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Laughlin BS, Van Der Walt C, Mangold AR, Breen WG, Rosenthal AC, Lester S, Hoppe B, Peterson J, Bogan A, Rule WG. Fine-Tuning Low-Dose Total Skin Electron Therapy for Optimal Management of Cutaneous T-Cell Lymphoma: A Comparative Analysis of Regimens. Adv Radiat Oncol 2024; 9:101502. [PMID: 38846486 PMCID: PMC11153052 DOI: 10.1016/j.adro.2024.101502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 02/25/2024] [Indexed: 06/09/2024] Open
Abstract
Purpose Low-dose total skin electron beam therapy (TSEBT) is a proven treatment for managing cutaneous T-cell lymphoma (CTCL) and Sezary syndrome with skin burden. We performed a retrospective comparison of response rates and time to progression for patients receiving low-dose TSEBT based on dose per fractionation, total dose, and stage. Methods and Materials One hundred and ten patients with CTCL and Sezary syndrome were treated with 135 courses of low-dose (400-1500 cGy) TSEBT or subtotal skin electron therapy at multiple centers of a single institution between August 2003 and June 2023. Patients were stratified according to total dose, dose per fraction, and stage. Results The median follow-up was 301 days (IQR, 141, 767). The median age at treatment was 69.9 years (range, 29.7-96.5). T-stage distribution was as follows: 3 (2.7%) T1, 74 (67.3%) T2, 16 (14.5%) T3, and 17 (15.5%) T4. American Joint Committee on Cancer eighth edition stage distribution was as follows: 3 (2.7%) IA, 53 (48.2%) IB, 3 (2.7%) IIA, 16 (14.5%) IIB, 8 (7.3%) IIIA, 19 (17.3%) IVA, and 8 (7.3%) IVB. There was no significant difference in disease distribution between patients treated with different fractionation schemes. The overall response rate was 89.6%. Forty-four courses (32.6%), 34 courses (25.2%), and 43 (31.9%) resulted in a complete, near-complete, and partial response, respectively. Fourteen courses (10.4%) resulted in no clinical response. For all patients, the median time to response was 43.0 days (IQR, 23.0-70). The median time to skin progression for all patients was 107.5 days (IQR, 67.8-233.5). Conclusions This analysis demonstrated that CTCL patients treated with low-dose radiation therapy delivered over various fractionation schemes had similar overall response rates and median time to progression.
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Affiliation(s)
| | - Charles Van Der Walt
- Department of Quantitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | | | - William G. Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Scott Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bradford Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Jennifer Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Aaron Bogan
- Department of Quantitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - William G. Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Lucido JJ, Penoncello GP, Laughlin BS, Armstrong MD, Lo SG, Rivera JN, Tang X, Chungbin SJ, Breen WG, Mangold AR, Comfere NI, Lester SC, Rule WG, Deufel CL, Foster MG. Development and Dosimetric Characterization of a Customizable Shield for Subtotal Skin Electron Beam Therapy. Adv Radiat Oncol 2023; 8:101289. [PMID: 37457824 PMCID: PMC10344686 DOI: 10.1016/j.adro.2023.101289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/08/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose Purpose: Subtotal skin electron beam therapy may be an option for patients with cutaneous lymphoma receiving radiation therapy to treat large areas of their skin but may benefit from sparing specific areas that may have had previous radiation therapy, are of specific cosmetic concern, and/or show no evidence of disease. We report here on the design, implementation, and dosimetric characteristics of a reusable and transparent customizable shield for use with the large fields used to deliver total skin electron beam therapy at extended distance with a conventional linear accelerator. Methods and Materials A shield was designed and manufactured consisting of acrylic blocks that can be mounted on a steel frame to allow patient-specific shielding. The dosimetry of the device was measured using radiochromic film. Results The shield is easy to use and well-tolerated for patient treatment, providing minimal electron transmission through the shield with a sharp penumbra at the field edge, with no increase in x-ray dose. We report on the dosimetry of a commercial device that has been used to treat more than 30 patients to date. Conclusions The customizable shield is well suited to providing patient-specific shielding for subtotal skin electron beam therapy.
