Sweeping-beam technique with electrons for large treatment areas as total skin irradiation : Dosimetric and technical aspects of a modified Stanford technique.

PURPOSE: Total skin electron beam therapy (TSEBT) is still a technical and therapeutic challenge today. Thus, we developed TSEBT using a sweeping-beam technique. METHODS: For treatment delivery, a linear accelerator Versa HD (ELEKTA, Stockholm, Sweden) with high-dose-rate electrons (HDRE) was used with a dose rate of 9000 MU/min. Dosimetry quality assurance was performed by multiple measurements with film dosimetry, 2D array, and Roos chamber. RESULTS: Clinical experience shows that treatment durations of 75 to 90 min are usual for the Stanford technique without using HDRE. With this new sweeping-beam irradiation technique, the total treatment time of a daily fraction could be reduced to 20 min while keeping over- and underdosing low. The treatment area is about 60 cmâ€¯× 200 cm and the dose distribution is uniform within 2% and 5% in vertical and horizontal directions, respectively. Initially, the electron energy of 6 MeV is reduced to 3.2 MeV by 1­cm polymethylmethacrylat (PMMA) scatter and the irradiation conditions of a source-surface distance (SSD) of 350 cm. The photon contamination drops to under 1%. CONCLUSION: These results show that the mean dose to total skin varies between 1.3 and 1.8 Gy. The sweeping-beam technique with electrons has a homogeneous dose distribution in connection with a short treatment time.

A prospective cohort study of condensed low-dose total skin electron beam therapy for mycosis fungoides: Reduction of disease burden and improvement in quality of life.

BACKGROUND: Low-dose total skin electron beam therapy (TSEBT) for mycosis fungoides is popular because of reduced toxicity with effective palliation. We condensed TSEBT, reducing visits by half and overall treatment length by one third. OBJECTIVE: To determine the efficacy and safety of a novel condensed low-dose TSEBT for mycosis fungoides. METHODS: We conducted a cohort study (2014-2018) with a median follow-up of 22.8 months. We delivered 12 Gy per 6 fractions with the modified Stanford technique, 3 fractions per week, with boosts to shadowed sites at risk between treatments, completing in 2 weeks. Primary outcomes included clinical response, duration of and time to response, and toxicity. Secondary outcomes included patient-reported quality of life (pain, pruritus, and Dermatology Life Quality Index) and physician-scored disease burden (body surface area involvement and Modified Skin Weighted Assessment Tool). RESULTS: Of 25 patients, stage IB was most common at the time of TSEBT (36%). The overall response rate was 88%. Most common was a near complete response (36%), and complete response was achieved in 6 (24%) patients. The median duration of response was 17.5 months (3.5-44.2), and the median time to response was 2 months (range, 0.9-4.1). No patients had toxicity of grade 3 or greater. QOL and disease burden showed significant benefit after TSEBT (P < .001). LIMITATIONS: Cohort study with limited sample size. CONCLUSIONS: Condensed, low-dose TSEBT has favorable outcomes and toxicity with logistical convenience.

Total skin electron beam therapy for primary cutaneous T-cell lymphomas: clinical characteristics and outcomes in a Mexican reference center.

AIM: The aim of this study was to assess treatment modalities, treatment response, toxicity profile, disease progression and outcomes in 14 patients with a confirmed diagnosis of primary cutaneous T-cell lymphoma (PCTCL) treated with total skin electron beam therapy (TSEBT). BACKGROUND: Primary cutaneous lymphomas (PCLs) are extranodal non-Hodgkin lymphomas originating in the skin without evidence of extracutaneous disease at diagnosis. Despite advances in systemic and local therapy options, the management of advanced stages remains mostly palliative. MATERIALS AND METHODS: This is a retrospective study of patients with PCTCL, diagnosed and treated in a reference center in Mexico City, analyzing treatment modalities, response to treatment, long-term outcome, and mortality. RESULTS: Eight males (57%) and 6 (43%) females were identified. Most patients were stage IVA (n = 5, 36%) followed by stage IB and IIB (28.5% and 21.4%, respectively). Eleven patients received the low-dose RT scheme (12 Gy), 1 patient, the intermediate-dose RT scheme (24 Gy), and 2 patients, the conventional-dose RT scheme (36 Gy). Mean follow-up time was 4.6 years. At first follow-up examination, 6-8 weeks after radiotherapy, the overall response rate (ORR) for the cohort was 85%. The median PFS for the whole cohort was 6 months. CONCLUSION: This study reinforces the role of TSEBT when compared with other treatment modalities and novel agents. Low-dose TSEBT is now widely used because of the opportunity for retreatment.

