Dose
Considerations
in Total Mycosis
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THEODORE
C.
M.
LO,’
Skin Electron
skin
most
effective
electron
irradiation
modes
of
(TSEI)
FERDINAND
remains
treatment
for
A.
one
SALZMAN,’
AND
KENNETH
A.
WRIGHT2
energies up to 3.5 MeV. We believe this energy is adequate for lesions not more than 1 cm thick. Both the physical aspects and the dosimetry of the apparatus have been described in detail [7].
The total the specified
treatment maximum
dose reported throughout this paper is entry dose computed with the formula SMD=(dfi’)
where
SMD
number
is the total
of cycles
per
per field,
f is the
designates
the
specified
maximum entry dose, c is the d is the daily entry dose of fields per cycle, and the subscript
treatment
number
technique
course,
used.
The
advantages
of
the
use
of
the SMD concept have been discussed [5]. It standardizes the method of reporting doses among various institutions when different techniques are employed, and it guides the therapist to limit total dose within acute and chronic normal tissue tolerance. Obviously, during each treatment session all fields used must be complementary to one another. All 200 patients presented with generalized multiple or confluent skin lesions covering at least 50% of the total skin area, and none had clinical evidence of nodal or systemic disease on the first day of TSEI. Pathology was reviewed and confirmed by our pathologists. Before January 1972, the six-field cycle technique was used, and since then, an eight-field cycle technique has been used. The details of these techniques have been discussed [5]. All patients were treated on a 5 day per week basis.
of the
generalized
for
Fungoides
Two hundred patients with generalized cutaneous mycosis fungoides were treated with total skin electron Irradiation (TSEI) in the Lahey Clinic Radiotherapy Department-MIT High Voltage Research Laboratory between 1964 and 1973. None of the patients had any clinical evidence of extracutaneous disease at presentation. The 3-year absolute survival rate was 54% (107 patients). Analysis of these 107 long-term survivors evaluated the relation between incidence of generalized cutaneous recurrence and total treatment dose given during the initial course of TSEI. Results indicated that in patients with erythroderma , the need for a second course of TSEI was inversely related to the total dose given during the first course. However, the curve seemed to flatten at about 1 ,500 cGy (rad). In plaque disease, the percentage of patients who received repeated courses of TSEI seemed to be relatively constant independent of total dose given during the initial course (65%-80%). In patients with tumor lesions, the incidence of generalized cutaneous recurrence was directly proportional to total dose. The optimal dose of TSEI for patients with mycosis fungoides may vary depending on types of skin lesions. Total dose during the initial course of TSEI should be kept relatively conservative, particularly in patients with generalized plaques where relapse rate is high allowing reserve of normal tissue tolerance for further TSEI when indicated.
Total
Irradiation
my-
cosis fungoides confined to the skin today [1-6]. Although cure rates are still low, its palliative value is definitely irrefutable [1 2, 5, 6]. However, once disease has progressed beyond the cutaneoussystem, prognosis becomes ominous, and survival is measured in terms of months [4] Unfortunately systemic chemotherapy, either single agent or combination drugs, has not been
Results
,
.
found
[4].
total
skin
effective
Thus,
in control
meaningful
electron
with for
was carried with respect
of the
assessment
irradiation
group of patients skin who survived study patients
after
would
disease
of the pertain
value
only
107
to
evaluate control
such a with TSEI.
Two
hundred
new patients
and
with
of
cosis fungoides were treated with total (TSEI) in the Lahey Clinic Radiotherapy
Voltage
Research
constant
potential
de Graaff Received
type with July
Laboratory
are
Methods
generalized
accepted
between
after
my-
1964
revision
and
1973.
overall
all 200
survival
patients.
56
for
3 years
patients
had tumors. was commonly
or longer;
had
The
survived
for
at 3 years Patients
into three subgroups by primary on the first day of TSEI. Of the
were
lesion type 200 patients,
32 patients
plaque
lesions,
had and
Fourteen
19
poor prognosis of patients with due to rapid onset of metastatic
3 years
only a irradiation,
or longer.
These
single and
patients
listed by primary lesion type shown in table 1. Table 2 shows the current status of this group patients
were
considered studied needed
ment since the initial course of TSEI. highest cure rate was demonstrated
of
“cured.” for at further
35 All
least 5 treat-
As expected, in the group
the of
30, 1978.
