Research ArticleClinical Studies
Open Access

Tailoring Radiation Therapy for Patients With Limited Cutaneous T Cell Lymphoma: Preliminary Clinical Experience With Subtotal Skin Electron Therapy

BRADY S. LAUGHLIN, ISABELLA ZANILETTI, MADELINE G. FOSTER, JOHN LUCIDO, AARON R. MANGOLD, ALLISON C. ROSENTHAL, CHARLES VAN DER WALT, WILLIAM BREEN, SCOTT LESTER, BRADFORD HOPPE, JENNIFER PETERSEN, MICHAEL D. ARMSTRONG, AARON BOGAN and WILLIAM G. RULE
Anticancer Research April 2024, 44 (4) 1491-1497; DOI: https://doi.org/10.21873/anticanres.16945

Abstract

Background/Aim: Total skin electron beam therapy (TSEBT) is an effective treatment for managing cutaneous T-cell lymphoma (CTCL), but may result in unnecessary toxicity. With the production of a custom rolling shield holding a configurable stack of plastic slats to block uninvolved skin, we implemented a program for subtotal skin electron beam therapy (STSEBT). We report our preliminary experience with STSEBT vs. TSEBT to manage CTCL. Patients and Methods: A retrospective review of 32 CTCL patients who were treated at a single institution between February 28th, 2017, and May 25th, 2022, was completed. Of these cases, seven patients received STSEBT and 25 received TSEBT. Results: Thirty-two patients underwent a course of STSEBT or TSEBT. The median follow-up was 465 days and the median age at diagnosis was 70.8 years. Stage distribution was as follows: one (3%) IA, 16 (50%) IB, 6 (19%) IIB, two (6%) IIIA, five (16%) IVA, and two (6%) IVB. The overall response rate was 96%. For patients receiving TSEBT (n=25), three (12%), 10 (40%), and 11 (44%) had a CR, NCR, and PR, respectively. For the patients receiving STSEBT, four (57.1%), three (42.9%), and zero (0%) had a CR, NCR, and PR, respectively. There was one patient (4%) with no response. Cumulative incidence of progressive skin disease requiring additional electron therapy at three months was 21.1% [IQR=8.6, 51.5%], 36.8% [IQR=20, 68%] at six months, and 57.9% [IQR=38.5, 87.1%] at one year. Low rates of toxicities were recorded. Conclusion: This analysis demonstrated that treatment of CTCL patients with low disease burden with STSEBT results in similar overall response and time to progression compared to treatment with TSEBT.

Key Words:

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma (CTCL) (1). Although MF is typically indolent with intermittent, stable, or slow progression of lesions, it can be associated with burdensome skin-related symptoms. Additionally, other types of cutaneous T cell lymphomas, especially aggressive types, can greatly impact patients’ quality of life. When other skin-directed therapies have failed to provide adequate relief and disease control, radiation therapy (RT) may be considered. While focal RT may treat areas of limited disease, total skin electron beam therapy (TSEBT) allows for treatment of the entire skin surface. With TSEBT, low-energy electrons deliver radiotherapeutic dose to the entire skin surface with very shallow depths of penetration, sparing deeper internal organs and tissues. However, given the fact that TSEBT is technically challenging to deliver (with requirements for specialized equipment/infrastructure and personnel), it may not be a routine clinical practice at certain radiation oncology centers (2).

When CTCL is limited to certain regions of the body but is still too extensive to treat with focal RT only, TSEBT is sometimes used, but may treat a large section of clinically uninvolved skin. This may introduce unnecessary toxicity and treatment exposure for the patient. Therefore, it may be ideal to treat with large field electrons as in standard TSEBT, while still shielding the regions of uninvolved skin. This form of electron beam therapy has been described as hemi-body electron irradiation (HBIe) or subtotal skin electron beam therapy (STSEBT) (Figure 1) (3, 4). While studies have evaluated TSEBT, there is little clinical data regarding STSEBT. At our institution, a custom rolling shield was designed to implement STSEBT (Figure 1).

Figure 1.
Figure 1.

A patient with cutaneous T cell lymphoma involving the thorax who received subtotal skin electron beam therapy (STSEBT).

The primary objective of this study was to examine our institutional experience to assess the effectiveness and toxicity of STSEBT compared to TSEBT. Following TSEBT, it is typical for patients to have progressive disease at 6-12 months. We hypothesized that patients undergoing STSEBT would have a similar time to disease progression and duration of clinical benefit.

