The effectiveness of radiotherapy for leukemia cutis

Ulcerating skin lesions from blastic plasmacytoid dendritic cell neoplasm responding to low-dose radiotherapy-a case report and literature review

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematologic malignancy that can manifest with skin nodules and erythematous plaques. In most cases BPDCN progresses rapidly, causing multiple skin lesions and also affecting internal organs and bone marrow, warranting initiation of systemic therapies or hematopoietic stem cell transplantation (HCT). Although not curative, radiotherapy for isolated lesions might be indicated in case of (imminent) ulceration and large or symptomatic lesions. To this end, doses of 27.0-51.0 Gy have been reported. Here, we present the case of an 80-year-old male with BPDCN with multiple large, nodular, and ulcerating lesions of the thorax, abdomen, and face. Low-dose radiotherapy of 2 × 4.0 Gy was administered to several lesions, which resolved completely within 1 week with only light residual hyperpigmentation of the skin in affected areas and reliably prevented further ulceration. Radiotoxicity was not reported. Therefore, low-dose radiotherapy can be an effective and low-key treatment in selected cases of BPDCN, especially in a palliative setting, with a favorable toxicity profile.

Is oligometastatic disease an applicable and useful concept in haematologic malignancies? A narrative review of radiation therapy standards, modern techniques, and innovations

PURPOSE

Haematologic malignancies are particular in that they can generally be cured, even when distant metastases are present at diagnosis, unlike solid malignancies. Systemic treatments, including chemotherapy, targeted therapies, and immunotherapy, are the standard of care with excellent results. The considerable progress made in the management of these diseases in the last 20years has redefined the role of radiation therapy as minor in many clinical situations. We propose a literature review of data, showing that radiation therapy still has a role in curative, salvage, and palliative therapy situations.

MATERIAL AND METHODS

A document and literature search was carried out in the following databases: Medline and ClinicalTrial.gov, for the terms "radiotherapy", "haematologic malignancies", "Hodgkin lymphoma", "non-Hodgkin lymphoma", "CAR T cells", "multiple myeloma", "solitary plasmocytoma", "intensity-modulated radiotherapy", "extracranial stereotactic body radiation therapy" and "proton therapy references".

RESULTS

Haemopathological malignancies include a wide range of diseases and radiation therapy indications have been assessed over the past 20years. Currently, radiation therapy is indicated for localized disease (solitary plasmocytoma), as an adjuvant (Hodgkin lymphoma), in palliative settings, or after systemic treatment in relapsed patients (chimeric antigen receptor [CAR] T-cells) with a low recurrence burden, which can therefore be considered "oligorecurrence". Radiation therapy, through total body irradiation, has important indications, thanks to its immunomodulatory and/or myeloablative effects. Moreover, recent technological developments have made possible significant improvement in safety, contributing to radiation therapy being positioned in the treatment strategy of several indications.

CONCLUSIONS

Given the effectiveness of systemic treatments in hematologic malignancies, the oligometastasis stage is of little importance. A curative intent after local radiation therapy, even advanced stage, is possible, both with residual disease for advanced Hodgkin lymphoma, aggressive non-Hodgkin lymphoma, or solitary plasmocytoma, and even without evidence of disease after chemotherapy for Hodgkin or non-Hodgkin lymphoma. The role of new treatments, such as CAR T cells, allows us to consider radiation therapy after systemic treatment of relapsed diseases with low volume recurrence, which can be considered oligorecurrence.

Acute myeloid leukemia cutis with KMT2A::MLLT3 fusion presenting with leonine facies

A 63-year-old woman presented with plaques covering 60 % body-surface-area and leonine facies. Blood work showed no diagnostic aberrancies. Skin biopsy contained a malignant CD4+/CD56+ mononuclear cell population concerning for blastic plasmacytoid dendritic cell neoplasm. A later bone marrow biopsy confirmed AML with KMT2A::MLLT10 fusion detected by next-generation sequencing (NGS). This patient's LC preceded blood and marrow based symptoms of AML. NGS of the initial skin biopsy should be considered as part of diagnostic guidelines in cases with LC in the differential as this may have led to earlier diagnosis in this case and future cases.