Presented at the annual meetina of the American Radium Society, New Orleans, April 1978. 1 Department of Radiotherapy, Lahey Clinic Foundation, Boston, Massachusetts 02215. Address reprint 2 High Voltage Research Laboratory, Massachusetts Institute of Technology, Cambridge, Massachusetts AJR 132:261-263, February 1979 © l979American Roentgen Ray Society
for
of these patients have now been years (table 3) and none of them
The
was of the Van electrons with
October
of TSEI
survived
of them
patients.
skin electron irradiation Department-MIT High
electrostatic generator used the capacity of producing
17, 1978;
cutaneous
absolute
visceral disease [5]. Among all 200 patients, 81 received course of TSEI without further electron 35
Subjects
(54%)
patients tumors
to the
group
initiation
the
erythroderma,
of
clinical disease confined to the a substantial length of time. A
out to to local
1 shows
categorized as presented
,
significantly
date
Table
261
requests 02139.
to T. C. M. Lo.
0361
-803X/79/1322-0261
$0.00
LO
262
MR:132,
ET AL.
TABLE
February
1979
1
Survival Plaque
Tumor
Total
57 32 (56)
89 56 (63)
54 19 (35)
200 107 (54)
36 (63)
25 (28)
20 (37)
81 (41)
19 (53)
13 (52)
3 (15)
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Erythroderma
Total patients Overall 3-year survival One course of TSEI: Patients studied Survived
3 years
Note-Numbers
in parentheses
TABLE Status
of 3-Year
Survivors
TABLE
2
Who Had Only One Course Erythro-
Plaque
derma
disease
6t
9
2
Died from disease
2
2
0
19
Total .
One patient died of intercurrent
disease
at 5 years
13
were
interested
long-term
survivors.
relation
between
the
with
erythroderma,
the
need for a second course of TSEI was inversely proportional to the total dose given during the initial course (table 5). Clinically this implies that for this type of lesion, high-dose irradiation would perhaps be indicated if tolerance
allowed.
However, tients
plaque
received
disease,
repeated
the
courses
percentage of TSE1
particular
to
type
of
lesion
even
with
an
with than
years
for
tumor 1,500
this
1,300
6
7
5 6 7 8 9 10
1,125 1,125 3,000 1,800 1,800 900 1,200
6 6 6 8 8 8 8
5 5 6 5 5 5 5
900 1,000
6 6
11 5
1,200
6
12
11
Plaque: 12 13
Tumor: 14 .
who rad),
analysis.
received only one
This
high-dose survived
patient
irradiation longer than
received
Specified
maximum
entry
dose.
TABLE All 3-Year Survivors
4
Who Had More Electron Course
Therapy
Than One
of TSEI Erythro-
Plaque
Tumor
43 78 5 15 28
16 84 4 6* lOt
derma
No % Spotsonly Dead Living with .
13 41 1 6 7
disease
One patient died of intercurrent
disease
(had two TSEI and one spot treatment). t One patient is NED 5 years after
(NED) 8 years after last spot irradiation
last spot
irradiation
(had
one
TSEI and
seven
treatments).
course
of TSEI
at 3 years
a second
and
is now
living
with
disease
at 5 years. Discussion
aggressive
initial approach. in patients with tumors the incidence of generalized cutaneous recurrence was directly related to total dose (table 5). Unfortunately, among the six patients (more
4
of paseemed
be relatively constant, ranging from 65% to 80% regardless of total dose given during the first course of TSE1 (table 5), suggesting a universally high relapse rate for this
12 6 5
spot
for
who
6 6 6
treat-
course of TSE1 and subserecurrence when a second among this group of 107
In patients
900 1,200 1,050
3
‘
in the
Survival (years)
2 3
1
patients with erythroderma. Of these 14 patients, 13 received a total dose of less than 2,000 rad. Unfortunately, once cutaneous disease recurred after the initial course of TSEI the chance of ‘cure” appeared to be extremely remote. Table 4 shows the outcome of the 72 3-year survivors who required further electron irradiation, either local spot treatment or TSEI or both, after the initial course of TSEI; only two patients could be considered “cured.” One patient with tumor died from an automobile accident 8 years after two courses of TSEI and one course of local “spot” irradiation, and another patient with tumor survived 5 years free of disease after one course of TSEI and seven courses of local spot treatments. We
nique (no. fields)
Erythroderma:
t One patient is now NED after a course of chlorambucil.
mont dose during the first quent generalized cutaneous course of TSEI was required
of TSEI Tech-
(NED).
