinical stage. Given the substantial inflammatory component in the skin lesions of MF and SS, one might expect that the production of acute phase proteins would be affected.9 Several acute phase proteins have been found to be increased in patients with MF.10 These have included ceruloplasmin, the major carrier protein for copper.10,11 The serum copper level will also be increased in inflammatory skin diseases and various cancers, including lymphoma.12-15 In the present study, we investigated the clinical significance of serum copper levels in patients with MF and E-CTCL.
Patients and Methods Laboratory studies were obtained as a part of the initial evaluation of patients referred for an evaluation of CTCL. Data were retrieved from an institutional review boardeapproved cutaneous lymphoma patient registry established for the correlation with the prognosis. The serum copper levels were measured in reference laboratories using atomic absorption spectrophotometry. The normal referent ranges were 70 to 140 mg/dL for men and 85 to 155 mg/dL for women. Ceruloplasmin was also measured for a few patients (normal range, 20-60 mg/dL). To adjust for the different laboratory methods used to measure lactate dehydrogenase (LDH), the LDH values are given as the LDH index (ie, the reported LDH values divided by the highest normal reference value). An increased LDH level was defined as 10% greater than the highest normal reference value (LDH index, 1.1) as reported by another study.16 A neutrophil/lymphocyte ratio (NLR) of 2.85 was defined as high according to another study.17 The patient population consisted of 115 patients consecutively evaluated from July 1980 to June 1985. Of the 115 patients, 98 had a diagnosis of MF (60 men and 38 women) and 17 a diagnosis of
E-CTCL (14 men and 3 women). Sixty-one of the MF patients presented with typical clinical findings. The remaining 37 patients had an atypical aspect to their presentation (evidence of poikiloderma or parakeratosis variegata - 21 patients; follicular mucinosis 5 patients; large cell transformation - 5 patients; coexisting lymphomatoid papulosis - 3 patients; unilesional MF - 2 patients; ichthyosiform MF - 1 patient). The E-CTCL group included 6 patients with SS (absolute Sézary cell count 1.0 K/mL in blood), 2 patients with E-MF (1 with large cell transformation), and 9 patients with E-NOS, according to the ISCL guidelines.4 The ISCL/EORTC clinical stage of patients with a diagnosis of MF was stage IA (n ¼ 46), IB (n ¼ 26), IIA (n ¼ 10), IIB (n ¼ 10), IVA2 (n ¼ 3), and IVB (n ¼ 3). The clinical stage of patients with E-CTCL was IIIA (n ¼ 7), IIIB (n ¼ 4), IVA1 (n ¼ 4), and IVA2 (n ¼ 2).
Statistical Analysis The results of the laboratory studies are presented as the mean standard error of the mean and/or the median with the range. The Fisher exact and Pearson c2 tests were used to test the 2 by 2 and R by C categorical tables, respectively. The Kruskal-Wallis test was used to compare the values of the independent samples. However, the Welch unequal variance t test using log-transformed data was also computed, and if a significant difference was found among 3 groups, the Games-Howell post hoc test was used. The Dunnett t test was used to compare the MF cohorts against the group with parapsoriasis en plaques as the inflammatory disease control group and the atypical MF cohorts against the typical MF group. The Spearman correlation coefficient (rho) was used to test for correlations between the percentages of cells. The overall and diseasespecific survival from the date of the serum copper measurements were determined using the Kaplan-Maier and Cox proportional hazards methods. The minus twice the logarithm of the maximized likelihood statistic (2 log L ) was used to compare alternative Cox models (the lower the value of 2 log L, the better the fit in the model).18 The statistical software programs used in the present study were SYSTAT10 and SPSS, version 13.0, for Windows (IBM Corp, Armonk, NY) and StatXact-3 (Cytel, Inc, Cambridge, MA).
Results General Observations The results of the clinical and laboratory studies for MF and E-CTCL are summarized in Table 1. A separate analysis showed no difference in copper levels between the typical and atypical presentations of MF (Supplemental Table 1; available in the online version). Therefore, all variants of MF were combined for the subsequent analyses. More men had a diagnosis of MF or E-CTCL compared with the women (male/female ratio, 1.8:1). Patients with MF were significantly younger with a longer duration of disease before evaluation compared with the patients with E-CTCL. The total leukocyte and absolute lymphocyte counts for patients with E-CTCL, which included 6 patients with SS, were greater than those for patients with MF. The eosinophil counts were also greater in the patients with E-CTCL. Differences in the NLR and serum copper and LDH levels are discussed in the subsequent sections.
