Total Skin Electron Beam Research Articles

Total Skin Electron Beam Therapy-Induced Erythrodermic Subacute Radiation Dermatitis in a 54-Year-Old Man with Underlying Cutaneous T-Cell Lymphoma

Total Skin Electron Beam Therapy-Induced Erythrodermic Subacute Radiation Dermatitis in a 54-Year-Old Man with Underlying Cutaneous T-Cell Lymphoma

PO-1792 Simple AP/PA techniques to deliver total skin electron beam therapy to frail patient while recumbent

PO-1792 Simple AP/PA techniques to deliver total skin electron beam therapy to frail patient while recumbent

Challenges in commissioning the "TSET" technique: A new approach towards monitor unit calculation and beam profile measurements.

Total skin electron beam therapy, commonly known as TSET, is a good choice of treatment for patients suffering from mycosis fungoides. The aim of this study was to introduce a new approach to the beam profile measurement using diodes and to calculate the monitor units required for the TSET treatment by the use of a simple setup of output measurement. Dosimetric measurements required for the treatment were taken to establish the Stanford technique in the department, and the measured data was compared with the published data. High-energy Linear Accelerator Clinac-DHX, Varian medical system, Palo Alto, CA, was commissioned for TSET. The output of the machine was measured by the use of a Parallel-Plate Chamber (PPC40) as per the TRS 398 recommendation. Diode dosimeters (EDD2 and EDD5) were used for beam profile measurements due to easy setup and to reduce the measurement time. Homogeneous dose distribution within a field size of 80 cm x160 cm was observed with the variation of -5.0% on the horizontal axis and -5.4% on the vertical axis. The calculated monitor unit to deliver 200 cGy per fraction per field at the source to surface (SSD) of 416 cm was 489 MU. The technique described for the output measurements is simple and accurate. Results of the absorbed dose and MU measured were within good agreement compared to the published literature.

Ultrahypofractionated Low-Dose Total Skin Electron Beam in Advanced-Stage Mycosis Fungoides and Sézary Syndrome

To assess the safety and efficacy of ultra-hypofractionated low-dose total skin electron beam therapy (TSEBT) regimen in patients with advanced mycosis fungoides (MF) or Sézary syndrome (SS). In this multicenter observational study from five German centers, 18 total patients with MF/SS underwent TSEBT with a total dose of 8 Gy in two fractions. The primary endpoint was the overall response rate (ORR). 15 of 18 patients with stage IIB-IV MF or SS were heavily pre-treated with a median of four prior systemic therapies. The ORR was 88.9% (95%-confidence interval (CI): 65.3-98.6), with three complete responses (17%). At a median follow-up period of thirteen months, the median time to next treatment (TTNT) was 12 months (95%-CI: 8.2-15.8), and the median progression-free survival was 8 months (95%-CI: 2-14). Asignificant reduction in the modified severity-weighted assessment tool (mSWAT), total Skindex-29 score (Bonferroni-corrected P-value < 0.005), and all subdomains (Bonferroni-corrected P-values < 0.05) was observed after TSEBT. Half of the irradiated patients (N=9) developed grade 2 acute and subacute toxicities. One patient had confirmed grade 3 acute toxicity. Chronic grade 1 toxicity has been observed in 33% of patients. Patients with erythroderma/SS or prior radiation therapy appear at higher risk of skin toxicities. TSEBT with 8 Gy in 2 fractions achieves good disease control and symptom palliation with acceptable toxicity, greater convenience, and fewer hospital visits.

Suggested Guidelines for the Treatment of Mycosis Fungoides in Countries with Limited Resources.

