Low Dose Total Skin Electron Beam Radiation in Cutaneous T-Cell Lymphoma: Review

Misty Gamble^1,2, Elizabeth Tocci³, Jennifer A. DeSimone^2,4

¹Department of Melanoma and Cutaneous Oncology, MedStar Washington Hospital Center, Washington DC, USA.
²Department of Dermatology, MedStar Georgetown University Hospital, Washington DC, USA.
³University of Massachusetts Medical School, Worcester, USA.
⁴Melanoma and Skin Oncology, INOVA Fairfax Hospital, Fairfax, USA.

DOI: 10.4236/jct.2014.514138                

Abstract

The treatment of advanced stage MF is especially challenging as single agent overall response rates are in the 35% range and chronic recurrence is the rule. The treatment of CTCL across all stages of disease is aimed at the goal of achieving and sustaining remission. Increasingly, low dose total skin electron beam therapy (TSEBT) is being utilized as a skin directed component in combination therapy for advanced stage CTCL. Researchers are seeking to better define the utility of low dose TSEBT as a method of debulking skin disease while simultaneously treating other disease compartments and in combination with sustained maintenance therapies of both the skin directed and systemic varieties. Data exists showing the efficacy of low dose TSEBT in early and advanced disease. There is also data documenting prolonged treatment responses with TSEBT plus adjuvant skin directed therapies such as PUVA and topical nitrogen mustard. Emerging data examining the role of low dose TSEBT in the prestem cell transplant preparation is also promising. This brief review summarizes the utility of low dose TSEBT in multiagent treatment regimens in CTCL.

Keywords

Cutaneous T-Cell Lymphoma, Mycosis Fungoides, Total Skin Electron Beam Therapy, Hematopoietic Stem Cell Transplantation