Clinical Lymphoma, Myeloma & Leukemia April 2019
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Prognostic Significance of Serum Copper in CTCL Table 1 Clinical and Laboratory Results for Patients With Cutaneous T-cell Lymphoma Variable
MF (n [ 98)
E-CTCL (n [ 17)
P Valuea .046
All Patients (n [ 115)
Age, y Median
56.5
67.0
Range
25-81
41-80
55.0 1.5
62.8 2.7
.018
56.1 1.4
44 (45)
11 (65)
.188
55 (48)
Male
60
14
.108
Female
38
3
White
89
15
Nonwhite
9
2
Mean SEM 60 y
57.0 25-81
Gender 74 41
Race .665
104 11
Overall duration,b y Median
7.2
3.0
Range
0.2-50.1
0.3-24.2
10.3 1.1
4.8 1.4
.003
.048
Mean SEM
.026
5.8 0.2-50.1 9.5 0.9
Duration from compatible histopathologic diagnosis,b mo Median
2.2
1.6
Range
0-308.5
0-7.6
15.3 3.8
2.1 0.5
.001 .997
Mean SEM
2.2 0-308.5 9.5 0.9
Copper, mg/dL Median
122.5
121.0
Range
68-227
86-163
Mean SEM
122.0 68-227
126.08 2.96
124.12 4.89
.733
125.79 2.61
Increased
19 (19)
3 (18)
1.0
22 (19)
SS
NA
n¼6
NA
NA
NA
NA
Median
124.5
Range
108-163
Mean SEM E-NOS
129.2 8.7 NA
Median
n¼9 117.0
Range
86-156
Mean SEM
119.8 7.3
Ceruloplasminc Median
39.6
NA
NA
NA
Range
28-66
NA
NA
NA
Mean SEM Increased
41.82 2.54
NA
NA
NA
1 (6)
NA
NA
NA
0.87
1.16
< .001
0.91
LDH indexd Median Range Mean SEM
0.42-1.80
0.82-1.79
0.90 0.03
1.25 0.07
< .001
0.96 0.03
0.42-1.80
1.10
9 (12)
8 (53)
.001
17 (19)
SS
NA
n¼4
NA
NA
Median
1.25
Range
0.82-1.54
NLRe
230
-
Median
3.27
2.29
Range
0.90-12.14
0.72-12.00
Clinical Lymphoma, Myeloma & Leukemia April 2019
.042
3.14 0.72-12.14
Eric C. Vonderheid, Andrew R. Martinez Table 1 Continued Variable Mean SEM 2.85
MF (n [ 98)
E-CTCL (n [ 17)
P Valuea
All Patients (n [ 115)
3.95 0.25
3.08 0.68
.240
3.82 0.24
57 (59)
7 (41)
.196
64 (56)
.004
WBC count, /mL Median
6.5
8.3
Range
3.1-35.4
5.2-13.4
7.08 0.35
8.72 0.62
.029 .360
Mean SEM
6.7 3.1-35.4 7.32 0.32
3
Neutrophil count, /mm Median
4257
5175
Range
1944-29,028
2756-7500
4976.2 300.9
5065.1 342.7
.846
4989.5 260.6
1435
2034
.011
1508 1710.9 98.6
Mean SEM
4385 1944-29,028
Lymphocyte count, /mm3 Median Range Mean SEM
350-4752
434-6298
1546.5 79.8
2658.5 424.7
.020
350-6298
< .001
Sézary cell count, /mm3 Median
0
511
Range
0-503
0-5320
36.9 12.4
938.03 315.43
.011 < .001
Mean SEM
0 0-5320 262.20 91.10
Eosinophil count, /mm3 Median
63
276
Range
0-1292
0-1125
116.9 18.4
407.5 89.1
Mean SEM
83 0-1292
.005
160.2 22.5
Data presented as n (%), unless otherwise noted. Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: E-CTCL ¼ erythrodermic cutaneous T-cell lymphoma; E-NOS ¼ erythrodermic cutaneous T-cell lymphoma, not otherwise specified; MF ¼ mycosis fungoides; NA ¼ not applicable; NLR ¼ neutrophil/lymphocyte ratio; SEM ¼ standard error of the mean; SS ¼ Sézary syndrome; WBC ¼ white blood cell. a Differences between MF and E-CTCL groups were tested using the Mann-Whitney U test, Welch t test, and Fisher exact test. b Duration of disease from onset of symptoms or first skin specimen with findings compatible with diagnosis of CTCL to date of laboratory testing. c Ceruloplasmin measured for 18 patients with MF. d LDH value divided by the highest normal laboratory reference value; LDH levels were obtained for 90 patients with MF and 15 patients with E-CTCL. e NLR not available for 1 patient.
Serum Copper Levels The serum copper levels were increased above normal for 19 of 98 patients with MF (19%) and 3 of 17 patients with E-CTCL (18%; Table 1). The levels were significantly higher in the women than in men for both MF (P ¼ .001) and E-CTCL (P ¼ .012; Supplemental Table 2; available in the online version). However, the proportion of men and women with greater than normal reference values was nearly 20% for each group. Ceruloplasmin was increased in only 1 of 18 patients with MF (1 man with extensive patch phase MF and a copper level of 227 mg/dL) and was not measured in patients with E-CTCL. The correlation of the copper levels with the findings for the clinical parameters is presented in Table 2. For patients with MF, the serum copper level was significantly greater in those patients with tumor phase disease, a T3 skin rating, and > 50% skin involvement. The difference between patch and plaque phase MF, a T1 and T2 skin rating, and < 10% and 10% to 50% skin involvement was not statistically significant. The difference among the substages of T1a, T1b, T2a, and T2b was not quite statistically significant (P ¼ .067). Moreover, the serum copper level for patients with E-CTCL was not different from that of the MF group and approximated that of the patients with plaque phase disease.