The treatment options for mycosis fungoides (MF) have been expanding but unfortunately many of the currently used treatment modalities are unavailable in Egypt and other African/Arab countries. In addition, there is a lack of consensus on the treatment of hypopigmented MF (HMF), which is a frequently encountered variant in our population. We aimed to develop regional treatment guidelines based on the international guidelines but modified to encompass the restricted treatment availability and our institutional experience. Special attention was also given to studies conducted on patients with skin phototype (III-IV). Treatment algorithm was formulated at Ain-Shams cutaneous lymphoma clinic through the collaboration of dermatologists, haematologists, and oncologists. Level of evidence is specified for each treatment option. For HMF, phototherapy is recommended as a first line treatment, while low-dose methotrexate is considered a second line. For early classical MF, we recommend Psoralen-ultraviolet A (PUVA), which is a well-tolerated treatment option in dark phenotype. Addition of either retinoic acid receptor (RAR) agonist and/or methotrexate is recommended as a second line. Total skin electron beam (TSEB) is considered a third-line option. For advanced stage, PUVA plus RAR agonist and/or methotrexate is recommended as first line, TSEB or monochemotherapy is considered a second line option. Polychemotherapy is regarded as a final option. All patients with complete response (CR) enter a maintenance and follow-up schedule. We suggest a practical algorithm for the treatment of MF for patients with dark phenotype living in countries with limited resources.

Paraffin gauze bolus as tissue compensator in photon irradiation for mycosis fungoides – regarding a case study

Abstract Introduction: Total skin electron beam therapy is a treatment option in patients with mycosis fungoides (MF) affecting a significant amount of the body surface. For patients with involvement of soles and interdigital folds, however, this approach is ineffective, requiring alternatives such as localised radiotherapy (RT). Although electron beams are well suited for superficial lesions, on irregular surfaces it provides inadequate tumour coverage and excess dose variance, requiring photon irradiation with tissue compensation. Methods: We present the case of a patient with extensive cutaneous MF with skin lesions spread over both lower limbs and treated on these affected areas with photon beam RT. Long sheets of paraffin gauze dressings were used to create a 0·5-cm-thick bolus. The patient received a single fraction of 8 Gy. In vivo dosimetry using Gafchromic films was performed. Results: After 3 months, a complete response was achieved. In this case, paraffin gauze bolus proved to be an inexpensive, convenient, effective and flexible method for irregular superficial cancer irradiations. Conclusion: Paraffin gauze bolus is a suitable option for irregular contours.

Near complete responses to concurrent brentuximab vedotin and ultra-hypofractionated low-dose total skin electron beam radiation in advanced cutaneous T-cell lymphoma.

Patients with advanced stage mycosis fungoides (MF) or Sézary syndrome (SS) have a poor prognosis. Despite many available active single agents for CTCL treatment, high remission rates and long-lasting responses are rarely achieved in advanced CTCL [1]. Therefore, it is important to find more effective strategies, e.g. combination therapy, which could enhance efficacy by targeting key pathways in a synergistic or additive manner. We report on three patients with tumor stage MF (IIB) with fast response and very good partial remission due to induction with BV with 1.8 mg/kg dose concurrently in combination with ultra-hypofractionated low dose TSEBT.

Low- Dose hypofractionated total skin electron beam therapy in mycosis fungoides—a single institutional experience

Low- Dose hypofractionated total skin electron beam therapy in mycosis fungoides—a single institutional experience

In vivo Dosimetry for Dose Verification of Total Skin Electron Beam Therapy Using Gafchromic® EBT3 Film Dosimetry.