Patients and Methods

This retrospective study was approved by the Institutional Review Board (#22-004274) and conducted per the Declaration of Helsinki of 1975 (as revised in 1985). Because of the retrospective nature of the study, the requirement for informed consent was waived. However, informed consent for patient images was obtained. A retrospective chart review was conducted of 32 patients with CTCL, treated between February 28th, 2017 and May 25th, 2022, at a single center. Of these cases, seven patients received STSEBT, and 25 received TSEBT.

Implementation of STSEBT stand. The limitations in shielding techniques prompted us to design and build a customizable STSEBT shielding system that is professional in appearance, allows for adjustable treatment window dimensions, is non-toxic, transparent, portable, and easy to disinfect in a hospital environment. Such a design was not available commercially (5). In collaboration with Radiation Products Design, we designed and built a universal STSEBT shielding stand. It consists of a mobile frame that can accommodate a tall stack of acrylic shielding slats. The stacked slat technique serves multiple functions: each 10 cm-tall piece is relatively lightweight, and it allows for flexibility in treatment window design (5). The tops and bottoms of the slats are ship-lapped, such that they interlock with the slats above and below them, promoting a tight and overlapping fit, minimizing leakage dose from between adjacent slats (5). The frame allows for mounting of slats in a variety of vertical positions, with the ability to hold a tall stack of slats up from the bottom for a lower extremity treatment. The dimensions are appropriate to provide stability for a fully loaded frame (5).

Radiation treatment planning and delivery. For TSEBT or STSEBT, electrons were delivered from an extended source to surface distance to produce a large field size at the skin surface. TSEBT was administered using the Stanford technique, which requires a patient to stand in 6 different positions, rotating in 60-degree increments, to adequately treat most of the skin surface. For STSEBT, the shielding stand described above was used, with shielding adapted to ensure shielding of uninvolved regions of the skin (Figure 1). Figure 1 highlights an example of a patient receiving STSEBT for their cutaneous T cell lymphoma involving the thorax.

All 12 Stanford fields (6 dual fields) were treated per treatment session. Separate electron fields were delivered en face for areas requiring a boost, which, depending on the patient and clinical needs, included the scalp, perineum, pannus, inframammary folds, and axillas.

Endpoints. Time to failure endpoints was calculated from the last day of TSEBT or STSEBT. The primary endpoint was the clinical response rate. Response was determined by percent clearance of skin lesions following electron therapy. Clearance of the entire skin surface (100%) constituted a complete response (CR) (6). Near complete response was defined as >95-99% clearance of skin lesions (6). Subtotal response was the clearance of ≥50% to 95% of skin lesions (6). Secondary endpoints included toxicity and time to progression. Time to skin progression was defined as ≥25% increase in skin disease from baseline following response seen at time of assessment. Toxicity following treatments was defined per Common Terminology Criteria for Adverse Events version 5.0 (CTCAE).

Follow-up. In follow-up, patients were evaluated by their dermatologist and radiation oncologist. Additional radiation treatment data were collected, and treatment courses defined as total skin, subtotal skin, or focal treatment. The time to subsequent treatment was defined as the end of STSEBT or TSEBT to the start of additional radiation treatment.

Statistical analysis. Categorical variables were summarized as count and percentages, while continuous variables were summarized as median and interquartile ranges (IQR). Baseline group characteristics were compared using Chi-square or Fisher’s exact if categorical, as appropriate, and Wilcoxon Rank Sum Tests if continuous. The cumulative incidence function (CIF) was used to determine the risk of progression as a function, accounting for the competing risk of mortality. Analyses were performed using R version 4.0.3 (R Foundation for Statistical Computing) and SAS version 9.3 (SAS Institute Inc., Cary, NC, USA) (7, 8). p-Values were derived from two-tailed tests. p-Values less than 0.05 were considered statistically significant.

Results

Thirty-two patients underwent TSEBT (n=25) or STSEBT (n=7). Table I lists the patient and treatment characteristics. The average age at diagnosis was 77.7 [IQR=71, 86.3] in the STSEBT group and 68.3 [IQR=64.5, 77.4] in the TSEBT group (p=0.072). The average age at first treatment was 83.3 [IQR=84.9, 86.9] in the STSEBT group and 71.7 [IQR=68, 79.7] in the TSEBT group (p=0.006). Twenty-one (65.6%) patients were male, and 11 (34.4%) were female. Most patients had an ECOG performance status of 0-1 (94%). Tumor stage distribution was as follows: one (3%) T1, 21 (66%) T2, six (19%) T3, and four (13%) T4. AJCC 8th edition Stage distribution was as follows: one (3%) IA, 16 (50%) IB, six (19%) IIB, two (6%) IIIA, five (16%) IVA, two (6%) IVB.

