Radiation Therapy for Cutaneous T-Cell Lymphomas

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.

Low-Dose Volumetric Modulated Arc Therapy for a Patient With Head and Neck Involvement of Mycosis Fungoides: A Case Report With a Review of Literature

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma that slowly progresses over a period of years to decades. In some cases, lesions that spread to the scalp, neck, or facial skin can have a significant impact on cosmetic appearance and a patient's quality of life. Among the various treatments, radiation therapy is one of the most effective treatment modalities for patients with symptomatic cutaneous lesions. We report on an MF patient who had gradually increasing patches and plaques on the scalp, face, and neck and who underwent irradiation with 20 Gy administered in 10 fractions using volumetric modulated arc therapy. After undergoing this highly conformal technique, the patient obtained prolonged local control and significant alleviation of symptoms with acceptable adverse events. This technique constitutes a promising approach for treating a complex target due to its ability to provide homogeneous coverage of irregularly shaped target volumes along with its ability to preserve organs at risk. In addition, we systematically reviewed clinical reports on the management of extensive cutaneous lesions in MF patients undergoing other irradiation techniques.

How to Sequence Therapies in Mycosis Fungoides

OPINION STATEMENT

Choice of therapy in mycosis fungoides is based on both patient- and lymphoma-specific factors, such as disease characteristics, comorbidities, symptoms and effect on quality of life, potential associated toxicities of therapy, response and tolerance to prior lines of therapy, and convenience and practicality. Generally, we sequence therapies from least toxic, targeted, nonimmunosuppressive to more toxic, immunosuppressive and from single agent to multiple agents, as necessary. If more toxic, immunosuppressive agents are required to alleviate disease burden or symptoms, we generally use them just long enough to control the disease, then transition to a maintenance regimen with less toxic, less immunosuppressive agents.

Recumbent Total Skin Electron Beam Therapy

Purpose

Our purpose was to describe preliminary dosimetric and clinical results of a recumbent total skin electron beam therapy (TSEBT) technique and compare this to a conventional standing TSEBT technique.

Methods and Materials

A customized treatment platform with recessed side wheels was constructed and commissioned for patients to be treated in a recumbent position. Dosimetric and clinical information was collected for patients treated with this new recumbent technique in addition to that of a cohort of patients treated contemporaneously using the conventional standing method. Dose delivery and clinical outcomes were compared for patients treated with the recumbent and standing techniques.

Results

Between 2017 and 2019, 27 patients were treated with TSEBT with the recumbent (n = 13) or conventional standing technique (n = 14) at our institution. Measured dose at 15 body sites could be directly compared. Of these, 10 showed no significant difference between the two techniques while five sites showed significant differences in median measured dose, including the top of left shoulder, right biceps, bend of left elbow, upper back, and medial right thigh (P < .003). Measured dose was significantly higher with the standing technique at these sites with the exception of the upper back. Rates of complete response (25% vs 23%), partial response (50% vs 69%), and stable disease (17% vs 8%) were similar between the standing and recumbent cohorts, respectively (P = .78).

Conclusions

We have developed, commissioned, and implemented a floor-based, recumbent technique that allows for treatment of patients who would otherwise not be eligible for TSEBT. Dosimetric and clinical measurements suggest that this technique is a viable alternative to the standing method.

[Dose Distribution Combinations of Different Electron Beam Energy for Treatment Region Expansion in High-energy Electron Beam Radiation Therapy: A Feasibility Study]

INTRODUCTION

External electron beams have excellent distributions in treatment for superficial tumors while suppressing influence deeper normal tissue. However, the skin surface cannot be given a sufficient dose due to the build-up effect. In this study, we have investigated the combination of electron beams to expand the treatment region by keeping the dose gradient beyond d_max.

MATERIALS AND METHODS

The percentage depth doses of different electron beams were superimposed on a spreadsheet to determine the combinations of electron beams so that the treatment range was maximized. Based on the obtained weight for electron beams, dose distributions were calculated using a treatment planning system and examined for potential clinical application.

RESULTS

With the combination of 4 MeV and 9 MeV electron beams, the 90% treatment range in the depth direction increased by 8.0 mm, and with 4 MeV and 12 MeV beams, it increased by 4.0 mm, with the same maximum dose depth and halfdose depth of the absorbed dose. The dose calculations were performed using the treatment planning system yielded similar results with a matching degree of ±1.5%.

CONCLUSIONS

Although the influences of low monitor unit values and daily output differences remain to be considered, the results suggest that the proposed approach can be clinically applied to expand treatment regions easily.

90Y-NM600 targeted radionuclide therapy induces immunologic memory in syngeneic models of T-cell Non-Hodgkin's Lymphoma

Finding improved therapeutic strategies against T-cell Non-Hodgkin’s Lymphoma (NHL) remains an unmet clinical need. We implemented a theranostic approach employing a tumor-targeting alkylphosphocholine (NM600) radiolabeled with ⁸⁶Y for positron emission tomography (PET) imaging and ⁹⁰Y for targeted radionuclide therapy (TRT) of T-cell NHL. PET imaging and biodistribution performed in mouse models of T-cell NHL showed in vivo selective tumor uptake and retention of ⁸⁶Y-NM600. An initial toxicity assessment examining complete blood counts, blood chemistry, and histopathology of major organs established ⁹⁰Y-NM600 safety. Mice bearing T-cell NHL tumors treated with ⁹⁰Y-NM600 experienced tumor growth inhibition, extended survival, and a high degree of cure with immune memory toward tumor reestablishment. ⁹⁰Y-NM600 treatment was also effective against disseminated tumors, improving survival and cure rates. Finally, we observed a key role for the adaptive immune system in potentiating a durable anti-tumor response to TRT, especially in the presence of microscopic disease.