Primary cutaneous T-cell lymphoma (mycosis fungoides and Sézary syndrome): part II. Prognosis, management, and future directions.

Both mycosis fungoides (MF) and Sézary syndrome (SS) have a chronic, relapsing course, with patients frequently undergoing multiple, consecutive therapies. Treatment is aimed at the clearance of skin disease, the minimization of recurrence, the prevention of disease progression, and the preservation of quality of life. Other important considerations are symptom severity, including pruritus and patient age/comorbidities. In general, for limited patch and plaque disease, patients have excellent prognosis on ≥1 topical formulations, including topical corticosteroids and nitrogen mustard, with widespread patch/plaque disease often requiring phototherapy. In refractory early stage MF, transformed MF, and folliculotropic MF, a combination of skin-directed therapy plus low-dose immunomodulators (eg, interferon or bexarotene) may be effective. Patients with advanced and erythrodermic MF/SS can have profound immunosuppression, with treatments targeting tumor cells aimed for immune reconstitution. Biologic agents or targeted therapies either alone or in combination--including immunomodulators and histone-deacetylase inhibitors--are tried first, with more immunosuppressive therapies, such as alemtuzumab or chemotherapy, being generally reserved for refractory or rapidly progressive disease or extensive lymph node and metastatic involvement. Recently, an increased understanding of the pathogenesis of MF and SS with identification of important molecular markers has led to the development of new targeted therapies that are currently being explored in clinical trials in advanced MF and SS.

Clinical results of the total skin electron irradiation of the mycosis fungoides in adults. Conventional fractionation and low dose schemes.

BACKGROUND: Mycosis fungoides (MF) is a rare skin condition, effectively treated by irradiation. Since 1951, different methods of total skin irradiation have been developed. Although dose-response effect has been demonstrated in many publications, controversies about low dose treatment still exist. AIM: The analysis of results of the total skin electron irradiation (TSEI), especially low dose TSEI in comparison with standard dose treatment is the subject of this review. Also, acute and late side effects of radiotherapy in MF are discussed. MATERIALS AND METHODS: Medline search and analysis of studies published between 1995 and 2012, containing key words: mycosis fungoides, standard dose TSEI, low dose TSEI, total skin electron beam therapy (TSEBT). RESULTS: Detailed analysis of relevant studies demonstrated that standard dose radiotherapy 30-36 Gy is the most effective treatment used in clinical practice. Objective response rate (ORR) is high, especially for less advanced stages of disease. Complete response rate (CR), although slightly lower, is still relatively high. For more advanced MF, TSEI serves as a very good method of palliative treatment and relief of symptoms, like pruritus, pain or desquamation. There is no consensus regarding low dose TSEI; the method is widely accepted as a palliative treatment or in case of reirradiation. CONCLUSIONS: Standard dose TSEI is an effective method of MF treatment for radical and palliative treatment, producing high rate of ORR and reasonably long time to progression (TTP). Acute and late side effect of treatment are mostly mild and easy to manage. Low dose TSEI is still in the phase of clinical studies.

Physical and clinical results of a radiation bra in patients treated with total skin electron beam therapy.