The copper levels for 6 patients with SS, with a relatively high tumor burden, were not significantly different statistically from those of the 11 patients with non-Sézary E-CTCL (P ¼ .546). To assess the effect of extracutaneous involvement on the copper levels, a comparison was also performed between stage I-II (skin limited) and stage IV for MF and stage III (skin limited) versus stage IV for E-CTCL (Table 2). Although the copper levels were higher in the 6 patients with MF and extracutaneous involvement than in the 92 patients with MF limited to the skin, the difference was not statistically significant (P ¼ .106). Additionally, no difference was apparent between the 10 patients with E-CTCL and intracutaneous disease (8 with E-NOS and 2 with E-MF) and the 7 patients with extracutaneous disease (6 with SS and 1 with E-NOS; P ¼ .696). These results suggest that advanced CTCL with extracutaneous involvement is not a major factor in determining the copper levels in patients with MF and E-CTCL. The relationship between the phase of MF and the disease extent was investigated further. Patients with stage IV disease were excluded to negate the influence of extracutaneous disease (Supplemental Table 3; available in the online version). The copper levels were significantly higher for patients with > 50% than for those with 50% skin surface involvement for the patch
Clinical Lymphoma, Myeloma & Leukemia April 2019
- 231
232
LDH Indexb
Copper Levels Variable
Patients, n
Mean ± SEM
Median (Range)
Patients, n
Mean ± SEM
NLR Median (Range)
Patients, n
Mean ± SEM
Median (Range)
Gender Male
74
118.41 2.82
116.5 (68-227)
56
0.97 0.04
0.92 (0.42-1.80)
74
3.99 0.30
3.32 (0.72-12.0)
Female
41
139.12 4.67
139.0 (85-220)
34
0.93 0.05
0.90 (0.55-1.77)
40
3.51 0.39
2.89 (0.78-12.14)
< .001
< .001
.454
.353
.258
.256
104
125.10 2.85
121.0 (68-227)
80
0.92 0.03
0.89 (0.42-1.80)
104
3.90 0.26
3.19 (0.72-12.14)
11
132.36 4.76
133.0 (99-150)
10
1.23 0.94
1.18 (0.79-1.77)
11
3.15 0.44
2.90 (1.34-5.58)
.107
.151
.004
.001
.473
.555
P valuec Race White Nonwhite P value Diagnosis Patch MF
58
125.45 4.07
121.0 (68-227)
42
0.83 0.03
0.79 (0.42-1.80)
57
3.57 0.29
2.88 (1.27-10.63)
Plaque MF
26
118.04 4.57
120.0 (85-170)
23
1.03 0.06
0.98 (0.52-1.77)
26
3.95 0.49
3.32 (0.90-12.14)
Tumor MF
14
143.64 7.07
140.5 (109-198)
10
0.88 0.04
0.87 (0.66-1.09)
14
5.54 0.81
5.00 (1.34-11.13)
P value
.010
.020
.008
.001
.044
.088
Post hoc
PT, PQ versus T
SS Non-SS
PT versus PQ
NA
6
129.17 8.75
124.5 (108-163)
4
1.25 0.18
1.25 (0.82-1.54)
6
1.13 0.15
1.15 (0.72-1.71)
11
121.36 5.99
121.0 (86-156)
11
1.27 0.08
1.16 (0.93-1.79)
11
4.15 0.90
3.44 (1.13-12.00)
.458
.546
.741
.514
< .001
.004
P value MF involvement extent < 10%
50
118.06 3.78
115.0 (68-220)
34
0.86 0.03
0.85 (0.55-1.14)
49
3.48 0.27
3.09 (1.27-9.67)
10%-50%
18
128.67 6.39
122.0 (92-198)
14
0.83 0.04
0.82 (0.52-1.05)
18
4.37 0.71
3.41 (1.65-12.14)
> 50%
30
137.90 5.72
136.5 (85-227)
27
0.98 0.06
0.91 (0.42-1.80)
30
4.48 0.53
3.84 (0.90-11.13)
P value
.013
.012
.262
.360
.338
.369
Post hoc
< 10 versus > 50
NA
NA
MF IntraC
92
124.82 3.01
121.5 (68-227)
69
0.90 0.03
0.84 (0.42-1.80)
91
3.80 0.25
3.19 (0.90-12.14)
ExtraC
6
145.50 12.91
156.0 (104-174)
6
0.91 0.03
0.93 (0.81-0.99)
6
6.33 1.15
7.06 (2.64-9.89)
.098
.106
.651
.359
.018
.025
P value E-CTCL IntraC
10
121.80 6.61
122.0 (86-156)
10
1.24 0.08
1.12 (0.93-1.79)
10
4.31 0.97
3.96 (1.13-12.00)
ExtraC
7
127.43 7.59
120.0 (108-163)
5
1.29 0.16
1.50 (0.82-1.57)
7
1.33 0.23
1.22 (0.72-2.50)
0.164
0.696
0.309
0.903
.043
.006
P value
Prognostic Significance of Serum Copper in CTCL
Clinical Lymphoma, Myeloma & Leukemia April 2019
Table 2 Results of Serum Copper, Serum LDH, and NLR Stratified by Clinical Parameters of Patients With CTCLa
Table 2 Continued LDH Indexb
Copper Levels Variable
NLR
Patients, n
Mean ± SEM
Median (Range)
Patients, n
Mean ± SEM
Median (Range)
Patients, n
Mean ± SEM
Median (Range)
T skin rating 46
117.37 4.05
113.5 (68-220)
33
0.86 0.03
0.83 (0.55-1.14)
45
3.38 0.27
3.09 (1.27-9.67)
T1a
36
119.67 4.83
115.0 (68-220)
25
0.83 0.03
0.82 (0.55-1.14)
35
3.34 0.32
2.88 (1.27-9.67)
T1b
10
109.10 6.40
102.0 (89-140)
8
0.94 0.05
0.93 (0.79-1.12)
10
3.50 0.45
3.26 (1.49-5.69)
38
130.16 4.77
125.5 (85-227)
32
0.95 0.06
0.91 (0.42-1.80)
38
4.05 0.45
3.00 (0.90-12.14)
T2a
22
134.91 6.94
126.5 (90-227)
17
0.83 0.07
0.75 (0.42-1.80)
22
3.92 0.57
2.81 (1.63-10.63)
T2b
16
123.63 5.98
121.5 (85-170)
15
1.08 0.08
0.99 (0.52-1.77)
16
4.23 0.74
3.63 (0.90-12.14)
T1
T2
T3
14
143.64 7.07
140.5 (109-198)
10
0.88 0.04
0.87 (0.66-1.09)
14
5.54 0.81
5.00 (1.34-11.13)
T4
17
124.12 4.88
121.0 (86-163)
15
1.25 0.07
1.16 (0.82-1.79)
17
3.08 0.68
2.29 (0.72-12.00)
.008
.009
< .001
< .001
.045
.023
P value All T ratings Post hoc T substage Post hoc
T1 versus T3 .067 NA
T1-T3 versus T4 .098
.020 T1a versus T2b
T3 versus T4 .002
.810
.766
NA
Clinical Lymphoma, Myeloma & Leukemia April 2019
Eric C. Vonderheid, Andrew R. Martinez
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: CTCL ¼ cutaneous T-cell lymphoma; E-CTCL ¼ erythrodermic cutaneous T-cell lymphoma; ExtraC ¼ extracutaneous involvement; IntraC ¼ intracutaneous (skin only); LDH ¼ lactate dehydrogenase; MF ¼ mycosis fungoides; NA ¼ not applicable; NLR ¼ neutrophil/lymphocyte ratio; PQ ¼ plaque MF; PT ¼ patch MF; SS ¼ Sézary syndrome; SEM ¼ standard error of the mean; T ¼ tumor MF. a Details of the entire MF and E-CTCL groups and the results of patients with skin-only involvement are provided in Supplemental Tables 2 and 3, respectively (available in the online version). b LDH value divided by top normal laboratory reference value. c Differences among cohorts tested with Mann-Whitney U test (median values) and 1-way analysis of variance using the Welch t test and Games-Howell post hoc test (mean values).
