Extracorporeal photopheresis during the COVID-19 pandemic: experience in Argentina

BACKGROUND: Patients with primary cutaneous lymphoma receive immunosuppressive therapy for long term disease control. Both cutaneous lymphoma and immunosuppressive treatment can contribute to the development of more severe COVID-19 complications. The real challenge during the COVID-19 pandemic remains the management of the advanced and aggressive forms of cutaneous lymphomas, including late-stage mycosis fungoides (MF) and Sézary syndrome (SS). Extracorporeal photopheresis (ECP) is one of those treatments. ECP is considered high risk therapy according to the United States Cutaneous Lymphoma Consortium recommendations for treatment of cutaneous lymphomas during the COVID-19 pandemic because it may require travel to the clinic or hospital. METHODS: In this cross-sectional retrospective study, data of patients with MF or SS who received ECP treatment were collected. ECP consisted of a two-session cycle every two to four weeks. In our group we did not carry out prophylactic interruption of the therapy, once started. In patients with stable disease (SD) or partial response (PR), ECP was administered every 4 weeks, until a 6-week maximum interval was reached, and the response maintained. During the study period, the frequency of treatments was decreased, especially for patients with severe comorbidities and/or older age. The associated therapy was considered individually, depending on the extension of the disease, comorbidities, and adverse effects of each agent. RESULTS: 16 patients with cutaneous lymphoma received ECP (9 (56%) with SS and 7 (44%) with MF). Their median age at diagnosis was 63 (57–67) years. The median number of treatments before ECP was 2 (1–3), which was typically either phototherapy or systemic corticosteroids. Regarding the associated treatment during ECP and pandemic, INF and retinoids were the first-choice treatments. In the MF group 3 patients (2 PR and 1 relapse) required additional therapy with acitretin and topic corticosteroids. In the SS group 5 patients (1 PR, 3 progressive disease and 1 relapse) received concomitant t treatment with INF alfa 2b, bexarotene and electron beam; the relapsed patient underwent mono chemotherapy. Three patients were infected with SARS-CoV-2, all of them were from the SS group, the contagion was outside the hospital environment. Two of the patients who developed COVID infection died. CONCLUSION: For patients with advanced forms of LCCT, who usually have multiple risk factors for a severe course of SARS-CoV-2 infection therapy. The critical patient subset includes those with advanced disease, who require treatment with polychemotherapy, ECP and checkpoint inhibitors. Treatment decisions should be made on an individual basis. In our experience, the continuous use of ECP during the pandemic did not increase the risk of contagion.