,
3
DoseS (rad)
c ass
1
with
(43)
after One Course
Tumor
2
Living
“Cure”
of TSEI
11
Cured
35
are percentages.
3
Mycosis
fungoides
lymphomatous system. The undetermined skin
means
electron
for
is
a
rare
and
chronic
form
of
malignancy arising from the cutaneous optimal treatment for this disease remains today. However, the distinct value of total irradiation,
local
control
as one
of this
of the
disease,
most
successful
is well
known.
AJR:132,
February
ELECTRON
1979
TABLE incidence
of Generalized
5
Downloaded from www.ajronline.org by 170.164.50.90 on 11/04/15 from IP address 170.164.50.90. Copyright ARRS. For personal use only; all rights reserved
(N
=
All 3-Year No. Patients
Recurrence Rate (%)
17 9 3 3
9(53) 2 (22) 0 1 (33)
28
19(68) 11 (65)
17
1,500-2,500
5
4
2,500-3,000 3,000-4,000
3 3
2 (67) 2 (67)
7
5 (71)
>1,500(1,687)
1
1(100)
Unfortunately, the prognosis becomes ominous as soon as the disease has spread beyond the cutaneous system, since response to chemotherapy has been poor [4]. Thus, we believe that meaningful assessment of the value of TSE1 would pertain only to the group of longterm survivors with disease still confined to skin. Our results are similar to those reported by others [2, 8]. In patients with generalized skin lesions, the cure after
one
single
course
of TSE1
is less
than
10%,
even when higher doses were given. Apparently TSE1 alone is not expected to be the curative mode of treatment for this disease. Many centers including ours have embarked on a program to give patients adjuvant topical nitrogen mustard after completion of TSEI. No significant improvement in long-term disease-free survival has been seen so far [9]. Others are also using a multidisciplinary approach with TSE1, total nodal photon irradiation, topical nitrogen mustard, and systemic chemotherapy. The results remain pending at present [8]. Our
results
suggest
that
in patients
with
erythroderma,
total dose during the initial course of TSE1 is inversely related to generalized recurrence rate. However, in patients with plaques or tumors, this relationship seems to be much less obvious. The Stanford group also found that while the incidence of complete regression was directly related
to treatment
dose
during
their
particularly relapse tolerance
group
of
patients
an inverse relationship tumor lesions [2].
lesions.
course
that the fungoides We
of
TSEI
rate for
believe
be
in patients is high, further
erythroderma, group
optimal dose of TSEI may vary depending that
should
with in their
with allowing TSEI
total kept
dose
generalized reserve
when
pa-
for patients on type of
during
relatively
of
the
initial
conservative, of
plaques normal
where tissue
indicated.
REFERENCES
DO, Salzman FA, Trump JG, Wright lymphoma cutis with low megavolt electron beam therapy; nine year follow-up in 200 cases. South Med J 54 : 769-776, 1961 2. Fuks ZY, Bagshaw MA, Farber EM: Prognostic signs and the management of the mycosis fungoides. Cancer 32: Fromer
KA:
6(55)
1,100-1,500
rate
skin
1.