Total skin electron beam therapy (TSEBT) is an important skin-directed radiotherapeutic procedure done in the treatment of cutaneous T-cell lymphomas, namely, mycosis fungoides (MF). This procedure is usually done at larger source-to-surface distances with the patient standing on a rotatory platform. As the patient has to stand in different positions without any rigid immobilization devices, there are chances that the total skin may not get uniformly irradiated which could lead to nonuniform dose distributions. Therefore, all the necessary arrangements should be made to evaluate the dose for different regions of the skin using suitable in vivo dosimeters at the radiotherapy centers offering these treatments. This study aimed to evaluate the consistency between the delivered and planned doses in vivo during TSEBT using Gafchromic EBT3 film dosimetry. The surface dose for the six MF patients treated for TSEBT at our hospital from 2018 to 2022 was measured and evaluated. 2 cm × 2 cm Gafchromic® EBT3 films were used to measure skin dose at reference body positions of clinical interest. All the patients were treated with the modified Stanford technique. The irradiated film strips were analyzed for the dose using the IMRT OmniPro software. The doses at respective positions were expressed as mean dose ± standard deviation and the deviation was calculated as the percentage of the prescribed dose. One hundred and fifty-four Gafchromic® EBT3 film strips irradiated on six TSEBT patients showed a maximum dose variation of 2.00 ± 0.14 Gy, in the central body regions. The dose variation in the peripheral areas such as hands and ears was larger. A variation of 2 ± 0.32 Gy was observed on the hands and ears. The uniformity of the dose delivered to maximum body parts was within -7% and +16% for the peripheral areas like hands. The American Association of Physicists in Medicine recommends a dose uniformity of 8% and 4% in the vertical and horizontal patient plane for direct incident beam; however, for oblique incidences like in the modified Stanford technique, the dose variation is about 15%. In vivo dosimetry using Gafchromic EBT3 film dosimetry for TSEBT yields objective data to find the under or overdose regions. That can be useful to provide quality treatment, especially when treatments tend to be as complex as TSEBT.

TCL-458 Real-World Treatment Patterns in Patients With Sézary Syndrome in the United States and the Impact of Covid-19.

Sézary syndrome (SS) is an aggressive type of cutaneous T-cell lymphomas (CTCL). Due to its low prevalence, there are limited data on real-world treatment patterns of available SS therapies. Furthermore, recent approvals of new agents for patients with CTCL as well as COVID-19 likely impacted real-world treatment patterns. To examine real-world treatment patterns and the impact of COVID-19 among SS patients treated in 2018-2020 in the United States. Patients in the 2018-2020 Symphony Health Solutions database were classified into 3 groups: ≥1 diagnosis of SS (ICD-10-CM code: C84.1x) in 2018, 2019, and 2020, respectively. Patient characteristics and treatment patterns for National Comprehensive Cancer Network guideline 2.2021 recommended therapies were examined: systemic therapy (e.g., extracorporeal photopheresis (ECP), parenteral, oral agents), skin-directed therapy (SDT, e.g., topical, local radiation, total skin electron beam therapy, phototherapy) and bone marrow transplant. The impact of COVID-19 was assessed using quarterly analysis. The analyses included 869, 882, and 853 SS patients in 2018, 2019, and 2020, respectively (mean age: 66.3, 66.9 and 67.3 years; male: 54.4%, 54.8%, and 55.6%). Overall, systemic therapy increased from 2018-2020 (41.8% to 46.5%), with increased parenteral (20.7% to 28.7%) but decreased ECP (17.0% to 13.5%) usage. SDT increased from 2018-2020 (48.9% to 52.9%), with increased topical (42.3% to 48.3%) but decreased phototherapy (6.3% to 4.1%) usage. ECP, mogamulizumab, and bexarotene were the most prescribed systemic therapies in 2019-2020, with mogamulizumab being the only one with increased usage over time. Quarterly analysis showed decreasing ECP from Q1 to Q4 within each year, with a notable drop in Q2 2020. For parental systemics, there was an increasing trend in 2019 and 2020, but lower utilization in Q4 2020 than in Q3 2020. For oral systemic, there was a notable drop in Q2 2020 but an increased trend in Q3-Q4 2020. This claims analysis indicated increased use in systemic and SDT among SS patients in 2018-2020. The quarterly analysis indicated that the drop in ECP and oral systemic usage in Q2 2020 coincided with the onset of the pandemic, but there was a stable use of parenteral systemic during 2020.

Short-term efficacy and safety of total skin electron beam therapy in mycosis fungoides: Systematic review and meta-analysis.