Total skin electron beam therapy (TSEBT) in female patients with large or pendulous breasts is usually associated with shaded inframammary folds. In this analysis, 18 patients with cutaneous malignancy and pendulous breasts were irradiated with a radiation bra and five patients received TSEBT without bra. All patients had moderate or severe sagging of the breasts. The median inframammary dose in the radiation bra group was 89% of the prescription dose versus 4% in the group without bra. The usage of the radiation bra enables an adequate radiation dose for the inframammary folds during TSEBT with no additional local irradiation.

Advances in the pharmacological management of cutaneous T-cell lymphoma.

INTRODUCTION: Current treatment guidelines for cutaneous T cell lymphoma (CTCL) advocate a stage-driven approach, considering clinical presentation, symptom burden, and patient comorbidities. Therapy selection hinges on factors like disease subtype, severity, and treatment availability. The primary goal is to enhance the quality of life by mitigating symptoms, as achieving lasting complete remission is infrequent. AREAS COVERED: Over the past decade (2013-2023), the therapeutic landscape of CTCL has experienced substantial transformation with the introduction of innovative therapies. This review explores the main pivotal developments in traditional treatment schedules and recently introduced drugs, aiming to offer clinicians and researchers a thorough perspective on the decade's progress in the field. EXPERT OPINION: Despite the progress made in CTCL therapeutics, ranging from topical chemotherapeutics to immunomodulatory agents, several unmet needs persist. Firstly, there is a pressing need for the incorporation of readily available predictors for treatment response, encompassing clinical, pathological, and molecular features. Secondly, a more profound comprehension of the tumor microenvironment is imperative to optimize the landscape of targetable molecules. Lastly, the undertaking of studies on combination regimens should be encouraged as it enhances therapy efficacies by synergistically combining agents with diverse modes of action.

Acute toxicity and risk of infection during total skin electron beam therapy for mycosis fungoides.

BACKGROUND: Detailed rates of acute toxicity and skin infection during total skin electron beam therapy (TSEBT) for mycosis fungoides have not been reported in a large, modern series. OBJECTIVE: We sought to demonstrate the rates of acute toxicity and skin infection during TSEBT. METHODS: We retrospectively reviewed 89 consecutive courses of TSEBT. In all, 82 courses were prescribed a dose of 30 to 36 Gy and were included in the toxicity analysis. We recorded the types and grades of acute treatment toxicities and the incidence of infection during TSEBT for comparison with the previously documented baseline incidence of infection in mycosis fungoides. RESULTS: The most common toxicities included erythema/desquamation (76%), blisters (52%), hyperpigmentation (50%), and skin pain (48%). The worst reported toxicity grade per patient was grade 1 in 21%, grade 2 in 67%, and grade 3 in 10%, with no grade 4 or 5 toxicities. According to the previously reported rate, a total of 2.4 infections were expected for our cohort at baseline. The number with skin infection was 26 (32%) (relative risk 10.8, P < .01), and of these, 12 (15%) were culture confirmed (relative risk 5.0, P < .01). LIMITATIONS: This was a retrospective study design. CONCLUSION: The risk of cutaneous infection is significant during TSEBT.

Low-dose total skin electron beam therapy for refractory cutaneous CD30 positive lymphoproliferative disorders.

We describe a case of a 48-year-old woman with a refractory cutaneous CD30 positive lymphoproliferative disorder treated successfully with total skin electron beam radiotherapy (TSEBT).

Technical report: 3D-printed patient-specific scalp shield for hair preservation in total skin electron beam therapy.

•Techniques for non-lead scalp-shielding in total skin therapy are lacking.•3D-printing is a promising technique for patient-specific conformal shielding.•We present a case of effective scalp shielding with 3D-printing.

Total Skin Electron Beam Therapy for Mycosis Fungoides Revisited With Adjuvant Systemic Therapy.