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Prognostic Significance of Serum Copper in CTCL Figure 1 Median-quartile Box Plot of Serum Copper Levels for Patients With Mycosis Fungoides (MF) Limited to the Skin According to the Extent of Skin Involvement and Parapsoriasis En Plaques (PEP)
parapsoriasis en plaques. The copper levels for these patients (n ¼ 8; mean, 139.50 8.30 mg/dL; median, 138 mg/dL; range, 99-178 mg/dL) were as high as those for patients with tumor phase MF limited to the skin (n ¼ 10; mean, 139.10 7.80 mg/dL; median, 135 mg/dL; range, 110-198 mg/dL) and were perforce higher than those for patients with patch or plaque phase MF (Figure 1). These observations suggest that the inflammatory component of MF lesions influences the copper levels to a greater degree than do the neoplastic cells in the early evolution of MF.
LDH Levels
(P ¼ .035) and plaque (P ¼ .037) phases but not for the tumor phase MF (P ¼ .819; Figure 1). The difference between patch and plaque phase MF with 50% involvement and patch and plaque MF with > 50% involvement was not significant. When the T ratings were divided into subgroups using the ISCL/EORTC recommendations,5 the copper levels tended to be greater for the patch-only subgroups compared with the corresponding subgroups of the plaques with or without patches (ie, copper level for T1a > T1b and T2a > T2b; Figure 2). Furthermore, for patients with a T4 skin rating without extracutaneous involvement (1 patient with E-MF and 6 with E-NOS), the copper values were significantly lower than those with T3 (P ¼ .037) and were comparable to those with substage T2b (P ¼ .801; Table 2). Finally, we observed copper values greater than the referent value in 25% of our patients with a diagnosis of
Figure 2 Median-quartile Box Plot of Serum Copper Levels for Patients With Mycosis Fungoides Limited to the Skin According to the ISCL/EORTC Skin T Ratings
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Clinical Lymphoma, Myeloma & Leukemia April 2019
LDH was measured in 75 patients with MF (42 with patch phase, 23 with plaque phase, 10 with tumor phase) and 15 patients with E-CTCL (4 with SS, 2 with E-MF, 9 with E-NOS). Unlike the copper levels, the LDH levels were significantly higher in those with E-CTCL than in those with MF (Table 1). No difference in the LDH levels was observed for those with MF with or without extracutaneous manifestations (Table 2; P ¼ .359). Furthermore, the LDH levels for patients with noneSézary E-CTCL (median LDH index, 1.12) were nearly identical to those for patients with SS (median LDH index, 1.32; P ¼ .713). For patients with MF limited to the skin, the LDH levels did not progressively increase according to the extent of skin involvement with MF nor was the LDH higher for tumor phase MF (median LDH index, 0.85) compared with patch or plaque phase MF (median LDH index, 0.84; P ¼ .958; Supplemental Table 3; available in the online version). In addition, the correlation between the LDH levels and T ratings was somewhat different from that observed for the serum copper levels. For example, the LDH levels tended to be higher for the T substages with plaques with or without patches compared with the T substages with patches only (ie, LDH levels for T1b > T1a and T2b > T2a; Figure 3). This observation suggests that neoplastic cells might be contributing to the LDH levels to a greater degree than the copper levels in clinical early-stage MF. Finally, no correlation was found
Figure 3 Median-quartile Box Plot of Serum Lactate Dehydrogenase (LDH) Levels for Patients With Mycosis Fungoides Limited to the Skin According to the ISCL/EORTC Skin T Ratings and Parapsoriasis En Plaques (PEP)
Eric C. Vonderheid, Andrew R. Martinez between the LDH and copper levels for all patients (rho ¼ 0.081; P ¼ .448) or for MF only (rho ¼ 0.156; P ¼ .181) and E-CTCL only (rho ¼ 0.338; P ¼ .218).