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Affiliation(s)
- J. John Lucido
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Stephanie G. Lo
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Judith N. Rivera
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Xueyan Tang
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - William G. Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Scott C. Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - William G. Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Kouhen F, Oqbani K, El Gouach H, Ahnach M, Dahbi Z. Overcoming Chemotherapy Resistance in Cutaneous T-Cell Lymphoma: A Successful Case of High-Dose Radiotherapy Management. Cureus 2023; 15:e43959. [PMID: 37746484 PMCID: PMC10514740 DOI: 10.7759/cureus.43959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
The management of refractory cutaneous T-cell lymphoma (CTCL) is challenging and requires a multimodal approach. Radiotherapy is one of the treatment options used in managing CTCL, particularly for localized disease or as a palliative measure to control symptoms in advanced cases. The rarity of the disease makes it difficult to conduct extensive clinical trials and gather sufficient data on the most effective treatment approaches. Lymphocytes are among the most sensitive cells to radiation's damaging effects. Because of this sensitivity, radiation therapy can be an effective treatment. This case illustrates the efficacy of radiotherapy and its potential as an effective treatment alternative for a severe and resistant CTCL to systemic therapy in a 61-year-old Moroccan patient. The patient underwent curative high-dose radiation therapy, utilizing three-dimensional conformal radiation therapy. At the 19-month follow-up post-radiotherapy, no evidence of local recurrence, either clinically or radiologically, was observed, and the patient maintained a good quality of life with unrestricted mobility of his arm.
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Affiliation(s)
- Fadila Kouhen
- Laboratory of Neurosciences and Oncogenetics, Department of Radiotherapy, Mohammed VI Center for Research and Innovation, International University Hospital Sheikh Khalifa, Mohammed VI University of Sciences and Health (UM6SS), Casablanca, MAR
| | - Kenza Oqbani
- Department of Pathology, International University Hospital Sheikh Khalifa, Mohammed VI University of Sciences and Health (UM6SS), Casablanca, MAR
| | - Hanae El Gouach
- Laboratory of Neurosciences and Oncogenetics, Department of Radiotherapy, Mohammed VI Center for Research and Innovation, International University Hospital Sheikh Khalifa, Mohammed VI University of Sciences and Health (UM6SS), Casablanca, MAR
| | - Meriem Ahnach
- Department of Hematology, International University Hospital Sheikh Khalifa, Mohammed VI University of Sciences and Health (UM6SS), Casablanca, MAR
| | - Zineb Dahbi
- Department of Radiotherapy, International University Hospital Sheikh Khalifa, Mohammed VI University of Sciences and Health (UM6SS), Casablanca, MAR
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Optimizing Palliative Focal Radiation Therapy Dose in Cutaneous T-Cell Lymphoma: How Low Can You Go? Pract Radiat Oncol 2023; 13:e192-e199. [PMID: 36307013 DOI: 10.1016/j.prro.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Primary cutaneous T-cell lymphomas (CTCLs) are radiosensitive tumors with variable and often relapsing courses. Local disease can be treated with low-dose focal palliative radiation therapy (RT), though little data supports the use of a specific dose. This study assesses clinical outcomes after focal RT to a total dose of 4 Gy, 8 Gy, or 12 Gy. METHODS AND MATERIALS An International Review Board-approved, retrospective, single-institution study was performed of 225 lesions in 41 patients with primary CTCL treated with low-dose focal RT from 2015 to 2020. Patient, tumor, and treatment characteristics were reviewed. The primary outcome was freedom from treatment failure (FFTF), defined as time to requiring local retreatment, and secondary outcomes included response rates and toxicities. RESULTS Of the 225 lesions, 90 received 4 Gy, 106 received 8 Gy, and 29 received 12 Gy. Lesions treated with 12 Gy (96%) or 8 Gy (92%) had a significantly higher 1-year FFTF compared with 4 Gy (77%) (P = .034). Overall response rate and complete response rate were not significantly different between different doses (P = .117), though there was a trend toward higher overall response rate at initial assessment with 8 Gy versus 4 Gy (91.5% vs 82.2%, P = .057). Toxicity was low, with 7.1% of lesions having grade 2 or higher radiation dermatitis. CONCLUSIONS In primary CTCL lesions treated with focal palliative RT, a dose response was noted favoring 8 to 12 Gy, with 1-year FFTF rates over 90%. However, 4 Gy resulted in substantially better outcomes than previously reported, with 77% requiring no further treatment at 1 year and comparable response rates to higher doses. While our data substantiates 8 to 12 Gy as the standard of care, it also suggests that 4 Gy should be considered an acceptable alternative in situations with concern for radiation toxicities, such as with fragile or heavily pretreated skin.
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Total Skin Treatment with Helical Arc Radiotherapy. Int J Mol Sci 2023; 24:ijms24054492. [PMID: 36901922 PMCID: PMC10002962 DOI: 10.3390/ijms24054492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/02/2023] Open
Abstract
For widespread cutaneous lymphoma, such as mycosis fungoides or leukemia cutis, in patients with acute myeloid leukemia (AML) and for chronic myeloproliferative diseases, total skin irradiation is an efficient treatment modality for disease control. Total skin irradiation aims to homogeneously irradiate the skin of the entire body. However, the natural geometric shape and skin folding of the human body pose challenges to treatment. This article introduces treatment techniques and the evolution of total skin irradiation. Articles on total skin irradiation by helical tomotherapy and the advantages of total skin irradiation by helical tomotherapy are reviewed. Differences among each treatment technique and treatment advantages are compared. Adverse treatment effects and clinical care during irradiation and possible dose regimens are mentioned for future prospects of total skin irradiation.
