Letter to the editor

International Journal of Stroke

2016, Vol. 11(4) NP48–NP49
! 2016 World Stroke Organization
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DOI: 10.1177/1747493016633302
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Risk of stroke in patients with mycosis
fungoides: A nationwide population-based
cohort study
Dear editor,
Hematologic malignancies increase the risk of ische-
mic or hemorrhagic stroke and lead to co-morbidities.1
Mycosis fungoides (MF) is a rare malignant T-cell
lymphoma that primarily involves skin and commonly
disseminates to internal organs.2,3 As MF involving the
central nervous system is rare, only few studies to date
have examined the neurological consequences of MF
on these patients.4,5 Moreover, the incidence and risk
of stroke in MF patients remain unknown.

Table 1. Incidence rates and risk of stroke stratified by sex, age, and co-morbidity in a multivariate Cox proportional hazards
regression model for patients with mycosis fungoides compared to those without mycosis fungoides

Mycosis fungoides

No Yes

Variables Event PY Ratea Event PY Ratea IRR (95% CI) Adjusted HRb (95% CI)
All 267 32,217 8.29 74 6060 12.2 1.47 (1.28, 1.70)*** 1.51 (1.17, 1.96)**

Sex

Female 89 13,537 6.57 27 2581 10.5 1.59 (1.27, 2.00)*** 1 (reference)

Male 178 18,680 9.53 47 3479 13.5 1.42 (1.18, 1.71)*** 1.19 (0.95, 1.49)

Age

40 4 10,400 3.8 5 2256 22.2 5.76 (4.43, 7.50)*** 1 (reference)

40–60 34 11,187 30.4 14 2105 66.5 2.19 (1.72, 2.78)*** 4.75 (2.33, 9.70)***

60–80 175 9185 190.5 41 1452 282.4 1.48 (1.16, 1.89)*** 23.4 (11.9, 45.8)***

>80 54 1445 373.7 14 248 564.5 1.51 (0.95, 2.42) 38.5 (18.9, 78.4)***

Number of co-morbidities

0 173 29,175 59.3 39 5100 76.5 1.29 (1.09, 1.53)** 1 (reference)

1 44 1751 251.3 22 623 353.1 1.41 (0.97, 2.03) 1.94 (1.46, 2.59)***

2 50 1292 387.0 13 337 385.8 1.00 (0.61, 1.63) 2.35 (1.75, 3.15)***
HR: hazard ratio; CI: confidence interval; IRR: incidence rate ratio; PY: person-year.
Note: Event: stroke.
*p < 0.05, **p < 0.01, ***p < 0.001.
a
Rate: incidence rate, per 10,000 person-years.
b
Adjusted HR: multivariable analysis including age, sex, and co-morbidities (diabetes, hypertension, hyperlipidemia, coronary heart disease, atrial
fibrillation, congestive heart failure).

International Journal of Stroke, 11(4)

Tsai et al.
In this cohort study, we investigated incidence rates
and risks of stroke in patients with MF by using
National Health Insurance Research Database in
Taiwan. This study received approval from the
Institutional Review Board at China Medical
University Hospital (CMUH104-REC2-115). From
1998 to 2010, a total of 1783 MF patients and 7132
age- and sex-matched normal controls were identified.
The mean age of the MF cohort was 51.6 years (SD,
20.6 years); 61% of the patients were male. The overall
incidence rate of stroke was 1.47-fold higher in the MF
cohort than in the non-MF cohort (12.2 vs. 8.29 per
10,000 person-years) with an adjusted hazard ratio
(HR) of 1.51 (95% confidence interval (CI), 1.17–
1.96) (Table 1). MF patients in older age group and
those with more co-morbidities, including diabetes,
hypertension, hyperlipidemia, coronary heart disease,
atrial fibrillation, congestive heart failure, had higher
risk of stroke (Table 1). The risk of ischemic stroke
among the MF patients was significantly higher by
1.56-fold (95% CI, 1.11–2.20) compared with the
non-MF cohort.
Patients with MF have a higher risk of stroke, espe-
cially ischemic stroke. Physicians should be more aware
of the possibility of cerebrovascular disease in cancer
patient with neurologic signs and symptoms and estab-
lish stroke-related intervention programs for patients
with MF to improve their long-term outcomes.
Authors’ contributions
Jeng-Dau Tsai, Yu-Ping Hsiao, and Chang-Ching Wei
conceptualized and designed the study, drafted the
initial manuscript, and approved the final manuscript
as submitted.
Cheng-Li Lin and Henry J Tsai carried out the initial
analysis, reviewed and revised the manuscript, and
approved the final manuscript as submitted.
Chang-Ching Wei coordinated and supervised data col-
lection, critically reviewed the manuscript, and
approved the final manuscript as submitted.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: The study was supported in part by Taiwan Ministry
of Health and Welfare Clinical Trial and Research Center of
NP49
Excellence (MOHW105-TDU-B-212-133019), China Medical
University Hospital, Academia Sinica Taiwan Biobank,
Stroke Biosignature Project (BM104010092), NRPB Stroke
Clinical Trial Consortium (MOST 103-2325-B-039-006),
Tseng-Lien Lin Foundation, Taichung, Taiwan, Taiwan
Brain Disease Foundation, Taipei, Taiwan, and Katsuzo
and Kiyo Aoshima Memorial Funds, Japan.
References
1. Haller S and Lyrer P. Malignancy and stroke. Semin
Cerebrovasc Dis Stroke 2005; 5: 47–54.
2. Weinstock MA and Horm JW. Mycosis fungoides in the
United States. Increasing incidence and descriptive epi-
demiology. JAMA 1998; 260: 42–46.
3. Hothali GIA. Review of the treatment of mycosis fun-
goides and Sézary syndrome: a stage-based approach. Int
J Health Sci 2013; 7: 220–239.
4. Vu BA and Duvic M. Central nervous system involvement
in patients with mycosis fungoides and cutaneous large-cell
transformation. J Am Acad Dermatol 2008; 59: S16–S22.
5. Benner MF, Jansen PM, Vermeer MH and Willemze R.
Prognostic factors in transformed mycosis fungoides: a
retrospective analysis of 100 cases. Blood 2012; 119:
1643–1649.
Jeng-Dau Tsai
School of Medicine, Chung Shan Medical University, Taichung,
Taiwan
Department of Pediatrics, Chung Shan Medical University and
Hospital, Taichung, Taiwan
Yu-Ping Hsiao
School of Medicine, Chung Shan Medical University, Taichung,
Taiwan
Department of Dermatology, Chung Shan Medical University
Hospital, Taichung, Taiwan
Cheng-Li Lin
Management Office for Health Data, China Medical University
Hospital, Taichung, Taiwan
Henry J Tsai
Department of Health and Nutrition Biotechnology, Asia
University, Taichung, Taiwan
Chang-Ching Wei
Children’s Hospital, China Medical University Hospital,
Taichung, Taiwan
School of Medicine, China Medical University, Taichung, Taiwan
Corresponding author:
Chang-Ching Wei, Children’s Hospital, China Medical University
Hospital, No. 2, Yu-Der Road, Taichung 40402, Taiwan.
Email: weilonger@gmail.com
International Journal of Stroke, 11(4)