Neutrophil/Lymphocyte Ratio Patients with E-CTCL had a higher total leukocyte count than patients with MF (Table 1). The difference was attributed to higher lymphocyte and eosinophil counts (and Sézary cell counts) in the ECTCL group. However, the difference in the absolute neutrophil count was not statistically significant. Thus, the NLR was significantly lower for patients with E-CTCL compared with those with MF. In addition, the NLR for patients with SS was lower (median, 1.22) than that of patients with noneSézary E-CTCL (median, 4.15; P ¼ .004; Table 2). Lymphopenia (absolute lymphocyte count < 1.0 K/mL) occurred in only 1 patient with noneSézary E-CTCL. In contrast, the NLR was 2.85 for 57 of the 97 patients with MF (59%), including 52 of 91 patients (57%) with intracutaneous MF and 5 of 6 patients (83%) with extracutaneous disease (P ¼ .396). A possible contributing factor was lymphopenia, which occurred in 23 of 98 patients (23%) with MF overall, including 20 of 92 (22%) with intracutaneous MF and 3 of 6 (50%) with extracutaneous MF (P ¼ .139). The difference in the absolute neutrophil or lymphocyte counts between those with intracutaneous MF and extracutaneous MF was not statistically significant (P ¼ .164 and P ¼ .233, respectively). In contrast, neutrophilia (> 15 K/mL) was not encountered in either cohort. Finally, for patients with MF limited to the skin, the NLR showed no significant increase with the phase of MF, extent of skin involvement, or T skin ratings (Supplemental Table 3; available in the online version). The box plot of NLR according to the ISCLEORTC T ratings is shown in Figure 4. Although the pattern was similar to that of LDH, no correlation between the NLR and LDH values was found (rho ¼ 0.056; P ¼ .646). The NLR also did not correlate with the serum copper values for all patients with MF (rho ¼ 0.041; P ¼ .682).
The other significant laboratory studies included the total leukocyte and absolute neutrophil count but not the absolute lymphocyte or eosinophil count. The presence of 6 Sézary cells/100 lymphocytes, but not the absolute Sézary cell count, was associated with a poor disease-specific prognosis, as was lymphopenia (< 1.0 K/mL). The ratio of neutrophils to lymphocytes was not significant. With the clinical stage and age entered as covariates in the Cox model, an increased serum copper level was the only laboratory study finding that remained significantly associated with both overall and disease-specific survival (Supplemental Table 4; available in the online version). This finding indicates that gender-adjusted high copper values provide prognostic information that is independent of clinical stage. When correlated with the clinical parameters that reflect disease severity (Table 3), the estimated mean survival tended to be shorter for patients with increased copper levels than for the corresponding patients with normal levels, although these differences were usually not statistically significant. Furthermore, the differences became smaller with more advanced involvement. Overall and disease-specific survival curves for all patients with MF, stratified according to normal or increased levels of serum copper, are shown in Figures 5 and 6.
Discussion The present study found higher than normal serum copper levels in nearly 20% of patients with MF or E-CTCL. Furthermore, patients with MF with hypercupremia, but not E-CTCL, were more likely to experience disease progression and shorter survival than were patients with normal copper levels. The correlation with an adverse prognosis seemed to be independent of clinical stage, which is the main determinant of prognosis for those with MF/E-CTCL. In contrast, increased serum LDH levels and a NLR of 2.85, both of which have been reported to correlate with the prognosis,17,19 did not correlate significantly with either overall or disease-specific survival in the present cohort of patients, nor was the correlation with copper values significant. The reason copper is increased in those with MF or E-CTCL is unknown. One possibility is that copper, similar to ceruloplasmin
Prognosis The prognostic importance of the clinical and laboratory variables for patients with MF were evaluated in the Cox model with patient age (< 60 and 60 years) as a covariate and any cause of death and disease-specific death as the endpoints (Supplemental Table 4; available in the online version). Patients with E-CTCL were excluded because no clinical or laboratory study findings were associated with survival, including the Sézary cell counts. Several clinical findings with known prognostic importance for patients with MF were found on univariate analysis to be significantly associated with survival. These included the phase of MF, extent of skin involvement, extracutaneous involvement, and ISCL-EORTC T ratings, and clinical stage. The 5-year overall and disease-specific survival rates were 81% and 88% for patients with normal copper levels and 58% and 65% for patients with increased copper levels, respectively. In addition, 13 of 22 patients (59%) with high copper values had experienced disease progression after the initial evaluation compared with 21 of 93 patients (23%) with normal values (P ¼ .002). In contrast, the rate of disease progression for patients with high LDH levels was not different from that of patients with normal values (P ¼ .569).
Figure 4 Median-quartile Box Plot of the Neutrophil/ Lymphocyte Ratio in the Blood of Patients With Mycosis Fungoides Limited to the Skin According to the ISCL/EORTC Skin T Ratings and Parapsoriasis En Plaques (PEP)
Clinical Lymphoma, Myeloma & Leukemia April 2019
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Prognostic Significance of Serum Copper in CTCL Table 3 Mean Overall and Disease-specific Survival for Patients With Cutaneous T-cell Lymphoma Stratified by Serum Copper Level Overall Survival ± SEM
Disease-specific Survival ± SEM
Increased CU/ Total, n (%)
Normal CU
Increased CU
P Value
All MF patients
19/98 (19)
21.94 1.53
11.06 2.94
.003
Stage I-IIB MF
16/92 (17)
22.71 1.52
12.90 3.29
.016
32.15 1.40
20.26 4.36
.002
9/58 (16)
27.89 1.47
17.60 4.00
.029
36.27 0.83
28.51 4.67
.031
Plaque phase
3/24 (13)
15.77 2.64
13.96 8.88
.811
26.09 3.12
20.65 10.50
.511
Tumor phase
4/10 (40)
3.00 1.26
1.39 0.48
.443
3.00 1.15
1.39 0.48
.443
Variable
Patch phase
a
Normal CU
Increased CU
P Valuea
31.39 1.47
18.13 4.12
.001
T1 rating
4/46 (9)
25.95 1.78
16.66 6.20
.257
35.89 1.07
28.38 6.72
.101
T2 rating
8/36 (22)
21.77 2.47
16.62 4.67
.411
30.92 2.32
25.66 5.68
.523
T3 rating
4/10 (40)
3.00 1.26
1.39 0.48
.443
3.00 1.15
1.39 0.48
.443
Stage IV MF
3/6 (50)
2.62 1.33
1.20 0.68
.277
2.96 1.69
1.27 0.15
.433
All E-CTCL patients
3/17 (18)
6.37 1.58
7.69 5.27
.469
9.83 2.16
7.69 5.27
.903
SS Non-SS
1/6 (17)
6.98 2.72
1.48
.247
8.43 2.97
1.48
.046
2/11 (18)
5.88 1.96
10.79 7.38
.274
9.38 2.27
10.79 7.38
.962
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: CU ¼ copper; E-CTCL ¼ erythrodermic cutaneous T cell lymphoma; MF ¼ mycosis fungoides; SS ¼ Sézary syndrome. a Log-rank test was used to test for differences between normal and increased CU levels in Kaplan-Meier survival curves.