View this table:
Table I.

Patient and treatment characteristics undergoing total skin electron beam therapy (TSEBT).

Before receiving TSEBT, three (12%) patients received focal radiation. There were zero patients who received focal radiation prior to STSEBT. Table II highlights the different dose-fractionation schemes for patients receiving STSEBT and TSEBT. The most common TSEBT regimen was 14 Gy in 14 fractions (6/25, 24%). The most common STSEBT regimens were 12 Gy in three fractions and 12 Gy in eight fractions (3 courses of treatment each). Table III highlights the sites treated in patients receiving STSEBT.

View this table:
Table II.

Dose and fractionation regimens for total skin electron beam therapy and subtotal skin electron beam therapy patients.

View this table:
Table III.

Sites treated (marked with an x) and spared (blank) in subtotal subtotal skin electron beam therapy (STSEBT).

The median follow-up was 262 days [IQR=171.5, 387.5] for the STSEBT group and 492 days [IQR=220, 1232] for the TSEBT group (p=0.209). Ninety-seven percent of patients experienced a response (97%). Seven courses (22%) resulted in a complete response, 13 resulted in a near complete response (41%), and 11 (34%) resulted in a partial response. For patients receiving TSEBT (n=25), three (12%), 10 (40%), and 11 (44%) had a CR, NCR, and PR, respectively. For the patients receiving STSEBT, four (57%), three (43%), and zero (0%) had a CR, NCR, and PR, respectively. There was one STSEBT patient with no response. The cumulative incidence of progression is highlighted in Figure 2. The median time to skin progression was 179.5 days for STSEBT and 142 days for TSEBT (p=0.844) (Figure 2). Two (25%) patients who underwent STSEBT failed: one patient failed in-field and the other failed in-field and out of field.

Figure 2.
Figure 2.

Cumulative incidence of progression of all patients receiving and total skin electron beam therapy (TSEBT) and subtotal skin electron beam therapy (STSEBT) for cutaneous T cell lymphoma.

Subsequent radiation therapy was delivered in one patient who underwent STSEBT and seven patients who underwent TSEBT. The cumulative incidence of skin progression requiring additional radiation treatment (TSEBT, STSEBT, or focal treatment) was 21.1% at three months, 36.8% at six months, 57.9% at one year. By the end of the follow-up period, eight (25%) patients had died (1 STSEBT and 7 TSEBT). Results from the univariate analysis did not show significant association between type of therapy, and other baseline characteristics, with progression.

All patients receiving TSEBT or STSEBT had low rates of physician-reported toxicities. Electron treatment was well tolerated. Most patients had grade 0-1 toxicity (84.3%). Five patients (all TSEBT) were reported to have grade 2 toxicity. Rates of grade 2 toxicity were one (3.1%) erythema, one (3.1%) pruritus, two (6.3%) lower extremity swelling, two (6.3%) alopecia, two (6.3%) six (6.3%) nail ridging, and one (3.1%) fatigue. There were no high-grade toxicities.

Discussion

To our knowledge, this preliminary experience adds to the literature by demonstrating a similar duration of clinical benefit of STSEBT with TSEBT as treatment for CTCL. In this limited data set, we demonstrated equivalence of response rates, time to progression, as well as duration of clinical benefit for patients with CTCL receiving STSEBT or TSEBT. STSEBT has several promising theoretical advantages in reducing toxicity: With TSEBT, patients may develop alopecia even if they do not have disease on their face. Patients may also develop lower extremity swelling. The use of STSEBT theoretically allows the reduction of these potential risks. Herein, we report the successful deployment of STSEBT and its comparison with a contemporary TSEBT cohort.

Clinical treatment of CTCL. Prior studies have demonstrated that standard doses of 30-36 Gy TSEBT are highly effective in the treatment of CTCL (9-11). Morris et al. reported an overall response rate of 95% with modern TSEBT delivering 30 Gy in 20 fractions over five weeks to the entire skin surface (9). In a retrospective analysis, Stanford University reported a 100% response rate (60% complete response) in 180 patients with MF. Although overall response rates are high, these treatments are extremely time-intensive and can occur over 5-10 weeks (9, 10). Additionally, the time until disease progression varied between 6-12 months (9, 10).