Total skin electron beam therapy (TSEBT) is one of the mainstays of treatment for mycosis fungoides. The most common modalities are standard dose (30-36 Gy) and low dose (10-12 Gy). To review the literature on the efficacy and safety profiles of standard dose and low dose TSEBT. We searched electronic databases for studies that enrolled patients with Mycosis Fungoides and treated with TSEBT. We estimated the event rates associated with low dose and standard dose TSEBT. The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was followed. Main outcomes were complete response rate, partial response rate, mild and severe adverse events rate low dose TSEBT had a Complete Response Rate of 28% [0.19, 0.37], an Overall Response Rate of 85% [0.76, 0.93], a mild adverse events rate of 93% [0.82, 1.04] and a severe adverse events rate of 5% [-0.04; 0.14] Standard dose TSEBT had a Complete Response Rate of 57% [0.41; 0.73], the Overall Response Rate was 99% [0.97; 1.02], the mild adverse events rate was 100%, the severe adverse events rate was 7% [-0.01; 0.16]. Comparing standard dose TSEBT in the early versus advanced stages, advanced stages patients had a Risk Ratio=0.77 in obtaining a Complete Response [0.64, 0.92](p=0.0158). TSEBT is an associated with an excellent short term safety profile. Both schedules show high ORR, with standard dose TSEBT demonstrating highest CRR. Advanced stage of disease negatively influence the CRR.

33870 Mechlorethamine gel as a maintenance treatment regimen in patients with mycosis fungoides

Background: Cutaneous T-cell lymphomas (CTCLs) are malignant proliferations in the skin that can invade blood, lymph nodes, or viscera. Mycosis fungoides (MF), the most common CTCL, is treated with topical agents, such as mechlorethamine gel 0.016%, in skin-limited stages. Currently, no data exist on maintenance therapy for patients in remission. Thomas Jefferson University has developed a unique protocol to use mechlorethamine as a maintenance regimen after total skin electron beam therapy. Purpose: To determine progression-free survival and efficacy of mechlorethamine as maintenance and active treatment regimens for MF. Methods: A retrospective review of MF patients seen at Thomas Jefferson University from 2012 to 2020 was conducted. Patients of all stages treated with mechlorethamine as maintenance or active treatment with 2 consecutive mSWATs (modified Severity Weighted Assessment Tool) documented were included. Treatment outcomes were assessed by change in mSWAT and progression-free survival. Dermatology Life Quality Index surveys before and after treatment were analyzed. Results: Of 186 MF patients, 44 met inclusion criteria. Patients on maintenance therapy had a 65.22% progression-free survival rate with median time to progression of 29.45 months. By-time analysis for responders on active and maintenance treatment showed an increased response over time. Peak responses were seen at last mSWAT recorded. Both cohorts experienced improved quality-of-life scores from initiation to discontinuation of mechlorethamine. Conclusions: Patients on maintenance and active mechlorethamine treatment regimens demonstrated improvement in mSWAT and quality-of-life. Mechlorethamine treatment showed progression-free survival for a median of 29.45 months, indicating this therapy may be an effective maintenance regimen.

Ther-PO-12 - Low vs. high-dose total skin electron beam therapy for mycosis fungoides: efficacy and safety analysis

Ther-PO-12 - Low vs. high-dose total skin electron beam therapy for mycosis fungoides: efficacy and safety analysis

Ther-O-06 - Near complete responses to concurrent brentuximab vedotin and ultra-hypofractionated low-dose total skin electron beam radiation in advanced CTCL

Ther-O-06 - Near complete responses to concurrent brentuximab vedotin and ultra-hypofractionated low-dose total skin electron beam radiation in advanced CTCL

Ther-PO-08 - Primary cutaneous gamma-delta lymphoma responding only to mogamulizumab and total skin electron beam therapy

Ther-PO-08 - Primary cutaneous gamma-delta lymphoma responding only to mogamulizumab and total skin electron beam therapy