Leukemia Cutis-The Current View on Pathogenesis, Diagnosis, and Treatment

Leukemia cutis (LC) is defined as the leukemic infiltration of the epidermis, the dermis, and the subcutaneous tissue. Leukemia cutis may follow or occur simultaneously with the diagnosis of systemic leukemia. However, cutaneous lesions are occasionally diagnosed as the primary manifestation of leukemia. Leukemic skin infiltrations demonstrate considerable variation regarding a number of changes, distribution, and morphology. The highest incidence of LC is observed in chronic lymphocytic leukemia, monocytic and myelomonocytic acute myeloid leukemia, and T-cell lineage leukemia. Although the pathogenic mechanism of the invasion of leukemic cells into the skin is not well understood, chemokine receptors and adhesion molecules as well as the genetic characteristics of leukemia are thought to play a role. Leukemic skin lesions may be localized or disseminated and may occur alone or in combination on any site of the skin, most frequently in the trunk and extremities. The most common clinical presentations of leukemia cutis are papules, nodules, macules, plaques, and ulcers. In most patients, the complete or partial resolution of cutaneous infiltrations occurs simultaneously with hematologic remission. However, in patients with resistant disease or recurrent skin infiltration, local radiotherapy can be used. This review presents recent data on the pathogenesis, diagnosis, and treatment of leukemic skin involvement in different types of leukemia.

The evolving role of reduced-dose total skin electron beam therapy in skin malignancies: the renaissance of a rare indication

Definitive radiation therapy is an effective local treatment for several cutaneous malignancies. Patients with diffuse or generalized skin manifestations might require total skin electron beam therapy (TSEBT) as an alternative treatment to the chasing technique. In this short communication, we highlight the evolving role of TSEBT and present its role in various forms of skin malignancies.

Radiotherapy in Philadelphia chromosome‑positive acute lymphoblastic leukemia with pericardial invasion after transplantation: A case report

The present report describes a case of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) with pericardial invasion following bone marrow transplantation. The patient exhibited recurrent pericardial effusion accompanied by wheezing symptoms. Despite undergoing multiple pericardial punctures and drainage procedures, pericardial injections, and systemic treatment, the patient continued to experience recurrent pericardial effusion. Ultimately, the patient underwent whole-heart radiotherapy, resulting in complete resolution of the pericardial effusion. After a follow-up period of 10 months, the pericardial effusion remained well-controlled, and there were no significant impairments in cardiac function. In conclusion, radiotherapy may be considered as a viable treatment option for refractory leukemia cases presenting with pericardial effusion.

Strahlentherapeutische Behandlung von Leukämien

Hintergrund

Ziel der Arbeit

Material und Methoden

Ergebnisse

Schlussfolgerung

Strahlentherapeutische Behandlung von Leukämien

Hintergrund

Lymphoide Zellen weisen eine hohe Strahlensensitivität auf, sodass die Strahlentherapie eine sinnvolle Ergänzung der Systemtherapie bei Leukämien darstellt. Vor allem als konditionierende Behandlung vor allogener Stammzelltransplantation ist die Radiotherapie in Form einer Ganzkörperbestrahlung etabliert.

Ziel der Arbeit

Die vorliegende Arbeit ermöglicht einen Überblick über Durchführung und Nebenwirkungen der strahlentherapeutischen Behandlung bei Leukämien. Hierbei werden insbesondere die (Langzeit‑)Nebenwirkungen nach Ganzkörperbestrahlung dargestellt.

Material und Methoden

Es erfolgte eine selektive Literaturrecherche über die Datenbank PubMed zur Radiotherapie von Leukämien und zu Ganzkörperbestrahlungen mit Fokus auf Nebenwirkungen sowie technische und konzeptionelle Neuerungen.

Ergebnisse

Die Ganzkörperbestrahlung ist eine effektive Therapie zur Konditionierung vor allogener Stammzelltransplantation und weist ein diverses, aber beherrschbares, Toxizitätsspektrum mit endokrinen, kardiopulmonalen, okulären, nephrologischen und neurologischen Langzeitnebenwirkungen sowie Sekundärneoplasien auf. Zusätzlich kann eine Radiotherapie in Niedrigdosis effektiv zur Behandlung myeloider Sarkome (Chlorome) angewendet werden.

