Introduction: Addressing the Maintenance Gap in Cutaneous T-Cell Lymphoma
Cutaneous T-cell lymphomas (CTCL), specifically advanced-stage mycosis fungoides (MF) and Sézary syndrome (SS), are rare and aggressive extranodal non-Hodgkin lymphomas. While various systemic therapies, including chemotherapy, biologics, and total skin electron beam (TSEB) therapy, can induce remission or disease control, these responses are often transient. The high relapse rate in advanced-stage disease poses a significant clinical challenge, as patients frequently cycle through multiple lines of treatment with diminishing returns. Until recently, there has been a lack of high-quality evidence supporting specific maintenance strategies to prolong disease control in this population. The RESMAIN trial, a multicentre, phase 2 randomized controlled study, sought to address this unmet need by evaluating the efficacy of resminostat, an oral histone deacetylase (HDAC) inhibitor, as a maintenance intervention.
Highlights of the RESMAIN Trial
The trial provides several critical insights into the management of advanced CTCL:
- Resminostat maintenance therapy significantly extended median progression-free survival (PFS) to 8.3 months compared to 4.2 months in the placebo group.
- The hazard ratio for disease progression or death was 0.62, representing a 38% reduction in the risk of progression.
- The benefit was observed in patients with both mycosis fungoides and Sézary syndrome who had achieved at least stable disease following prior systemic therapy.
- The safety profile was manageable, though gastrointestinal side effects were frequent and required proactive clinical management.
Background and Disease Burden
Mycosis fungoides and Sézary syndrome represent the most common forms of CTCL. While early-stage disease is often managed with skin-directed therapies and has a favorable prognosis, advanced-stage disease (Stage IIB-IVB) is characterized by systemic involvement, severe pruritus, and a significant risk of infection. For these patients, the goal of therapy is not only to achieve a response but to maintain it. However, the median duration of response to many standard-of-care systemic agents is short. HDAC inhibitors, which modulate gene expression by preventing the removal of acetyl groups from histones, have shown activity in CTCL by inducing apoptosis and cell cycle arrest in malignant T-cells. Resminostat is a novel, potent HDAC inhibitor that targets Class I, IIb, and IV HDACs, making it a logical candidate for maintenance therapy following initial disease stabilization.
Study Design and Methodology
The RESMAIN trial (NCT02953301) was a double-blind, randomized, placebo-controlled phase 2 trial conducted across 55 centers in 12 countries. The study enrolled 201 adult patients with histologically confirmed MF or SS (stages IIB-IVB) who had achieved disease control (complete response, partial response, or stable disease) after at least one previous systemic therapy or TSEB.
Patient Randomization and Intervention
Participants were randomly assigned in a 1:1 ratio to receive either oral resminostat (600 mg once daily) or a matching placebo. The dosing schedule followed a 14-day cycle: five consecutive days of treatment followed by a nine-day rest period. Randomization was stratified by disease stage and the quality of remission following previous therapy. The primary endpoint was progression-free survival (PFS), assessed by the investigators using standardized global response criteria for CTCL.
Key Findings: Efficacy and Survival Outcomes
The results of the RESMAIN trial represent a significant milestone in CTCL clinical research. Between 2017 and 2022, 100 patients were assigned to resminostat and 101 to placebo. The median age of participants was 64 years, and the majority had advanced-stage disease (Stage IVA1 or higher).
Primary Endpoint: Progression-Free Survival
The study met its primary endpoint, demonstrating a statistically significant improvement in PFS for patients receiving resminostat. The median PFS was 8.3 months (95% CI 4.2–15.7) in the resminostat group versus 4.2 months (95% CI 2.8–6.4) in the placebo group. The hazard ratio (HR) was 0.62 (95% CI 0.42–0.92; p=0.015). This doubling of the median time to progression suggests that resminostat effectively alters the kinetics of disease relapse in the maintenance setting.
Secondary Analysis and Subgroups
While the study was powered for the overall population, subgroup analyses suggested that the benefit of resminostat was consistent across various demographic and clinical cohorts. Notably, patients who entered the trial with stable disease appeared to derive substantial benefit, emphasizing the role of resminostat in preventing early progression even when a deep remission had not been achieved by the prior line of therapy.
Safety and Tolerability Profile
As with other HDAC inhibitors, resminostat was associated with a specific profile of adverse events (AEs). Grade 3 or higher AEs occurred in 38% of the resminostat group compared to 15% in the placebo group. Importantly, there were no treatment-related deaths reported.
Gastrointestinal and Constitutional Symptoms
The most frequent treatment-related adverse events were gastrointestinal. Nausea was reported in 68% of the resminostat group (vs. 6% in placebo), followed by diarrhea (44% vs. 9%) and vomiting (32% vs. 1%). Fatigue was also common, affecting 29% of patients treated with resminostat. These symptoms led to dose interruptions or reductions in some patients, highlighting the need for supportive care.
Management Strategies
The investigators noted that the gastrointestinal side effects were generally manageable with standard anti-emetic and anti-diarrheal medications. Future clinical use of resminostat in the maintenance setting will likely necessitate the proactive use of anti-emetic prophylaxis to improve patient adherence and quality of life during long-term therapy.
Expert Commentary and Clinical Implications
The RESMAIN trial is the first large-scale, randomized, placebo-controlled trial to demonstrate a clear benefit for maintenance therapy in advanced CTCL. Traditionally, maintenance therapy in this field has been heterogeneous, often relying on low-dose skin-directed therapies or observational approaches. The doubling of PFS with resminostat provides clinicians with an evidence-based option to extend the duration of disease control.
Biological Plausibility
The efficacy of resminostat in this setting likely stems from its ability to maintain a state of epigenetic modulation that suppresses the proliferative capacity of malignant T-cell clones. By inhibiting HDACs, resminostat may prevent the re-emergence of the disease by keeping pro-apoptotic pathways primed and oncogenic signaling pathways suppressed.
Study Limitations
One limitation of the study is the higher rate of adverse events in the active treatment arm, which may have impacted the blinding for some investigators or patients. Additionally, while PFS is a robust endpoint in oncology, further data on long-term overall survival and patient-reported quality of life will be essential to fully characterize the clinical value of resminostat maintenance.
Conclusion: A New Tool for CTCL Management
The findings from the RESMAIN trial support the use of resminostat as a maintenance therapy for patients with advanced-stage mycosis fungoides or Sézary syndrome. By significantly extending the period of disease control, resminostat addresses a critical gap in the current treatment paradigm. While the gastrointestinal toxicity requires careful monitoring and supportive care, the potential to delay disease progression offers a meaningful benefit to patients facing a chronic and often devastating malignancy. As the field moves toward more personalized and sequenced therapeutic approaches, resminostat provides a much-needed foundation for maintenance strategies in CTCL.
Funding and Registration
This study was funded by 4SC AG. The trial is registered with ClinicalTrials.gov, number NCT02953301.
References
Stadler R, Quaglino P, Woei-A-Jin FJSH, et al. Resminostat for maintenance treatment in patients with advanced-stage mycosis fungoides or Sézary syndrome: a multicentre, double-blind, randomised, placebo-controlled, phase 2 trial. Lancet Haematol. 2026 Feb;13(2):e98-e109. doi: 10.1016/S2352-3026(25)00322-9. PMID: 41651641.