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Bradford, P.T., Devesa, S.S., Anderson, W.F. and Toro, J.R. (2009) Cutaneous Lymphoma Incidence Patterns in the United States: A Population-Based Study of 3884 Cases. Blood, 113, 10. http://dx.doi.org/10.1182/blood-2008-10-184168
[2]	Willemze, R., Jaffe, E.S., Burg, G., Cerroni, L., Berti, E. and Swerdlow, S.H. (2005) WHO-EORTC Classification for Cutaneous Lymphomas. Blood, 105, 3768-3785. http://dx.doi.org/10.1182/blood-2004-09-3502
[3]	James, W.D., Berger, T. and Elston, D. (2011) Mycosis Fungoides. Andrews’ Diseases of the Skin: Clinical Dermatology—Expert Consult—Online. 11th Edition, Saunders, Philadelphia.
[4]	Wood, G.S., Hong, S.R., Sasaki, D.T., Abel, E.A., Hoppe, R.T., Warnke, R.A. and Morhenn, V.B. (1990) Leu-8/CD7 Antigen Expression by CD3+ T Cells: Comparative Analysis of Skin and Blood in Mycosis Fungoides/Sézary Syndrome Relative to Normal Blood Values. Journal of the American Academy of Dermatology, 22, 602-607. http://dx.doi.org/10.1016/0190-9622(90)70080-2
[5]	Criscone, V.D. and Weinstock, M.A. (2007) Incidence of Cutaneous T-Cell Lymphoma in the United States, 1973-2002. Archives of Dermatology, 143, 854-859.
[6]	Hinds, G.A. and Heald, P. (2009) Cutaneous T-Cell Lymphoma in Skin of Color. Journal of the American Academy of Dermatology, 60, 359-375. http://dx.doi.org/10.1016/j.jaad.2008.10.031
[7]	Girardi, M., Heald, P.W. and Wilson, L.D. (2004) The Pathogenesis of Mycosis Fungoides. The New England Journal of Medicine, 350, 1978-1988. http://dx.doi.org/10.1056/NEJMra032810
[8]	Wong, H. (2013) Novel Biomarkers, Dysregulated Epigenetics, and Therapy in Cutaneous T-Cell Lymphoma. Discovery Medicine, 16, 71-78.
[9]	Aschebrook-Kilfoy, B., Cocco, P., La Vecchia, C., Chang, E.T., Vajdic, C.M., Kadin, M.E., et al. (2014) Medical History, Lifestyle, Family History, and Occupational Risk Factors for Mycosis Fungoides and Sezary Syndrome: The Interlymph Non-Hodgkin Lymphoma Subtypes Project. Journal of the National Cancer Institute Monographs, 48, 98-105. http://dx.doi.org/10.1093/jncimonographs/lgu008
[10]	Hoppe, R.T., Wood, G.S. and Abel, E.A. (1990) Mycosis Fungoides and the Sezary Syndrome: Pathology, Staging, and Treatment. Current Problems in Cancer, 14, 293-371. http://dx.doi.org/10.1016/0147-0272(90)90018-L
[11]	Schlaak, M., Pickenhain, J., Theurich, S., Skoetz, N., von Bergwelt-Baildon, M. and Kurschat, P. (2013) Allogeneic Stem Cell Transplantation versus Conventional Therapy for Advanced Primary Cutaneous T-Cell Lymphoma. Cochrane Database of Systematic Reviews, 2013, Article ID: CD008908. http://dx.doi.org/10.1002/14651858.CD008908.pub3
[12]	Trautinger, F., Knobler, R., Willemze, R., et al. (2006) EORTC Consensus Recommendations for the Treatment of Mycosis Fungoides/Sezary Syndrome. European Journal of Cancer, 42, 1014-1030. http://dx.doi.org/10.1016/j.ejca.2006.01.025
[13]	Jones, G.W., Kacinski, B.M., Wilson, L.D., et al. (2002) Total Skin Electron Radiation in the Management of Mycosis Fungoides: Consensus of the European Organization for Research and Treatment of Cancer (EORTC) Cutaneous Lymphoma Project Group. Journal of the American Academy of Dermatology, 47, 364-370. http://dx.doi.org/10.1067/mjd.2002.123482
[14]	Whittaker, S.J. and Foss, F.M. (2007) Efficacy and Tolerability of Currently Available Therapies for the Mycosis Fungoides and Sezary Syndrome Variants of Cutaneous T-Cell Lymphoma. Cancer Treatment Reviews, 33, 146-160. http://dx.doi.org/10.1016/j.ctrv.2006.08.006
[15]	Trump, J.G., Wright, K.A., Evans, W.W., et al. (1953) High Energy Electrons for the Treatment of Extensive Superficial Malignant Lesions. American Journal of Roentgenology, Radium Therapy, and Nuclear Medicine, 69, 623-629.
[16]	Lo, T.C., Salzman, F.A., Moschella, S.L., Tolman, E.L. and Wright, K.A. (1979) Whole Body Surface Electron Irradiation in the Treatment of Mycosis Fungoides. An Evaluation of 200 Patients. Radiology, 130, 453-457. http://dx.doi.org/10.1148/130.2.453
[17]	Podgorsak, E.B., Pla, C., Pla, M., Lefebvre, P.Y. and Heese, R. (1983) Physical Aspects of a Rotational Total Skin Electron Irradiation. Medical Physics, 10, 159-168. http://dx.doi.org/10.1118/1.595296
[18]	Moraes, F.Y., Carvalho, H., Hanna, S.A., et al. (2014) Literature Review of Clinical Results of Total Skin Electron Irradiation (TSEBT) of Mycosis Fungoides in Adults. Reports of Practical Oncology and Radiotherapy, 19, 92-98. http://dx.doi.org/10.1016/j.rpor.2013.08.003
[19]	Fuks, Z.Y., Bagshaw, M.A. and Farber, E.M. (1973) Prognostic Signs and the Management of the Mycosis Fungoides. Cancer, 32, 1385-1395. http://dx.doi.org/10.1002/1097-0142(197312)32:6<1385::AID-CNCR2820320617>3.0.CO;2-#
[20]	Levi, J.A. and Wiernik, P.H. (1975) Management of Mycosis Fungoides—Current Status and Future Prospects. Medicine (Baltimore), 54, 73-88. http://dx.doi.org/10.1097/00005792-197501000-00004