Schlussfolgerung

Die Vielfalt der Nebenwirkungen nach Ganzkörperbestrahlung erfordert eine interdisziplinäre und langfristige Nachsorgebetreuung durch internistische Onkolog*innen/Transplantationsmediziner*innen und Radioonkolog*innen. Technische Entwicklungen der Strahlentherapie können in Zukunft eine selektive Adressierung des Knochenmarks sowie der lymphatischen Organe realisieren. Aktuell sind diese noch nicht in der klinischen Routine etabliert und werden im Rahmen klinischer Studien evaluiert.

Myeloid sarcoma, chloroma, or extramedullary acute myeloid leukemia tumor: A tale of misnomers, controversy and the unresolved

The World Health Organization classification and definition of "myeloid sarcoma" is imprecise and misleading. A more accurate term is "extramedullary acute myeloid leukemia tumor (eAML)." The pathogenesis of eAML has been associated with aberrancy of cellular adhesion molecules, chemokine receptors/ligands and RAS-MAPK/ERK signaling. eAML can present with or without synchronous or metachronous intramedullary acute myeloid leukemia (AML) so a bone marrow evaluation is always recommended. Accurate diagnosis of eAML requires tissue biopsy. eAML confined to one or a few sites is frequently treated with local therapy such as radiotherapy. About 75-90% of patients with isolated eAML will develop metachronous intramedullary AML with a median latency period ranging from 4 to 12 months; thus, patients with isolated eAML may also be treated with systemic anti-leukemia therapy. eAML does not appear to have an independent prognostic impact; selection of post-remission therapy including allogeneic hematopoietic cell transplant (alloHCT) is typically guided by intramedullary disease risk. Management of isolated eAML should be individualized based on patient characteristics as well as eAML location and cytogenetic/molecular features. The role of PET/CT in eAML is also currently being elucidated. Improving outcomes of patients with eAML requires further knowledge of its etiology and mechanism(s) as well as therapeutic approaches beyond conventional chemotherapy, ideally in the context of controlled trials.

Leukaemia cutis as a specific skin involvement in chronic myelomonocytic leukaemia and review of the literature: Acknowledgments

The skin involvement of myeloid leukaemia is conventionally divided into specific malignant lesions and non-specific benign lesions, and these categories are also applicable in chronic myelomonocytic leukaemia (CMML). According to the 2016 World Health Organization (WHO) classification of tumours of haematopoietic and lymphoid tissues, CMML is defined as a myeloid neoplasm with characteristics of myelodysplastic syndrome (MDS) and myeloproliferative neoplasms (MPNs). As a specific cutaneous sign of extramedullary infiltration, leukaemia cutis (LC) is a rare occurrence in patients with CMML, and only approximately 89 cases have been reported in the literature thus far. The clinical features of LC are varied, and LC in CMML exhibits heterogeneous histopathologic features, with manifestations as cutaneous nodules or papules that are composed of blast cells showing either granulocytic or monocytic differentiation. Skin biopsy and further immunohistochemical examination are essential at the time of diagnosis to evaluate pathological type and determine the clinical course. Generally, once diagnosed as LC in CMML, this unusual skin lesion might be an indicator of transformation to acute myeloid leukaemia (AML) and is associated with a poor prognosis. The main treatment is allogeneic stem cell transplantation (ASCT). Therefore, early diagnosis and accurate identification have important therapeutic and prognostic significance in CMML patients with skin infiltration.

Leukemia cutis in a medical center in southern Taiwan: A retrospective study of 42 patients

BACKGROUND/PURPOSE

Leukemia cutis (LC), by definition, is the infiltration of neoplastic leukocytes in the skin. The overall incidence of LC is rare. We aimed to investigate the association between clinical characteristics, classifications and prognosis among different types of LC in Taiwan.

METHODS

We performed a retrospective analysis of forty-two patients with histopathology proven LC based on skin biopsies in a medical center in Southern Taiwan from 1997 to 2018. The study involved medical records of the patients, clinical manifestations, and outcomes according to different types of leukemia.