Low dose TSEBT has been demonstrated in multiple studies to provide high overall response rates, a mild side effect profile, but variable times to progression or duration of clinical benefit. In a pooled analysis of three separate trials, Hoppe et al. demonstrated that low dose (12 Gy) TSEBT provided a rapid reduction of disease with an overall response rate of 88% and median duration of clinical benefit of 70.7 weeks (6). Similarly, Morris et al. reported that 12 Gy in eight fractions of TSEBT in 113 patients in the UK Cutaneous Lymphoma Group study was effective for patients with MF (12). In comparison to other skin-directed therapies as recommended by the National Comprehensive Cancer Network, low-dose TSEBT therapy provides durable response rates (13). In a single institution retrospective series, Jeans et al. evaluated low dose hypofractionated total skin electron beam therapy (H-TSEBT) for CTCL. With a total of 40 patients receiving 57 courses of H-TSEBT, the overall response rate was 100%, with 31 (57.4%) courses resulting in a complete response and 23 (42.6%) courses resulting in a subtotal response (14). Jeans and colleagues reported a median time to skin progression of 89 days (14). A prospective study by Rolf et al. demonstrated that low dose TSEBT of 8 Gy in two fractions in six patients was safe, with low toxicity rates and improvement in health-related quality of life and tumor burden (15, 16). Here, we report a 100% response rate with median time of progression of 142-180 days and duration of clinical benefit of 142-189 days. Although we report a median time of progression higher than that reported by Jeans et al., this is much lower than that reported by Hoppe et al. (6, 14). The variation in times to progression or duration of clinical benefit may be attributable to several factors, including heterogeneity in clinical practice in defining or recognizing progression or clinical benefit and the unique biology underlying a patient’s specific CTCL.

Application of STSEBT. Our STSEBT stand provides a nuanced approach to treat CTCL. The stand, which is rolled into place in front of our standard TSEBT cage, utilizes an interlocking vertically stacked slat technique that provides flexibility in treatment window design. Because of this, specific regions of skin may be blocked, depending on patient-specific distributions of disease. This allows for a high degree of customization/personalization in treatment, with uninvolved regions of skin protected from unnecessary radiotherapeutic exposure. For example, the skin of the thorax may be exposed while the skin of the head/neck and legs is blocked, or the head and neck exposed while blocking the rest of the skin surface. In addition, the STSEBT paradigm may allow for nuanced approaches to reirradiation in patients who have previously received TSEBT. Our study demonstrated that in select patients with CTCL, STSEBT may be a viable option. We demonstrated that STSEBT leads to favorable outcomes similar to TSEBT: 50% vs. 12.5% CR, 37.5% vs. 41.7% NCR, and 12.5% vs. 45.8% PR.

This retrospective study is limited by several weaknesses. Given that CTCL is heterogeneous, there was large variability in the disease presentation for our patient population. Additionally, STSEBT was applied particularly for patients with limited disease, and those patients required different blocking. Therefore, patients receiving STSEBT did not necessarily receive the “same” treatment. Deciding which regions of skin to treat and which regions of skin to shield is a clinical decision that is left to the discretion of the treating physician. This is a process that inherently depends on the clinical experience as well as bias of the treating physician. Additionally, treating only the lower extremities is obviously quite different than shielding the lower extremities and treating the rest of the skin surface. There will be different expectations for risk/benefit, toxicities, and there may indeed be inherent differences in the disease biology between one presentation and the other. One of the main concerns with delivering STSEBT is that regions of skin with potential subclinical involvement do not receive treatment, and therefore, at least in theory, may be at a higher risk of relapsing. Our clinical observation was that there was similarity in response rates or time to progression with STSEBT vs. the TSEBT cohort. Comparison of studies of CTCL may be challenging because the same rigor cannot be applied to assessing clinical response, time to progression, or duration of clinical benefit. Another limitation of the study is variability of assessments following electron radiation for CTCL. As there is individual variability in the timing of the assessment of each patient, there can be large variability in the time to skin progression for patients in both cohorts. Therefore, time to next radiation treatment may be a more reliable indicator of durability of treatment. Additionally, systemic therapies and topical agents may have an impact on response and durability of response. However, it is quite challenging to track timing of systemic therapies and topical agents and their relationship with radiation therapy and their potential impact on response in a retrospective study.