Hernandez et al. show the effectiveness of ⁹⁰Y for targeted radionucleotide therapy of T-cell Non-Hodgkin’s Lymphoma (NHL). This study suggests that delivering radiation to all NHL disease sites elicits minimal toxicity and induces a memory T-cell response, inviting combination therapies with immune activating agents.

Cutaneous T-cell lymphomas: modern data of pathogenesis, clinics and therapy

Cutaneous T-cell lymphomas (CTCL) are a heterogeneous group of extranodal non-Hodgkin’s lymphomas that are characterized by skin infiltration with malignant monoclonal T lymphocytes. More common in adults aged 55 to 60 years, the annual incidence is about 0.5 per 100 000 people. Mycosis fungoides, Sézary syndrome and CD30+ lymphoproliferative diseases are the main subtypes of CTCL. To date, CTCL have a complex concept of etiopathogenesis, diagnosis, therapy and prognosis. The article presented summary data on these issues.

Clinical outcomes and prognostic factors in patients with mycosis fungoides who underwent radiation therapy in a single institution

PURPOSE

We aimed to evaluate clinical outcomes including progression-free survival (PFS), overall survival (OS), partial response, and complete response in patients who underwent radiation therapy (RT) for mycosis fungoides (MF). Also, we sought to find prognostic factors for clinical outcomes. Materials and.

METHODS

Total 19 patients confirmed with MF between 1999-2015 were retrospectively reviewed. Clinical and treatment characteristics, clinical outcomes, and and toxicities were analyzed.

RESULTS

Eleven patients were treated with total skin electron beam radiotherapy (TSEBT) and 8 patients with involved field radiation therapy (IFRT) with median dose of 30 Gy, respectively. The median time interval from diagnosis to RT was 2.6 months (range, 0.4 to 87.3 months). The overall response rate was 100%; 11 patients (57.9%) had a complete response and 8 patients (42.1%) a partial response. The presence of positive lymph node at the time of consultation of RT was associated with lower OS (p = 0.043). In multivariate analysis, PFS was significantly lower for patients with increased previous therapies experienced following RT (p = 0.019) and for patients showing PR during RT (p = 0.044). There were no reported grade 3 or more skin toxicities related with RT.

CONCLUSION

Both IFRT and TSEBT are effective treatment for MF patients. Patients with short disease course before RT or complete response during RT are expected to have longer PFS. Positive lymph node status at the initiation of RT was associated woth poor OS, suggesting other treatment modalities such as low-dose RT for patients with low life-expectancy.

Total skin electron therapy as treatment for epitheliotropic lymphoma in a dog

BACKGROUND

Mycosis fungoides (MF) is an uncommon cutaneous neoplasm in dogs. Treatment options are limited. Total skin electron therapy (TSET) has been suggested as a possible therapy for canine MF.

OBJECTIVE

To describe the use of TSET as palliative treatment for MF in a dog.

RESULTS

An adult dog, previously diagnosed with nonepidermolytic ichthyosis, was presented with generalized erythroderma, alopecia and erosions. Histopathology revealed a densely cellular, well-demarcated, unencapsulated infiltrate extending from the epidermis to the mid-dermis compatible with MF. The infiltrate exhibited epitheliotropism multifocally for the epidermis, infundibula and adnexa. Due to a lack of response to chemotherapy, TSET was elected. Six megavoltage electrons were delivered using a 21EX Varian linear accelerator. A dose of 6 Gy was delivered to the skin surface and a 100 cm skin to surface distance was used for dog setup. The treatment time for the cranial half treatment was 3 h. The treatment was divided in two sessions (cranial and caudal halves of the body) 15 days apart. Clinical and histopathological complete remission was achieved and the dog was kept in remission with no additional treatments for 19 months before relapse and development of Sézary syndrome.

CONCLUSION AND CLINICAL SIGNIFICANCE

To the best of the authors' knowledge, this is the first case reporting the use of TSET for medically refractory canine MF with post treatment follow-up. This case suggests that the use of TSET may be an effective palliative treatment for canine MF.

An overview of cutaneous T cell lymphomas

Cutaneous T cell lymphomas (CTCLs) are a heterogeneous group of extranodal non-Hodgkin’s lymphomas that are characterized by a cutaneous infiltration of malignant monoclonal T lymphocytes. They typically afflict adults with a median age of 55 to 60 years, and the annual incidence is about 0.5 per 100,000. Mycosis fungoides, Sézary syndrome, and primary cutaneous peripheral T cell lymphomas not otherwise specified are the most important subtypes of CTCL. CTCL is a complicated concept in terms of etiopathogenesis, diagnosis, therapy, and prognosis. Herein, we summarize advances which have been achieved in these fields.