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Lucido JJ, Veres AJ, Kehret SM, Angeli JA, Highet RD, Foote RL, Lester SC, Deufel CL. Development of transparent eye shields for total skin electron beam radiotherapy. J Appl Clin Med Phys 2022; 23:e13722. [PMID: 35816454 PMCID: PMC9512336 DOI: 10.1002/acm2.13722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/16/2022] [Accepted: 06/20/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose For total skin electron (TSE) beam radiation therapy, the anterior eye and conjunctiva can be protected with eye shields to prevent keratitis, xerophthalmia, and cataractogenesis. Conventional metal eye shields can reduce patient balance by obscuring vision and thus increasing the risk for falls. We report on the design, fabrication, and clinical use of transparent acrylic eye shields for TSE. Methods The primary design goals were a seven‐fold reduction in the dose to the anterior eye and conjunctiva to meet published dose‐recommendations, preservation of vision for the wearer, and biocompatibility for external use. Resembling thick swim goggles, the design features 23 mm thick acrylic lenses that are mounted in a 3‐D printed support structure that conforms to the eye socket and can be worn with a strap. Dose measurements were performed in a simulated Stanford‐technique treatment with an anthropomorphic phantom using Gafchromic EBT film Results The transparent eye shields were manufactured using a 3D‐printer and CNC‐machine. Based on measurements from the simulated treatments for each of the eye shields, the eye shields provided a 12‐fold reduction in dose to the lens. After use in more than 200 fractions, the shields were well tolerated by patients, and there were no reports of any incidents or adverse events. Conclusion Transparent TSE eye shields are able to reduce the dose to the eyes while maintaining vision during treatment at a reasonable cost.
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Affiliation(s)
- J John Lucido
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew J Veres
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shawn M Kehret
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - John A Angeli
- Department of Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert D Highet
- Department of Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott C Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Chris L Deufel
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Primary cutaneous epidermotropic marginal zone B-cell lymphoma treated with total skin electron beam therapy. JAAD Case Rep 2021; 15:15-18. [PMID: 34386563 PMCID: PMC8342534 DOI: 10.1016/j.jdcr.2021.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Chadsey LE, Cook MR, Green EE, Jennings RN, Moore PF, Vernau W, Kisseberth WC, Diaz SF. Treatment of indolent cutaneous T-cell lymphoma with hypofractionated radiation therapy in three cats. Vet Dermatol 2021; 32:515-e143. [PMID: 34240483 DOI: 10.1111/vde.13002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 05/09/2021] [Accepted: 05/17/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Feline indolent cutaneous T-cell lymphoma (ICL) is an uncommon neoplastic disease. There is currently no consensus on treatment recommendations for ICL. OBJECTIVE To report the clinical outcome of three cats with ICL treated with hypofractionated electron-beam radiotherapy (RT). ANIMALS Three privately owned cats with ICL. MATERIALS AND METHODS Medical records and client surveys were reviewed. A diagnosis of probable ICL was based on history, clinical presentation and histopathological findings, and confirmed using CD3 immunohistochemical analysis and PCR for antigen receptor gene rearrangement (PARR). All cats were treated with hypofractionated RT (four fractions of 8 Gy). RESULTS All cats presented with skin lesions characterised by erythema and alopecia that were refractory to previous treatment with systemic glucocorticoids. Before hypofractionated RT treatment, lesions were histologically described as having diffuse infiltration of the dermis with CD3+ T cells. Molecular clonality analysis revealed clonal T-cell receptor gamma gene rearrangement. After RT, two cats showed histological improvement defined by decreased infiltration of lymphocytes, with cellular infiltrate present only in the deeper dermis; one cat had near complete histological resolution of lesions with only minimal residual lymphocytes. One cat was determined to have a complete clinical response while the other showed partial responses. No acute adverse effects of radiation were observed; chronic effects included leukotrichia, partial alopecia and mild fibrosis. All clients reported improvement in quality of life for their cats. CONCLUSIONS AND CLINICAL IMPORTANCE Clinical and histological improvement in these cats suggests that hypofractionated RT can be a useful treatment modality for cats with ICL.