To assess response, the mSWAT tool was intended to be employed in patients to serve as a marker for disease severity. However, it was not employed routinely in our patient cohorts given variable reporting by the dermatologist and radiation oncologist evaluating treatment response in our patients.

Regarding toxicity, our preliminary experience demonstrates that STSEBT is associated with low rates of toxicity. We anticipated that STSEBT might have lower rates of toxicity given the smaller region of skin surface exposure, but it is certainly possible that global underreporting of toxicities was present for TSEBT and STSEBT cohorts, making conclusions regarding differences in toxicity between the two treatments quite difficult.

Conclusion

In CTCL patients with limited areas of disease, STSEBT is a valuable option to provide clinical response and avoid uninvolved skin. As CTCL is a very heterogeneous disease, a larger cohort must be evaluated to determine better selection of patients for STSEBT. Additionally, further work must explore the impact of systemic and topical therapies on durability of response in patients receiving STSEBT or TSEBT.

Footnotes

  • Authors’ Contributions

    BSL and WGR performed and provided the conceptualization, data curation, formal analysis, investigation, methodology, validation, visualization, and the writing of the original draft of this study. IZ and CVDW performed the formal analysis of this study. IZ performed the statistical analysis. All Authors read and approved the final manuscript.

  • Conflicts of Interest

    All Authors have no relevant conflicts of interest to disclose in relation to this study.

  • Received December 27, 2023.
  • Revision received January 12, 2024.
  • Accepted January 22, 2024.

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).

