A systematic review (meta-analysis) of open uncontrolled and mostly retrospective studies of TSEB as monotherapy for 952 patients with all stages of CTCL has established that the rate of CR is dependent on stage of disease, skin surface dose and energy, with CR rates of 96% in stage IA/IB/IIA disease, 36% in stage IIB disease and 60% in stage III disease.71 Greater skin surface dose (32-36 Gy) and higher energy (4-6 MeV electrons) were significantly associated with a higher rate of CR; 5-year relapse-free survivals of 10-23% were noted.71
An RCT has compared TSEB with topical mechlorethamine in 42 patients, with similar rates of CR and duration of response in both groups in early stages of disease but better ORs in later stages of disease with TSEB.72
A retrospective study of TSEB (median dose 32 Gy; median treatment time 21 days) as monotherapy for 45 patients with erythrodermic CTCL (28 stage III, 13 stage IVA, 4 stage IVB) showed a 60% CR rate, with 26% disease free at 5 years.73 Overall median survival was 3-4 years, which was associated significantly with an absence of peripheral blood involvement (stage III disease). Higher rates of CR (74%) and disease-free progression (36%) were noted in those patients receiving a more intense regimen (32-40 Gy and 4-6 MeV).
A retrospective study of 66 CTCL patients (1978-96) treated with 30 Gy in far fewer fractions (12 fractions over 40 days) showed a CR rate of 65% with progression-free survival of 30% at 5 years and 18% at 10 years.74 Responses and specifically 5-year OS were highest in those with early-stage disease (79-93% for IA/IB/III compared with 44% for IIB/IVA/B).
Although it has been recommended that TSEB can only be given once in a lifetime, several reports have described multiple courses in CTCL.75,76 A retrospective analysis of 15 patients (1968-90) with mycosis fungoides who received two courses of TSEB reported a mean dose of 32-6 Gy for the first course and 23-4 Gy for the second, with a mean interval of 41-3 months. No additional toxicities were noted but the CR rate for the second course was lower (40% compared with 73%).75 A further retrospective study of 14 patients with CTCL revealed a mean dose of 36 Gy for the first (93% CR) and 18 Gy for the second course (86% CR).76 In this series five patients received a third course (total dose 12-30 Gy). The median duration of response was 20 months for the first and 11-5 months for the second course. No additional toxicities were reported. In both of these studies the fractionation regimens employed may have been critical for tolerability (1 Gy per day at 6 MeV over 9-12 weeks).
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