Radiotherapy for cutaneous lymphomas

HintergrundPrimär kutane Lymphome (KL) sind sehr strahlenempfindlich. Deshalb ist die Strahlentherapie ein integraler Bestandteil der multimodalen Behandlung.Ziel der ArbeitDie vorliegende Arbeit ermöglicht einen Überblick über Indikationen, Entwicklungen der Techniken und Dosiskonzepte der Ganzhautelektronenbestrahlung (TSEBT), der lokalen Radiatio sowie Erhaltungstherapien und aktuelle Kombinationsstudien kutaner T‑ und B‑Zell-Lymphome.Material und MethodenEs erfolgte eine selektive Literaturrecherche über die Datenbank PubMed zur Radiotherapie der KL, eine Recherche aktueller Studien mittels clinicaltrials.gov, Darstellung interner Behandlungsstrategien sowie Zusammenfassung der nationalen und internationalen Leitlinien.ErgebnisseDie Niedrigdosis-TSEBT wird als Alternative zur konventionellen 36-Gy-TSEBT national und international empfohlen. Die wichtigsten Vorteile sind die bessere Verträglichkeit, die Möglichkeit der Wiederholung, ein verkürzter Verlauf (ca. 3 Wochen) und eine kurze Dauer bis zum Ansprechen. In den aktuellen Studien wird die TSEBT in der Regel mit 12 Gy durchgeführt und mit unterschiedlichen Immuntherapeutika und epigenetischen Regulatoren kombiniert. Die lokale Radiatio ist indiziert bei Tumoren der Mycosis fungoides und ein kuratives Behandlungsschema für andere KL, insbesondere bei primär kutanen B‑Zell-Lymphomen.DiskussionDie TSEBT ist eine sehr effektive Behandlungsoption der Mycosis fungoides (MF) und bietet einen wichtigen palliativen Nutzen, da sie zügig zur Symptomlinderung und Verbesserung der Lebensqualität führt. Sie ist eine wichtige Behandlungsoption, insbesondere bei Patienten mit ausgeprägten generalisierten Plaques oder im Tumorstadium. Die lokale Radiatio wird im Rahmen der TSEBT für Tumoren und Aufsättigung unterversorgter Areale eingesetzt. Andere KL sind primär kurativ mit einer lokalen Radiatio behandelbar.

Development of transparent eye shields for total skin electron beam radiotherapy.

PurposeFor 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.MethodsThe 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 filmResultsThe 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.ConclusionTransparent TSE eye shields are able to reduce the dose to the eyes while maintaining vision during treatment at a reasonable cost.

Real-world treatment patterns in patients with Sézary syndrome in the United States and the impact of Covid-19.

e19578 Background: Sézary syndrome (SS) is an aggressive type of cutaneous T-cell lymphomas (CTCL). Due to its low prevalence, there are limited data on real-world treatment patterns of currently available SS therapies. Furthermore, recent approvals of new agents for patients with CTCL as well as COVID-19 likely impacted real-world treatment patterns. Objective: To examine real-world treatment patterns and the impact of COVID-19 among SS patients treated in 2018-2020 in the US. Methods: Patients with public or private insurance in the 2018-2020 Symphony Health Solutions database were classified into 3 groups: ≥1 diagnosis of SS (ICD-10-CM code: C84.1x) in 2018, 2019, and 2020, respectively. Patient characteristics and treatment patterns for all therapies recommended by the National Comprehensive Cancer Network guidelines version 2.2021 were examined: systemic therapy (e.g., extracorporeal photopheresis (ECP), parenteral, or oral agents), skin-directed therapy (SDT, e.g., topical, local radiation, total skin electron beam therapy, or phototherapy) and bone marrow transplant. The impact of COVID-19 was assessed via quarterly analysis. National drug codes, current procedural terminology and healthcare common procedure coding system codes were used to identify all treatments. Results: The analyses included 869, 882, and 853 SS patients in 2018, 2019, and 2020, respectively (mean age: 66.3, 66.9 and 67.3 years; male: 54.4%, 54.8%, and 55.6%). Overall, systemic therapy increased from 2018 to 2020 (41.8% to 46.5%), with increased parenteral (20.7% to 28.7%) but decreased ECP (17.0% to 13.5%) usage. SDT increased from 2018 to 2020 (48.9% to 52.9%), with increased topical (42.3% to 48.3%) but decreased phototherapy (6.3% to 4.1%) usage. ECP, mogamulizumab, and bexarotene were the most prescribed systemic therapies in 2019-2020, with mogamulizumab being the only one with increased usage over time. Quarterly analysis showed a decreasing ECP from Q1 to Q4 within each year, with a notable drop in Q2 2020. For parental systemics, there was an increasing trend in 2019 and 2020, but utilization in Q4 2020 was lower than that of Q3 2020. For oral systemic, there was a notable drop in Q2 2020 but an increased trend in Q3-Q4 2020. Conclusions: This claims analysis indicated increased use in systemic and SDT among SS patients in 2018-2020. The quarterly analysis indicated that the drop in ECP and oral systemic usage in Q2 2020 coincided with the onset of the pandemic, but there was a stable use of parenteral systemic during 2020.