References

  1. ↵
    1. Swerdlow SH,
    2. Campo E,
    3. Pileri SA,
    4. Harris NL,
    5. Stein H,
    6. Siebert R,
    7. Advani R,
    8. Ghielmini M,
    9. Salles GA,
    10. Zelenetz AD,
    11. Jaffe ES
    : The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood 127(20): 2375-2390, 2016. DOI: 10.1182/blood-2016-01-643569
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Piotrowski T,
    2. Milecki P,
    3. Skórska M,
    4. Fundowicz D
    : Total skin electron irradiation techniques: a review. Postepy Dermatol Alergol 30(1): 50-55, 2013. DOI: 10.5114/pdia.2013.33379
    OpenUrlCrossRefPubMed
  3. ↵
    1. Müller-Sievers K,
    2. Ertan E,
    3. Kober B
    : Dosimetry of rotational partial-skin electron irradiation. Radiother Oncol 58(2): 187-192, 2001. DOI: 10.1016/s0167-8140(00)00329-7
    OpenUrlCrossRefPubMed
  4. ↵
    1. Delinikolas P,
    2. Patatoukas G,
    3. Kouloulias V,
    4. Dilvoi M,
    5. Plousi A,
    6. Efstathopoulos E,
    7. Platoni K
    : A novel Hemi-Body Irradiation technique using electron beams (HBIe−). Phys Med 46: 16-24, 2018. DOI: 10.1016/j.ejmp.2017.12.022
    OpenUrlCrossRefPubMed
  5. ↵
    1. Lucido JJ,
    2. Penoncello GP,
    3. Laughlin BS,
    4. Armstrong MD,
    5. Lo SG,
    6. Rivera JN,
    7. Tang X,
    8. Chungbin SJ,
    9. Breen WG,
    10. Mangold AR,
    11. Comfere NI,
    12. Lester SC,
    13. Rule WG,
    14. Deufel CL,
    15. Foster MG
    : Development and dosimetric characterization of a customizable shield for subtotal skin electron beam therapy. Adv Radiat Oncol 8(6): 101289, 2023. DOI: 10.1016/j.adro.2023.101289
    OpenUrlCrossRefPubMed
  6. ↵
    1. Hoppe RT,
    2. Harrison C,
    3. Tavallaee M,
    4. Bashey S,
    5. Sundram U,
    6. Li S,
    7. Million L,
    8. Dabaja B,
    9. Gangar P,
    10. Duvic M,
    11. Kim YH
    : Low-dose total skin electron beam therapy as an effective modality to reduce disease burden in patients with mycosis fungoides: Results of a pooled analysis from 3 phase-II clinical trials. J Am Acad Dermatol 72(2): 286-292, 2015. DOI: 10.1016/j.jaad.2014.10.014
    OpenUrlCrossRefPubMed
  7. ↵
    1. Team RDC
    : R: A language and environment for statistical computing. 4.0.3 ed. Vienna, Austria: R Foundation for Statistical Programming, 2010.
  8. ↵
    1. SAS Institute Inc.
    SAS®9.4. Cary, NC, USA. SAS Institute Inc., 2013.
  9. ↵
    1. Morris SL,
    2. McGovern M,
    3. Bayne S,
    4. Wain M,
    5. Child F,
    6. Whittaker S
    : Results of a 5-week schedule of modern total skin electron beam radiation therapy. Int J Radiat Oncol Biol Phys 86(5): 936-941, 2013. DOI: 10.1016/j.ijrobp.2013.04.042
    OpenUrlCrossRefPubMed
  10. ↵
    1. Navi D,
    2. Riaz N,
    3. Levin YS,
    4. Sullivan NC,
    5. Kim YH,
    6. Hoppe RT
    : 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. Arch Dermatol 147(5): 561, 2011. DOI: 10.1001/archdermatol.2011.98
    OpenUrlCrossRefPubMed
  11. ↵
    1. Piotrowski T,
    2. Fundowicz M,
    3. Pawlaczyk M
    : Total skin electron beam therapy with rotary dual technique as palliative treatment for mycosis fungoides. In Vivo 32(3): 517-522, 2018. DOI: 10.21873/invivo.11269
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Morris S,
    2. Scarisbrick J,
    3. Frew J,
    4. Irwin C,
    5. Grieve R,
    6. Humber C,
    7. Kuciejewska A,
    8. Bayne S,
    9. Weatherhead S,
    10. Child F,
    11. Wain M,
    12. Whittaker S
    : The results of low-dose total skin electron beam radiation therapy (TSEB) in patients with mycosis fungoides from the UK Cutaneous Lymphoma Group. Int J Radiat Oncol Biol Phys 99(3): 627-633, 2017. DOI: 10.1016/j.ijrobp.2017.05.052
    OpenUrlCrossRefPubMed
  13. ↵
    1. National Comprehensive Cancer Network
    . Mycosis Fungoides/Sezary Syndrome (Version 2.2022). Available at: https://www.nccn.org/professionals/physician_gls/pdf/primary_cutaneous.pdf [Last accessed on December 22, 2022]
  14. ↵
    1. Jeans EB,
    2. Hu YH,
    3. Stish BJ,
    4. King B,
    5. Davis M,
    6. Harmsen WS,
    7. Fruth KM,
    8. Locher SE,
    9. Deufel CL,
    10. Evans JD,
    11. Martenson JA,
    12. Lester SC
    : Low-dose hypofractionated total skin electron beam therapy for adult cutaneous T-cell lymphoma. Pract Radiat Oncol 10(6): e529-e537, 2020. DOI: 10.1016/j.prro.2020.08.001
    OpenUrlCrossRefPubMed
  15. ↵
    1. Rolf D,
    2. Elsayad K,
    3. Eich HT
    : Ultra-hypofractionated low-dose total skin electron beam followed by maintenance therapy: Preliminary findings from a prospective open-label study. J Am Acad Dermatol 85(6): 1601-1603, 2021. DOI: 10.1016/j.jaad.2020.11.058
    OpenUrlCrossRefPubMed
  16. ↵
    1. Rolf D,
    2. Elsayad K,
    3. Eich HT
    : Acute and sub-acute toxicity profile of ultra-hypofractionated low-dose total skin electron beam with two 4 Gy fractions for cutaneous T cell lymphoma. J Cancer Res Clin Oncol 147(6): 1757-1761, 2021. DOI: 10.1007/s00432-020-03449-7
    OpenUrlCrossRefPubMed
Back to top

In this issue

Print
Download PDF
Article Alerts
Email Article
Citation Tools
Reprints and Permissions
Tailoring Radiation Therapy for Patients With Limited Cutaneous T Cell Lymphoma: Preliminary Clinical Experience With Subtotal Skin Electron Therapy
BRADY S. LAUGHLIN, ISABELLA ZANILETTI, MADELINE G. FOSTER, JOHN LUCIDO, AARON R. MANGOLD, ALLISON C. ROSENTHAL, CHARLES VAN DER WALT, WILLIAM BREEN, SCOTT LESTER, BRADFORD HOPPE, JENNIFER PETERSEN, MICHAEL D. ARMSTRONG, AARON BOGAN, WILLIAM G. RULE
Anticancer Research Apr 2024, 44 (4) 1491-1497; DOI: 10.21873/anticanres.16945
Twitter logo Facebook logo Mendeley logo

Jump to section

Keywords