BACKGROUND: Although standard-dose total skin electron beam therapy (TSEBT) has been thought to provide the greatest clinical benefit for mycosis fungoides, recent studies have shown that low-dose TSEBT may also provide high rates of disease control. MATERIALS AND METHODS: A retrospective chart review was conducted for patients receiving TSEBT for mycosis fungoides at a single institution from 2009 to 2017. Patients were evaluated for overall survival, progression-free survival, and duration of clinical benefit. Partial response was defined as any documented clinical regression of lesions, whereas complete response was defined as complete resolution of lesions. RESULTS: Twenty patients were included in the study. Twelve patients received low-dose radiation (≤ 12 Gy), and 8 received standard-dose radiation (> 12 Gy). Response rate was 100% in both groups. The rate of complete response was 38% in the standard-dose group and 25% in the low-dose group. There was no difference in overall survival between the 2 groups (P = .84). There was also no difference in median progression-free survival (P = .95) or duration of clinical benefit (P = .95) between the 2 groups. Of low-dose patients, 33% received immediate systemic therapy, whereas 92% received adjuvant topical or systemic therapy. In the standard-dose group, only 25% received systemic adjuvant therapy, and 63% received adjuvant topical or systemic therapy. CONCLUSION: Low-dose TSEBT with adjuvant therapy results in adequate symptom palliation, comparable to standard-dose TSEBT. Low-dose TSEBT should be considered a standard treatment option in this population.

Total skin electron beam therapy in mycosis fungoides-a shift towards lower dose?

Cutaneous T-cell lymphoma is a rare group of malignancies characterized by the proliferation of CD4+ T-cells, of which mycosis fungoides (MF) is the predominant subtype. The neoplastic lymphocytes of MF are extremely radiosensitive and even low doses of radiation can produce excellent responses. As such, radiotherapy (RT) is considered to be the most efficacious single agent treatment option for MF. Total skin electron beam therapy (TSEBT) is a special RT technique that allows for homogenous irradiation of the entire skin. The effectiveness of conventional-dose (cd) TSEBT (30-36 Gy), particularly at inducing complete cutaneous responses, has been well documented over the years. Nonetheless, most patients eventually relapse. In these cases, cd-TSEBT is limited as RT toxicity is dose-dependent. Consequently, clinicians are moving towards low-dose (ld) TSEBT (10-12 Gy). Institutional studies and prospective trials have shown similar response rates, overall survival and symptomatic relief with this regimen, albeit at the cost of complete response. Advantages of ld-TSEBT include decreased treatment length, improved side effect profile, and the opportunity for multiple applications following disease recurrence. This comprehensive review evaluates TSEBT techniques, clinical outcomes, impact of different dose regimens, and toxicities in the treatment of MF. Future applications of TSEBT with newer systemic agents are also discussed.

Total Skin Electron Beam Therapy in the Treatment of Mycosis Fungoides: A Review of Conventional and Low-Dose Regimens.

Mycosis fungoides (MF) is the most prevalent subtype of cutaneous T-cell lymphoma, which is characterized by the proliferation of CD4+ T cells. While often an indolent disease, most patients eventually develop progression from isolated patches to tumors and finally nodal or visceral involvement. Treatment choice is largely based on disease burden, though prognostic factors such as disease stage, patient age, and extracutaneous involvement must be taken into consideration. Radiotherapy represents one of the most effective therapeutic modalities in the treatment of MF. Lymphocytes are exquisitely radiosensitive, and excellent responses are observed even with low doses of radiation. Total skin electron beam therapy (TSEBT) is a special technique that allows for the homogenous irradiation of the entire skin. There are well-documented radiation dose-response relationships for achieving a complete response. As such, TSEBT doses ≥ 30 Gy comprise the current standard of care. Although highly effective, most patients experience recurrent disease even after conventional-dose (≥ 30 Gy) TSEBT. In addition, toxicity is cumulatively dose dependent, and there is reluctance to administer multiple courses of conventional-dose TSEBT. Consequently, there has been renewed interest in determining the utility of TSEBT at lower total (≤ 30 Gy) doses. Advantages of low-total-dose (with standard dose per fraction) TSEBT include a shortened treatment course, the potential to minimize the risk of adverse events, and the opportunity to allow for retreatment in cases of disease recurrence. This comprehensive review compares the impact of different TSEBT dosing schemes on clinical outcomes of MF.