Radiotherapy of advanced mycosis fungoides: indications and results of total skin electron beam and photon beam irradiation

Background: The goals of this retrospective study of advanced mycosis fungo ides are (1) to describe the indications of a combination of total skin ele ctron beam and photon beam irradiation and (2) to analyze the results of to tal body or segmental photon irradiation for patients with extension beyond the skin. Methods: From January 1975 to December 1995, 45 patients with pathologicall y-confirmed mycosis fungoides or Sezary syndrome received a combination of TSEB and photon beam irradiation for advanced disease: 34 males and 11 fema les, mean age 61 years (range 27-87 years). The mean follow-up was 111 mont hs (range 18-244 months, median 85 months). Whole-skin irradiation treatmen t to a depth of 3-5 mm with a 6-MeV electron beam was produced by a linear accelerator to a total dose of 24-30 Gy in 8-15 fractions, 3-4 times a week , In cases of thick plaques or tumors that were beyond the scope of low ene rgy electron beams of for treating nodal areas (especially in the head and neck area or axilla involvement), regional irradiation (RRT) with Co-60 pho ton beams was followed by whole-skin electron beam irradiation (15 patients ). In cases of diffuse erythrodermia, Sezary syndrome, nodal or visceral in volvement, total body irradiation was delivered with a 25-MV photon beam us ing a split-course regimen to prevent hematological toxicity (22 patients). The first course consisted of 1.25 Gy delivered in ten fractions and 10 da ys. Subsequently, patients received TSEB, Four to 6 weeks after TSEB, they received a second course of 1.25 Gy. The cumulative TBI dose ranged from 2. 5 to 3 Gy in about 3 months. Hemi-body irradiation (HB) with Co-60 (and a b olus) was given in cases of multiple regional tumors with large and thick i nfiltration of the skin to a dose of 9-12 Gy (using fractions of 1-1.5 Gy/d ay) which, once flattened, were boosted with whole-skin electron beam thera py (8 patients). Results: At 3 months, the overall response rate was 75% with 23/45 (51%) pa tients in complete response and 24% in partial response; one patient had st able lesions and 1 patient presented progressive disease, The overall respo nse rate was 81% for T3 patients, 61% for T4, 79% for N1 and 70% for N3. Th e complete response rate was 67% for T3 and 28% for T4. Sixty-four percent of N1 patients and 41% of N3 had a complete response. The 5-year actuarial overall survival was 37% for T3 and 44% for T4 (P = 0.84). Patients with cl inically abnormal lymph nodes that were pathologically negative (N1) presen ted a 5-year survival of 63%. Patients with pathologically positive lymph n odes (N3) experienced a 5-year survival rate of 32% (P = 0.040). Conclusions: TSEB provides an excellent quality of life by reducing itching and discharge from the skin. Patients with more advanced disease may be tr eated and cured by the addition of photon beams in combination with TSEB. A selection of patients with advanced skin disease and regional extension ma y be cured by a combination of TSEB and photon beam irradiation. The region al treatment allows the use of electrons after the reduction of the plaques or thick tumors and a prophylactic irradiation of the adjacent nodal area. (C) 2000 Elsevier Science Ireland Ltd. All rights reserved.