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and other acute phase proteins,9 is released from the liver via stimulation with pro-inflammatory cytokines produced at the skin lesion sites of MF/E-CTCL. For example, interleukin-1 and interleukin-6 (IL-6), the most important cytokine involved in the production of most acute-phase proteins by the liver, has been demonstrated in exudates from MF lesions20 and in the blood of patients with MF and SS.21-23 If this hypothesis is correct, the source of the cytokines could be the inflammatory cell component or neoplastic T cells, or both. Regarding the neoplastic T cells as a possible source of IL-6, neoplastic cell lines are capable of secreting IL-6,24,25 and IL-6 mRNA has been demonstrated in MF tumors.26 In addition, C-reactive protein, which is particularly responsive to IL-6 stimulation, has been reported to be increased in patients with MF.10,11 One study reported an increase in mean C-reactive protein levels in tandem with the increased clinical stage of MF.10 Therefore, it is
likely that neoplastic cells provide a significant source of IL-6, especially in the advanced phases of MF. Given that macrophages are a major source of IL-6,27 the inflammatory component of MF skin lesions could provide another mechanism for the increased copper levels. Hypercupremia has been reported in patients with psoriasis and atopic dermatitis,12 and we observed higher than normal copper values in 25% of our patients with a diagnosis of parapsoriasis en plaques. We found it surprising that the copper levels in the patients with parapsoriasis en plaques were as high as those with tumor phase MF limited to the skin. In addition, although not statistically significant, the copper levels tended to be higher in patients with limited-extent patch phase MF (5 of 40 patients with 50% of the skin surface had copper levels higher than normal) compared with those with plaque phase MF (none of 15 patients with 50% of the skin surface had copper levels higher than normal). One possibility that could not be
Figure 5 Overall Survival of Patients With Mycosis Fungoides (MF) According to Serum Copper Level
Figure 6 Disease-specific Survival of Patients With Mycosis Fungoides (MF) According to Serum Copper Level
Clinical Lymphoma, Myeloma & Leukemia April 2019
Eric C. Vonderheid, Andrew R. Martinez retrospectively addressed is that topically applied corticosteroid preparations might have influenced the serum copper levels in some patients with early MF. Nevertheless, these observations suggest that the inflammatory component of MF lesions influences the copper levels to a greater degree than do the neoplastic cells at least until the tumor phase or extracutaneous involvement has developed. Another question is why the presence of hypercupremia signifies a worse prognosis independently of the clinical stage. This question was interesting considering that 2 other reported prognostic indicators for MF (ie, increased LDH16,19 and high NLR17,28) did not correlate with the prognosis in this cohort of patients, even using univariate analysis. This might be explained by a difference in the mechanism. If IL-6 regulates serum copper levels and if most IL-6 emanates from non-neoplastic cells in skin lesions of MF as theorized, perhaps patients with relatively high serum copper levels at any particular phase of disease are those in whom the neoplastic cells in the lesions contribute substantially to the total IL-6 production. Thus, the amount of IL-6 secreted by the biomass of activated neoplastic cells added to the amount secreted by non-neoplastic cells in lesional skin might yield a greater total IL-6 release in some patients and, consequently, higher than normal serum copper levels. If this hypothesis is correct, a positive correlation could be expected between the copper levels and activation of proliferation markers in skin lesions such as CD30 or Ki-67.29,30 Alternatively, it is conceivable that a higher level of IL-6 production from non-neoplastic cells in MF lesions might encourage the progression of disease in some patients. For example, IL-6 from activated tumor-associated macrophages (M2 macrophages) in situ might directly promote tumor progression via stimulation of the STAT3 pathway.31-34 These possibilities are not mutually exclusive. Finally, high IL-6 levels, as suggested by high serum copper levels, might affect overall survival by increasing the risk of coronary artery disease, as recently reported.11 However, our patients had an increased risk of progressive MF and impaired disease-specific survival. This effect became less evident for patients with advanced disease (tumor phase MF or extracutaneous involvement) and for patients with E-CTCL. Additional studies of the prognostic implications of C-reactive protein, which is more stable and easier to measure than IL-6,10 M2 macrophage markers such as CD163 and CCL18,33,35 and perhaps soluble CD25,23 would be of interest.
Conclusion Patients with patch/plaque phase MF and higher than normal serum copper levels were more likely to experience disease progression and have a shorter mean survival than were patients with normal levels. In contrast, the LDH levels and NLR did not identify patients at risk of progression. We hypothesized that IL-6 and other inflammatory cytokines released primarily by non-neoplastic cells at the lesion sites might be stimulating copper release from the liver and also promoting neoplastic cell progression in situ.
Clinical Practice Points To the best of our knowledge, the present study is the first to
show that patients with patch or plaque phase MF and increased serum copper levels are prone to disease progression and, hence, a worse prognosis than patients with normal levels.
Additional studies are required to understand the role that non-
neoplastic cells might be playing in promoting disease progression.
Disclosure The authors have stated that they have no conflicts of interest.
Supplemental Data Supplemental tables accompanying this article can be found in the online version at https://doi.org/10.1016/j.clml.2018.12.020.