RESULTS

This series consisted of 27 males and 15 females, and the mean age was 55.7 years old. The most common cutaneous features were papules (38%) and nodules (29%), followed by plaques (16%) and ulcers (10%). The most commonly affected sites were the trunk (33%) and extremities (31.5%), although generalized distribution (14%) was not rare. The prognosis of LC was very poor, 76.2% of patients (32/42) died during the follow-up, and the median survival time was 7.2 months (95% CI, 4.53-9.87 months). No statistical significance was found (P = 0.068 for survival curves) among different types of LC.

CONCLUSION

This study was the first large-scale research in regarding to LC of Han Chinese. The commonest clinical presentations were papules and nodules, and the predilection sites were trunk and extremities. Besides, there was the high frequency of LC from AML and MDS in Taiwan. Clinicians should pay more attention to the leukemia patients with extramedullary manifestations due to poor survival outcomes.

Low-dose total skin electron beam therapy: Quality of life improvement and clinical impact of maintenance and adjuvant treatment in patients with mycosis fungoides or Sezary syndrome

PURPOSE

Total skin electron beam therapy (TSEBT) has proved to be a safe and effective treatment for cutaneous T‑cell lymphomas. Here, we examined the impact of this treatment on patient quality of life and outcome.

PATIENTS AND METHODS

Forty-four patients with mycosis fungoides (MF) or Sezary syndrome (SS) received 48 TSEBT courses with a median dose of 12 Gy within the past 8 years at our institute. Patient and treatment characteristics for these cases as well as the impact of TSEBT on quality of life and duration of response were retrospectively analyzed and compared.

RESULTS

The median modified Severity-Weighted Assessment Tool score before the start of TSEBT was 44. The overall response rate was 88%, with a complete response (CR) rate of 33%. The median follow-up period was 13 months. The median duration of response (DOR) and progression-free survival (PFS) for the entire cohort were 10 months and 9 months, respectively. Patient-reported symptom burden was measured with the Dermatological Life Quality Index and Skindex-29 questionnaires. The mean symptom reductions were 6 ± 8 (P = 0.005) and 21 ± 24 (P = 0.002), respectively. In the Functional Assessment of Cancer Therapy-General Assessment, significant improvements in the emotional (P = 0.03) domains were observed after TSEBT. Patients who received maintenance or adjuvant treatments had a longer PFS (P = 0.01).

CONCLUSION

TSEBT improved disease symptoms and significantly improved emotional domains of patients' quality of life in patients with MF or SS. In addition, our results indicate that maintenance or adjuvant therapy after TSEBT may improve the PFS.

Simultaneous integrated boost with helical arc radiotherapy of total skin (HEARTS) to treat cutaneous manifestations of advanced, therapy-refractory cutaneous lymphoma and leukemia - dosimetry comparison of different regimens and clinical application

Background

Helical irradiation of the total skin (HITS) was modified as simultaneous integrated boost (SIB)-helical arc radiotherapy of total skin (HEARTS) technique and applied to an acute myeloid leukemia (AML) patient with disseminated leukemia cutis.

Methods

The original HITS plan was revised for different regimens, i.e. HEARTS, low-dose HEARTS and SIB-HEARTS. The uniformity index (UI), conformity index (CI), and dose of organs at risk (OARs) were used to evaluate the plans. Additionally, the SIB-HEART (21/15 Gy) was delivered to the total skin and chloromas.

Results

No significant differences were observed for the CI and UI between HITS and HEARTS regimens. Compared with HITS, the reduced mean doses to various bone marrows ranged from 17 to 88%. The mean OARs doses for the head, chest and abdomen of a patient with AML treated with SIB-HEARTS (21/15 Gy) were 2.1 to 21.9 Gy, 1.8 to 7.8 Gy and 1.7 to 3.3 Gy, respectively. No severe adverse effects were noted except for grade 4 leukocytopenia and thrombocytopenia.

Conclusion

HEARTS and different regimens reduced the dose to OARs and bone marrow while maintaining the uniformity and conformity. SIB-HEARTS deliveries different doses to the total skin and enlarged tumors simultaneously.