Changes in total skin electron beam therapy modalities for mycosis fungoides: A single-centre study

BackgroundMycosis fungoides (MF) is a highly radiosensitive disease. Total skin electron beam therapy (TSEBT) is an effective option that may allow prolonged response for several months. Recently, a low-dose regimen (12 Gy) has been reported more frequently, with less complete response than for standard doses (36 Gy) but better safety. Our aim was to compare patients treated with 12-Gy and 36-40-Gy TSEBT regimens at our centre for efficacy and safety. MethodsThis retrospective, monocentric study in Bordeaux University Hospital included all MF patients treated with 12-Gy or 36-40-Gy TSEBT between 2011 and 2020. ResultsPatients presented with MF at the following stages: 15 T2, including 9 folliculotropic MF; 2 T3, including 1 folliculotropic; 8 T4, including 2 Sézary syndromes. The mean follow-up time after TSEBT was 43.5 months [range: 2–128] for the 36-40-Gy group and 25.2 months [range: 4–45] for the 12-Gy group. The 3-month overall response rate (ORR) was similar for both groups (84.6% for 36-40 Gy and 91.7% for 12 Gy), but there was a tendency to more complete response in the 36-40-Gy group (30.8% vs 8.3%, P=0.35). Progression-free survival (PFS) tended to be better in the 36-40-Gy group than in the low-dose group (15.7 months vs 5.3 months; P=0.28). Patients treated with low-dose TSEBT had a lower incidence of radiation dermatitis (16.7% vs 38.4%, P=0.42). ConclusionWe confirm that TSEBT is an effective option, including at lower doses. Differences between low- and standard-dose regimens were not significant in our series. Although a low-dose regimen seemed to result in lower complete response and long-term efficacy rates in comparison with a standard dose, treatment at lower doses presents the advantage of repeatability, with fewer and weaker side effects, in the event of disease recurrence. Second-line treatments were mostly skin-directed in this group.

Total skin electron beam therapy (TSEBT) in management of mycosis fungoides: a case series

In Aga Khan University, a retrospective review was conducted from January 2013-December 2020 for patients who received Total Skin Electron Beam Therapy (TSEBT) for the management of Mycosis Fungoides (MF). The clinical response rate and disease-free interval (DFI) was evaluated for three patients. All of the patients received a 3600 cGy dose of radiation. Clinical complete remission (cCR) was observed in two out of three patients, while one patient showed clinical partial response. Following the cCR to TSEBT, the DFI of the first patient with stage 1B lasted 30 months, while the second patient with stage IIB remained disease free for five months. TSEBT is an effective treatment for MF disease. It can thus be expected that patients with limited disease in the early stage can acquire a cCR with a longer DFI. ---Continue