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31. Sommer VH, Clemmensen OJ, Nielsen O, et al. In vivo activation of STAT3 in cutaneous T-cell lymphoma: evidence for an antiapoptotic function of STAT3. Leukemia 2004; 18:1288-95. 32. Yu H, Pardoll D, Jove R. STATs in cancer inflammation and immunity: a leading role for STAT3. Nat Rev Cancer 2009; 9:798-809. 33. Sugaya M, Miyagaki T, Ohmatsu H, et al. Association of the numbers of CD163(þ) cells in lesional skin and serum levels of soluble CD163 with disease progression of cutaneous T cell lymphoma. J Dermatol Sci 2012; 68:45-51. 34. Wu X, Schulte BC, Zhou Y, et al. Depletion of M2-like tumor-associated macrophages delays cutaneous T-cell lymphoma development in vivo. J Invest Dermatol 2014; 134:2814-22. 35. Miyagaki T, Sugaya M, Suga H, et al. Increased CCL18 expression in patients with cutaneous T-cell lymphoma: association with disease severity and prognosis. J Eur Acad Dermatol Venereol 2013; 27:e60-7.
Eric C. Vonderheid, Andrew R. Martinez Supplemental Table 1 Serum Copper Levels With Clinically Typical and Atypical Expression of MF Copper (mg/dL) Diagnostic Group Typical MF
P Valuea
Increased/Total, n/N (%)
Median (Range)
Mean ± SEM
10/61 (16)
120.0 (68-220)
123.07 3.58
2/15 (13)
115.0 (86-157)
117.00 5.53
.986
1/6 (17)
132.0 (104-180)
135.17 10.56
.851
b
Atypical MF
MF with poikiloderma MF with PKV MF with LCL
3/5 (60)
151.0 (104-174)
141.40 13.63
.658
MF with LyP
0/3 (0)
125.0 (123-139)
129.00 5.03
.995
MF with FM
2/5 (40)
123.0 (109-202)
146.00 17.89
.495
Abbreviations: FM ¼ follicular mucinosis; LCL ¼ large cell lymphoma; MF ¼ mycosis fungoides; PKV ¼ parakeratosis variegata; LyP ¼ lymphomatoid papulosis; SEM ¼ standard error of the mean. a Atypical MF groups compared with the typical MF group as a control using Dunnett’s t test. b Atypical expression of MF included patients with evidence of poikiloderma, PKV, FM, LyP, and transformation to LCL.
Clinical Lymphoma, Myeloma & Leukemia April 2019
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Prognostic Significance of Serum Copper in CTCL Supplemental Table 2 Clinical and Laboratory Results for Patients With Cutaneous T-cell Lymphoma Stratified by Gender MF Variable
Men (n [ 60)
E-CTCL
Women (n [ 38)
P Value .094
Men (n [ 14)
Women (n [ 3)
P Value .377
Age, y Median
60
55
68
55
Range
60 (25-81)
55 (25-78)
41-80
54-67
57.13 1.85
51.50 2.50
63.71 3.19
58.67 4.18
10 (71%)
1 (33%)
3.2
3.02
Mean SEM 60 y
31 (52%)
13 (34%)
Overall duration,a y Median Range Mean SEM
6.3
7.6
.810
0.2-50.1
0.4-40.4
0.3-24.2
0.34-3.68
10.58 1.45
9.96 1.50
5.28 1.66
2.35 1.02
.529
Duration from first compatible histopathologic diagnosis,a mo Median
2.4
2.2
1.1
2.07
Range
0-308.5
0-131.4
0-7.6
1.64-5.58
16.22 5.57
13.85 4.41
1.89 0.58
3.10 1.25
Mean SEM
.726
.208
Copper Median
115.0
136.0
Range
68-227
85-220
118.60 3.36
137.89 4.98
Mean SEM Increased
11 (18%)
.001
118.5
156.0
86-150
145-163
117.57 4.01
154.67 5.24
1 (7%)
2 (67%)
.830
1.24
0.93
1.00-1.79
0.82-1.50
.691
1.30 0.08
1.08 0.21
7 (58%)
1 (33%)
.242
2.40
1.09
0.72-12.00
0.78-3.05
.250
3.39 0.79
154.67 5.24
6 (43%)
1 (33%)
.858
1962
5978.0
.001
8 (21%)
.012 .001
LDH indexb Median Range Mean SEM 1.10
0.85
0.90
0.42-1.80
0.55-1.77
0.89 0.03
0.92 0.05
5 (11%)
4 (13%)
3.38
2.9
.149 .397
NLR Median Range Mean SEM 2.85
c
1.27-11.13
0.9-12.1
4.13 0.32
3.66 0.41c
37 (62%)
20 (54%)
.166 .269
Lymphocyte count, /mm3 Median Range Mean SEM
1485
1374
.131
462-4292
350-4752
434-4482
1364-6298
1499.1 89.9
1621.5 149.8
.562
2254 338
4547 1594
.310
63
63
.531
346
186
.344
0-1125
0-488
.674
446.64 102.55
224.67 142.19
Eosinophil count, /mm3 Median Range Mean SEM
0-760
0-1292
114.9 19.0
120.22 37.45
.943
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: E-CTCL ¼ erythrodermic cutaneous T-cell lymphoma; LDH ¼ lactate dehydrogenase; MF ¼ mycosis fungoides; NLR ¼ neutrophil/lymphocyte ratio; SEM ¼ standard error of the mean. a Duration of disease from onset of symptoms or first skin specimen with findings compatible with a diagnosis of CTCL to the date of laboratory testing. b LDH value divided by highest normal laboratory reference value; LDH obtained for 44 men and 31 women with MF and 12 men with E-CTCL. c NLR not available for 1 patient.