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Affiliation(s)
- Laura E Chadsey
- Department of, Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Matthew R Cook
- Department of, Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Eric E Green
- Department of, Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Ryan N Jennings
- Department of, Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Peter F Moore
- Department of Pathology, Microbiology, Immunology, School of Veterinary Medicine, University of California, Davis, CA, USA
| | - William Vernau
- Department of Pathology, Microbiology, Immunology, School of Veterinary Medicine, University of California, Davis, CA, USA
| | - William C Kisseberth
- Department of, Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Sandra F Diaz
- Department of, Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
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Ultra-hypofractionated low-dose total skin electron beam followed by maintenance therapy: Preliminary findings from a prospective open-label study. J Am Acad Dermatol 2020; 85:1601-1603. [PMID: 33271220 PMCID: PMC7836520 DOI: 10.1016/j.jaad.2020.11.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/24/2022]
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10
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Rolf D, Elsayad K, Eich HT. Acute and sub-acute toxicity profile of ultra-hypofractionated low-dose total skin electron beam with two 4 Gy fractions for cutaneous T cell lymphoma. J Cancer Res Clin Oncol 2020; 147:1757-1761. [PMID: 33219856 PMCID: PMC7680066 DOI: 10.1007/s00432-020-03449-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/31/2020] [Indexed: 12/14/2022]
Abstract
Purpose Low-dose total skin electron beam therapy (TSEBT) over 3 weeks has proved to be a safe and effective treatment for cutaneous T cell lymphomas (CTCL). In this prospective trial, we examined the feasibility of ultra-hypofractionated low-dose TSEBT regimen in two fractions with 4 Gy combined with systemic therapy to minimize the number of visits to radiation centers. Patients and methods Six patients with mycosis fungoides (MF) or Sézary syndrome (SS) received TSEBT with a total radiation dose of 8 Gy in two fractions between April 2020 and June 2020. Patient and treatment characteristics, tumor burden, the impact on the quality of life using Skindex-29 questionnaires, and acute toxicities were analyzed. Results During TSEBT, all patients developed grade 1 toxicities while two patients developed grade 2 toxicities. One patient experienced sepsis. The most common adverse effects were erythema and edema. All grade 2 toxicities regressed after 4 weeks following TSEBT. Based on the reported symptoms measured by Skindex-29, we detected a significant reduction in total Skindex-29 score after 8 weeks of radiation (P = 0.03), particularly in the symptoms (P = 0.01) and emotional domains (P = 0.04). Conclusion Ultra-hypofractionated low-dose TSEBT followed by systemic therapy seems to be a safe and feasible alternative to conventional fractionated TSEBT for patients with MF/SS. The skin tumor burden and the health-related quality of life have been significantly improved within 8 weeks following radiotherapy.
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Affiliation(s)
- Daniel Rolf
- Department of Radiation Oncology, University Hospital of Muenster, Building A1, 1 Albert Schweitzer Campus, 48149, Muenster, Germany
| | - Khaled Elsayad
- Department of Radiation Oncology, University Hospital of Muenster, Building A1, 1 Albert Schweitzer Campus, 48149, Muenster, Germany.
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital of Muenster, Building A1, 1 Albert Schweitzer Campus, 48149, Muenster, Germany
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Elmasry MF, Youssef R, Elbendary A, Helmy K, Abdelkader HA. Cutaneous lymphomas and COVID-19: What is known so far? Dermatol Ther 2020; 34:e14463. [PMID: 33112053 DOI: 10.1111/dth.14463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/13/2020] [Accepted: 10/23/2020] [Indexed: 01/08/2023]
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic spreads quickly all over the world. There are no sufficient data in the literature about COVID-19 infection and cutaneous lymphomas. This review sheds the light on what is known so far about COVID-19 with a cutaneous lymphoma perspective. Cutaneous T-cell lymphoma (CTCL) diagnosis does not represent a predisposing factor to viral infections and most of CTCL patients have indolent disease. However, physicians should be cautious with patients with aggressive primary cutaneous lymphomas and advanced CTCL. Different treatment strategies for cutaneous lymphomas should be taken into consideration during the COVID-19 pandemic. Thus, it is highly needed to estimate the benefit-to-risk ratio on a case-by-case basis.
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Affiliation(s)
- Maha Fathy Elmasry
- Faculty of Medicine, Department of Dermatology, Cutaneous Lymphoma Clinic, Cairo University, Egypt
| | - Randa Youssef
- Faculty of Medicine, Department of Dermatology, Cutaneous Lymphoma Clinic, Cairo University, Egypt
| | - Amira Elbendary
- Faculty of Medicine, Department of Dermatology, Cutaneous Lymphoma Clinic, Cairo University, Egypt
| | - Kholoud Helmy
- Faculty of Medicine, Department of Dermatology, Cutaneous Lymphoma Clinic, Cairo University, Egypt
| | - Heba Ahmed Abdelkader
- Faculty of Medicine, Department of Dermatology, Cutaneous Lymphoma Clinic, Cairo University, Egypt
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