Rituximab has been established as an effective and safe therapy for cutaneous B-cell lymphoma (CBCL). Different survival pathways, that is the Raf/MEK/Erk-or the p38MAPK cascade, have been suggested as downstream mediators of rituximab and may be involved in treatment failure. Biopsies from four patients, suffering from different subtypes of CBCL, which were obtained at various time points of relapse during or after therapy with 375 mg rituximab per m 2 of body surface area, were analysed for the expression of CD20, CD3, Ki-67, Raf-kinase inhibitory protein (RKIP) and bcl-2 by immunohistochemistry. No CD20-loss variants, that is the suggested main tumour escape mechanism to rituximab therapy, were observed in any specimen of relapsing CBCL. Notably, the expression of proapoptotic RKIP remained increased in these tumour samples. This was concomitated by a constant to slightly reduced proliferation status as demonstrated by Ki-67 staining. However, relapsing CBCL exhibited a strong upregulation of the antiapoptotic molecule bcl-2 in comparison to pretherapeutic levels. The immunohistochemical analyses of this case series of rituximab refractory CBCL suggest that upregulation of bcl-2 may play a major role in therapy resistance. The exact in vivo mechanisms of rituximab still remain elusive but likely include antibody-dependent cellular cytotoxicity (ADCC), complement-mediated lysis (CDC) and immune responses (Reff et al, 1994;Selenko et al, 2001). Furthermore, rituximab inhibits crucial survival pathways by upregulating the Raf-kinase inhibitory protein (RKIP), thus directly modifying the extracellular signal-regulated kinase1/2-and nuclear factor-k B, respectively (Jazirehi and Bonavida, 2005).Despite a high initial response rate, local or distant recurrence of CBCL is frequently observed in rituximab therapy. To delineate possible factors predicting or being associated with relapse, we scrutinised recurrent CBCL from four patients before, during and after systemic rituximab therapy.
PATIENTS AND METHODS
Patient characteristicsFour patients with multifocal CBCL (classified according to the WHO-EORTC classification for primary cutaneous lymphoma (Willemze et al, 2005)) were treated with rituximab intravenously at doses of 375 mg m À2 body surface area at