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Supplemental Table 3 Results of Serum Copper, Serum LDH, and NLR Stratified by Clinical Parameters of Patients With Cutaneous T-cell Lymphoma and Involvement Limited to Skin (Stage IV Excluded) LDH Indexa
Copper Variable
NLR
Patients, n
Mean
Median (Range)
Patients, n
Mean
Median (Range)
Patients, n
Mean
Median (Range)
Patch MF
58
125.45
121.0 (28-227)
42
0.83
0.79 (0.42-1.80)
57
3.57
2.88 (1.27-10.63)
Plaque MF
24
117.33
120.0 (85-170)
21
1.04
0.95 (0.52-1.77)
24
3.90
3.32 (0.90-12.14)
Tumor MF
10
139.10
135.0 (110-198)
6
0.87
0.85 (0.66-1.09)
10
4.85
3.99 (1.34-11.13)
Diagnosis
P valueb
.045
Post hoc
.087
.023
PQ versus T
.002
.348
PT versus PQ
.291
NA
Extent of skin involvement (MF only) < 10%
50
118.06
115.0 (68-220)
34
0.86
0.85 (0.55-1.14)
49
3.48
3.09 (1.27-9.67)
10%-50%
17
126.00
121.0 (92-198)
13
0.82
0.80 (0.52-1.05)
17
4.17
3.33 (1.65-12.14)
50%
67
120.08
116.0 (68-220)
47
0.85
0.83 (0.52-1.14)
66
3.66
3.14 (1.27-12.14)
> 50%
25
137.52
134.0 (85-227)
22
1.00
0.91 (0.42-1.80)
25
4.17
3.37 (0.90-11.13)
P value
.028
.020
.279
.392
.643
NA
.718
NA
T rating T1
Clinical Lymphoma, Myeloma & Leukemia April 2019
46
117.37
113.5 (68-220)
33
0.86
0.83 (0.55-1.14)
45
3.38
3.09 (1.27-9.67)
T1a
36
119.67
115.0 (68-220)
25
0.83
0.82 (0.55-1.14)
35
3.34
2.88 (1.27-9.67)
T1b
10
109.10
102.0 (89-140)
8
0.94
0.93 (0.79-1.12)
10
3.45
3.26 (1.49-5.69)
36
130.36
125.5 (85-227)
30
0.95
0.87 (0.42-1.80)
36
4.03
3.00 (0.90-12.14)
T2a
22
134.91
126.5 (90-227)
17
0.83
0.75 (0.42-1.80)
22
3.92
2.81 (1.63-10.63)
T2b
14
123.21
121.5 (85-170)
13
1.10
1.04 (0.52-1.77)
14
4.19
3.63 (0.90-12.14)
T3
10
139.10
135.0 (110-198)
6
0.87
0.85 (0.66-1.09)
10
4.85
3.99 (1.34-11.13)
T4
10
121.80
122.0 (86-156)
10
1.24
1.12 (0.93-1.79)
10
4.31
3.96 (1.13-12.00)
T2
P value (all T) Post hoc T substage Post hoc
.036 T1 versus T3 .069 NA
.041
.001
.002
.535
T1-T3 versus T4
NA
.029
0.849
T1a, T2a versus T2b
NA
- 238.e3
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: LDH ¼ lactate dehydrogenase; MF ¼ mycosis fungoides; NA ¼ not applicable; NLR ¼ neutrophil/lymphocyte ratio; PQ ¼ plaque MF; PT ¼ patch MF; T ¼ tumor MF. a Differences among cohorts tested using the Mann-Whitney U test (median values) and 1-way analysis of variance using the Welch t test and Games-Howell post hoc test (mean values). b LDH value divided by the highest normal laboratory reference value.
.478
Eric C. Vonderheid, Andrew R. Martinez
< 10% versus 50%
Post hoc
Prognostic Significance of Serum Copper in CTCL Supplemental Table 4 Results of Univariate and Multivariate Analysis in Cox Proportional Hazards Model of Various Clinical and Laboratory Parameters for Patients with Mycosis Fungoides All-cause Death Parameter Male versus female White versus nonwhite Phase of MF Extent of involvement ISCL/EORTC T rating ISCL/EORTC stage Substage MF only Intra- versus extracutaneous disease Increased LDHc WBC count ANC ALC Lymphopenia (< 1.0 K/mL) Neutrophilia (> 8.0 K/mL) AEC Sézary cell < 6% or 6% Absolute Sézary cell count NLR NLR < 2 versus 2 NLR < 2.85 versus 2.85 Serum copper Increased copper Ceruloplasmin
MF-related Death
Univariatea
Multivariateb
Univariatea
Multivariateb
.612 .687 < .001 .039 < .001 < .001 .063 < .001
NS NS .084 .943 e e NS NS
.077 .059 < .001 .007 < .001 < .001 .006 < .001
NS NS .075 .675 e e NS NS
.465 .002 < .001 .882 .464 .084 .465 .435 .265 .302 .058 .090 .022 .061 .646
NS .001 .001 NS NS NS NS NS NS NS NS NS .041 .076 NS
.355 .015 .006 .826 .047 .756 .473 .029 .121 .246 .774 .163 .001 .002 .529
.106 .121 .170 NS .269 NS NS .162 NS .297 .754 .877 .008 .022 NS
Bolded values show the statistically significant values, (i.e.) P values less than .05. Abbreviations: AEC ¼ absolute eosinophil count; ALC ¼ absolute lymphocyte count; ANC ¼ absolute neutrophil count; ISCL/EORTC ¼ International Society for Cutaneous Lymphomas/European Organization for Research and Treatment of Cancer; LDH ¼ lactate dehydrogenase; MF ¼ mycosis fungoides; NLR ¼ neutrophil/lymphocyte ratio; NS ¼ not significant; WBC ¼ white blood cell. a Univariate P values with age < 60 and 60 years as covariate for all deaths. b Multivariate P values analyzed with age < 60 and 60 years and ISCL/EORTC clinical stage as covariates. c LDH index 1.1.
238.e4
-
Clinical Lymphoma, Myeloma & Leukemia April 2019