Trial registration

Retrospectively registered and approved by the Institutional Review Board of our hospital (FEMH-106151-C).

Use of Radiation in Extramedullary Leukemia/Chloroma: Guidelines From the International Lymphoma Radiation Oncology Group

Survival times for patients with leukemia generally have improved in recent decades, and this improvement has been attributed to an enhanced understanding of the genetics driving the cause of the disease and improved combinations of chemotherapy and targeted therapy. Durable control of systemic disease in blood and bone marrow has significantly improved survival, but extramedullary relapse can pose therapeutic challenges for which radiation therapy can have an important role. This report discusses the current role of radiation therapy for patients with leukemia, specifically the extramedullary manifestations of leukemia.

In-vivo dosimetric analysis in total skin electron beam therapy

Background and purpose

Thermoluminescent dosimetry (TLD) is an important element of total skin electron beam therapy (TSEBT). In this study, we compare radiation dose distributions to provide data for dose variation across anatomic sites.

Materials and methods

Retrospectively collected data on 85 patients with cutaneous lymphoma or leukemia underwent TSEBT were reviewed. Patients were irradiated on two linear accelerators, in one of two positions (standing, n = 77; reclined, n = 8) and 1830 in vivo TLD measurements were obtained for various locations on 76 patients.

Results

The TLD results showed that the two TSEBT techniques were dosimetrically heterogeneous. At several sites, the dose administered correlated with height, weight, and gender. After the first TLD measurement, fourteen patients (18%) required MU modification, with a mean 10% reduction (range, −25 to +35). Individual TLD results allowed us to customize the boost treatment for each patient. For patients who were evaluated in the standing position, the most common underdosed sites were the axilla, perineum/perianal folds, and soles (each receiving 69%, 20%, and 34% of the prescribed dose, respectively). For patients evaluated in a reclining position, surface dose distribution was more heterogeneous. The sites underdosed most commonly were the axilla and perineum/perianal folds (receiving less than one third of prescribed dose). Significant variables were detected with model building.

Conclusion

TLD measurements were integral to quality assurance for TSEBT. Dose distribution at several anatomical sites correlated significantly with gender, height, and weight of the treated individual and might be predicted.

Radiotherapy for isolated granulocytic sarcoma: Case report and review of literature

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Isolated chloroma should be considered as a systemic disease.

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Consolidation radiotherapy has been related with prolonged failure free survival.

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Excellent local control of chloroma is achieved with low-dose radiotherapy.

Low-dose total skin electron beam therapy for cutaneous lymphoma : Minimal risk of acute toxicities

BACKGROUND

Low-dose total skin electron beam therapy (TSEBT) is attracting increased interest for the effective palliative treatment of primary cutaneous T‑cell lymphoma (pCTCL). In this study, we compared toxicity profiles following various radiation doses.

PATIENTS AND METHODS

We reviewed the records of 60 patients who underwent TSEBT for pCTCL between 2000 and 2016 at the University Hospital of Munster. The treatment characteristics of the radiotherapy (RT) regimens and adverse events (AEs) were then analyzed and compared.

RESULTS

In total, 67 courses of TSEBT were administered to 60 patients. Of these patients, 34 (51%) received a standard dose with a median surface dose of 30 Gy and 33 patients (49%) received a low dose with the median surface dose of 12 Gy (7 salvage low-dose TSEBT courses were administered to 5 patients). After a median follow-up of 15 months, the overall AE rate was 100%, including 38 patients (57%) with grade 2 and 7 (10%) with grade 3 AEs. Patients treated with low-dose TSEBT had significantly fewer grade 2 AEs than those with conventional dose regimens (33 vs. 79%, P < 0.001). A lower grade 3 AE rate was also observed in patients who had received the low-dose regimen compared to those with the conventional dose regimens (6 vs. 15%, P = 0.78). Multiple/salvage low-dose TSEBT courses were not associated with an increased risk of acute AEs.

CONCLUSION

Low-dose TSEBT regimens are associated with significantly fewer grade 2 acute toxicities compared with conventional doses of TSEBT. Repeated/Salvage low-dose TSEBT, however, appears to be tolerable and can even be applied safely in patients with cutaneous relapses.