Total Electric Skin Beam Therapy in Mycosis Fungoides

Chrissy Cornejo

Outline
Background on mycosis fungoides What is total skin electron beam therapy? Treatment of MF with TSEB Evidence for low dose TSEB

Total skin electron beam therapy

Fields: stationary (multiple dual angle) or rotational Energy: 4-9 MeV
Less than 5% of dose penetrates beyond 2 cm

6 Positions: AP, PA, RAO, LAO, RPO, LPO Stanford protocol

Smith et al, 2007.

2 Gy per cycle to a total dose to 30-36 Gy over 8-10 weeks -> 1 week gap in tx for relief from skin RT rxn Cycle: Day 1-AP, RPO, LPO; Day 2- PA, RAO, LAO

TSEB set-up

Morris. 2012.

Smith et al. Oncology, 2003

EORTC Recommendations for TSEB

80% isodose should be at least 4 mm deep to skin surface Dose at 20 mm deep should be less than 20% maximum dose at skin surface Photon contamination at level of bone marrow must be less than 0.7 Gy for a full course of TSEB to avoid hematological sequelae

TSEBT Toxicities

Who do we treat?
Primary application = MF
1st line for extensive patch/plaque disease that is too extensive for topical tx 2nd line for stage IA/IB who have relapsed or progressed after sequential topical txs

Other applications:
Cancers arising in skin - Kaposis sarcoma Cancers metastasizing to skin - nodular or inflammatory breast cancer Skin dominated leukemia Anaplastic and B cell lymphomas Benign disorders of skin - scleroderma, lymphomatoid papulosis

Classification of cutaneous lymphoma

T-cell and NK-cell lymphomas
Mycosis fungoides Mycosis fungoides variants and subtypes Folliculotropic MF Pagetoid reticulosis Granulomatous slack skin Sezary syndrome Adult T-cell leukemia/lymphoma Primary cutaneous CD30+ lymphoproliferative disorders Primary cutaneous anaplastic large cell lymphoma Lymphatoid papulosis Subcutaneous panniculitis-like T-cell lymphoma

B-cell lymphomas
Primary cutaneous marginal zone B-cell lymphoma Primary cutaneous follicle center lymphoma Primary cutaneous diffuse large B-cell lymphoma

Mycosis fungoides is the most common subgroup of CTCL and has a heterogenous presentation

A) Patch, B) Plaque, C) Large tumor with necrosis and ulceration, D) Generalized erythroderma

Smith et al, 2007

History of radiation for mycosis fungoides

Dramatic responses of MF to low doses of X-ray therapy first reported by Sholtz in 1902 Early approach to management of MF using RT was entirely palliative individual lesion were treated with low doses of soft x-rays
High rate of lesion recurrence Increased risk of side effects from penetrating RT

Localized superficial radiotherapy has become an invaluable form of tx for all stages of MF

Wheres the evidence?

Study Design Methods Treatment
TSEB only

Results
CR rates: 96% in stages IA/IB/IIA, 36% in stage IIB, 60% in stage III Greater skin dose (32-36 Gy) and higher energy (4-6 MeV) associated with higher rate of CR 5-year relapse free survivals of 1023%

Jones et Meta952 patients al, 1995 analysis of with all stages open of CTCL uncontrolled and mostly retrospective studies Small RCT 42 patients treated with TSEB vs. topical mechlorethami ne

Retrospectiv e study

Study Design: Results:

Current and future research

Stanford, Phase I/II Study: Low dose (12 Gy) TSEBT + Vorinostat vs low dose TSEBT monotherapy in MF

Take home points

TSEB is an effective treatment for all stages of MF Standard TSEB regimen: 30-36 Gy delivered in 2 Gy fractions Low dose:

Big thanks to
Dr. Plastaras Abby Berman Jacob Shabason Everyone else!

References
Smith BD, Wilson LD: Cutaneous Lymphomas. Semin Radiat Oncol 17:158168, 2007 Chinn DM, Chow S, Kim YH, Hoppe RT. Total skin electron beam therapy with or without adjuvant topical nitrogen mustard or nitrogen mustard alone as initial treatment of T2 and T3 mycosis fungoides. Int J Radiat Oncol Biol Phys. 1999;43:951--8.53. Jones GW, Kacinski BM, Wilson LD, Willemze R, Spittle M, Hohenberg H, et al. Total skin electron radiation in the man- agement of mycosis fungoides: consensus of the European Organization for Research and Treatment of Cancer (EORTC) Cutaneous Lymphoma Project Group. J Am Acad Dermatol. 2002;47:36470 Jones GW, Hoppe RT, Glatstein E. Electron beam treatment for cutaneous T cell lymphoma. Haematol Oncol Clin North Am 1995;9:1057e1076. Harrison C, Young J, Navi D, et al. Revisiting low dose total skin electron beam radiotherapy in mycosis fungoides. Int J Radiat Oncol Biol Phys 2011;81(4):e651ee657. Kamstrup M, Specht L, Skovgaard G, et al. A prospective, open-label study of low-dose total skin electron beam therapy in mycosis fungoides. Int J Radiat Oncol Biol Phys 2008;71(4):1204e1207.