[21]	Harrison, C., Young, J., Navi, D., et al. (2011) Revisiting Low-Dose Total Skin Electron Beam Therapy in Mycosis Fungoides. International Journal of Radiation Oncology, Biology, Physics, 81, e651-e657. http://dx.doi.org/10.1016/j.ijrobp.2011.01.023
[22]	Kamstrup, M.R., Specht, L., Skovgaard, G.L. and Gniadecki, R. (2008) A Prospective, Open-Label Study of Low-Dose Total Skin Electron Beam Therapy in Mycosis Fungoides. International Journal of Radiation Oncology, Biology, Physics, 71, 1204-1207. http://dx.doi.org/10.1016/j.ijrobp.2007.11.039
[23]	Kazmierska, J. (2014) Clinical Results of the Total Skin Electron Irradiation of the Mycosis Fungoides in Adults. Conventional Fractionation and Low Dose Schemes. Reports of Practical Oncology and Radiotherapy, 19, 99-103. http://dx.doi.org/10.1016/j.rpor.2013.08.008
[24]	Kamstrup, M.R., Lindahl, L.M., Gniadecki, R., et al. (2012) Low-Dose Total Skin Electron Beam Therapy as a Debulking Agent for Cutaneous T-Cell Lymphoma: An Open-Label Prospective Phase II Study. British Journal of Dermatology, 166, 399-404. http://dx.doi.org/10.1111/j.1365-2133.2011.10670.x
[25]	Kaye, F.J., Bunn Jr., P.A., Steinberg, S.M., et al. (1989) A Randomized Trial Comparing Combination Electron-Beam Radiation and Chemotherapy with Topical Therapy in the Initial Treatment of Mycosis Fungoides. The New England Journal of Medicine, 321, 1784-1790. http://dx.doi.org/10.1056/NEJM198912283212603
[26]	Lloyd, S., Chen, Z., Foss, F., Girardi, M. and Wilson, L. (2013) Acute Toxicity and Risk of Infection during Total Skin Electron Beam Therapy for Mycosis Fungoides. Journal of the American Academy of Dermatology, 69, 537-543. http://dx.doi.org/10.1016/j.jaad.2013.04.063
[27]	Roberge, D., Muanza, T., Blake, G., Shustik, C., Vuong, T. and Freeman, C.R. (2007) Does Adjuvant Alpha-Interferon Improve Outcome When Combined with Total Skin Irradiation for Mycosis Fungoides? British Journal of Dermatology, 156, 57-61. http://dx.doi.org/10.1111/j.1365-2133.2006.07559.x
[28]	Navi, D., Riaz, N., Levin, Y.S., Sullivan, N.C., Kim, Y.H. and Hoppe, R.T. (2011) The Stanford University Experience with Conventional-Dose, Total Skin Electron-Beam Therapy in the Treatment of Generalized Patch or Plaque (T2) and Tumor (T3) Mycosis Fungoides. Archives of Dermatology, 147, 561-567. http://dx.doi.org/10.1001/archdermatol.2011.98
[29]	Quiros, P.A., Jones, G.W., Kacinski, B.M., et al. (1997) Total Skin Electron Beam Therapy Followed by Adjuvant Psoralen/Ultraviolet—A Light in the Management of Patients with T1 and T2 Cutaneous T-Cell Lymphoma (Mycosis Fungoides). International Journal of Radiation Oncology, Biology, Physics, 38, 1027-1035. http://dx.doi.org/10.1016/S0360-3016(97)00127-2
[30]	Wilson, L.D., Licata, A.L., Braverman, I.M., et al. (1995) Systemic Chemotherapy and Extracorporeal Photochemotherapy for T3 and T4 Cutaneous T-Cell Lymphoma Patients Who Have Achieved a Complete Response to Total Skin Electron Beam Therapy. International Journal of Radiation Oncology, Biology, Physics, 32, 987-995. http://dx.doi.org/10.1016/0360-3016(95)00073-8
[31]	Wilson, L.D., Jones, G.W., Kim, D., et al. (2000) Experience with Total Skin Electron Beam Therapy in Combination with Extracorporeal Photopheresis in the Management of Patients with Erythrodermic (T4) Mycosis Fungoides. Journal of the American Academy of Dermatology, 43, 54-60. http://dx.doi.org/10.1067/mjd.2000.105510
[32]	Chinn, D.M., Chow, S., Kim, Y.H. and Hoppe, R.T. (1999) 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. International Journal of Radiation Oncology, Biology, Physics, 43, 951-958. http://dx.doi.org/10.1016/S0360-3016(98)00517-3
[33]	Wilson, L.D., Quiros, P.A., Kolenik, S.A., et al. (1996) Additional Courses of Total Skin Electron Beam Therapy in the Treatment of Patients with Recurrent Cutaneous T-Cell Lymphoma. Journal of the American Academy of Dermatology, 35, 69-73. http://dx.doi.org/10.1016/S0190-9622(96)90499-5
[34]	Becker, M., Hoppe, R.T. and Knox, S.J. (1995) Multiple Courses of High-Dose Total Skin Electron Beam Therapy in the Management of Mycosis Fungoides. International Journal of Radiation Oncology, Biology, Physics, 32, 1445-1449. http://dx.doi.org/10.1016/0360-3016(94)00590-H
[35]	Duarte, R.F., Schmitz, N., Servitje, O. and Sureda, A. (2008) Hematopoietic Stem Cell Transplantation for Patients with Primary Cutaneous T-Cell Lymphoma. Bone Marrow Transplant, 41, 597-604. http://dx.doi.org/10.1038/sj.bmt.1705968
[36]	Olavarria, E., Child, F., Woolford, A., Whittaker, S.J., Davis, J.G., McDonald, C., et al. (2001) T-Cell Depletion and Autologous Stem Cell Transplantation in the Management of Tumour Stage Mycosis Fungoides with Peripheral Blood Involvement. British Journal of Haematology, 114, 624-631. http://dx.doi.org/10.1046/j.1365-2141.2001.02919.x
[37]	Duvic, M., Donato, M., Dabaja, B., Richmond, H., Singh, L., Wei, W., et al. (2010) Total Skin Electron Beam and Non-Myeloablative Allogeneic Hematopoietic Stem-Cell Transplantation in Advanced Mycosis Fungoides and Sezary Syndrome. Journal of Clinical Oncology, 28, 2365-2372. http://dx.doi.org/10.1200/JCO.2009.25.8301