11
in
was with
263
(80)
19):
1,10O
TSEI
FUNGOIDES
We conclude with mycosis
56):
=
MYCOSIS
there tients
Survivors
32):
1,100-1,500
Tumor(N
FOR
of
Recurrence:
SMD (rad)
Erythroderma 1,100 1,100-1,500 1,500-2,500 2,500-3,500 Plaque (N = 1,100
IRRADIATION
the first course
1385-1395,
JL, Johnston Management of
1973
3. Hare HF, Fromer JL, Trump JG, Wright KA, Anson JH: Cathode ray treatment for lymphomas involving the skin. Arch Dermatol 68 : 635-642, 1953 4. Levi JA, Wiernik PH: Management of mycosis fungoidescurrent status and future prospects. Medicine 54:73-88, 1975
Lo TCM, Salzman FA, Moschella SL, Tolman EL, Wright KA: Whole body surface electron irradiation in the treatment of mycosis fungoides: an evaluation of 200 patients. Radiology. In press, 1979 6. Smedal Ml, Johnston DO, Salzman FA, Trump JG, Wright KA: Ten year experience with low megavolt electron therapy.AJR 88:215-228, 1962 7. Trump JG, Wright KA, Evans WE, Anson JH: High energy electrons for treatment of extensive superficial malignant lesions.AJR 69:623-629, 1953 8. Wallner PE, Brady LW, Vonderheid E, Van Scott EJ: Technical considerations for a program of remission induction and maintenance of mycosis fungoides utilizing total body electrons, total nodal photons, topical nitrogen mustard and systemic chemotherapy. Presented at the annual meeting of the American Society of Therapeutic Radiologists, Denver, November 1977 9. Price NM, Hoppe RT, Constantine VS, Fuks ZY, Farber EM: The treatment of mycosis fungoides: adjuvant topical mechlorethamine after electron beam therapy. Cancer 40:28512853, 1977 5.
Considerations
in Total Mycosis
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THEODORE
C.
M.
LO,’
Skin Electron
skin
most
effective
electron
irradiation
modes
of
(TSEI)
FERDINAND
remains
treatment
for
A.
one
SALZMAN,’
AND
KENNETH
A.
WRIGHT2
energies up to 3.5 MeV. We believe this energy is adequate for lesions not more than 1 cm thick. Both the physical aspects and the dosimetry of the apparatus have been described in detail [7].
The total the specified
treatment maximum
dose reported throughout this paper is entry dose computed with the formula SMD=(dfi’)
where
SMD
number
is the total
of cycles
per
per field,
f is the
designates
the
specified
maximum entry dose, c is the d is the daily entry dose of fields per cycle, and the subscript
treatment
number
technique
course,
used.
The
advantages
of
the
use
of
the SMD concept have been discussed [5]. It standardizes the method of reporting doses among various institutions when different techniques are employed, and it guides the therapist to limit total dose within acute and chronic normal tissue tolerance. Obviously, during each treatment session all fields used must be complementary to one another. All 200 patients presented with generalized multiple or confluent skin lesions covering at least 50% of the total skin area, and none had clinical evidence of nodal or systemic disease on the first day of TSEI. Pathology was reviewed and confirmed by our pathologists. Before January 1972, the six-field cycle technique was used, and since then, an eight-field cycle technique has been used. The details of these techniques have been discussed [5]. All patients were treated on a 5 day per week basis.
of the
generalized
for
Fungoides
Two hundred patients with generalized cutaneous mycosis fungoides were treated with total skin electron Irradiation (TSEI) in the Lahey Clinic Radiotherapy Department-MIT High Voltage Research Laboratory between 1964 and 1973. None of the patients had any clinical evidence of extracutaneous disease at presentation. The 3-year absolute survival rate was 54% (107 patients). Analysis of these 107 long-term survivors evaluated the relation between incidence of generalized cutaneous recurrence and total treatment dose given during the initial course of TSEI. Results indicated that in patients with erythroderma , the need for a second course of TSEI was inversely related to the total dose given during the first course. However, the curve seemed to flatten at about 1 ,500 cGy (rad). In plaque disease, the percentage of patients who received repeated courses of TSEI seemed to be relatively constant independent of total dose given during the initial course (65%-80%). In patients with tumor lesions, the incidence of generalized cutaneous recurrence was directly proportional to total dose. The optimal dose of TSEI for patients with mycosis fungoides may vary depending on types of skin lesions. Total dose during the initial course of TSEI should be kept relatively conservative, particularly in patients with generalized plaques where relapse rate is high allowing reserve of normal tissue tolerance for further TSEI when indicated.
Total
Irradiation
my-
cosis fungoides confined to the skin today [1-6]. Although cure rates are still low, its palliative value is definitely irrefutable [1 2, 5, 6]. However, once disease has progressed beyond the cutaneoussystem, prognosis becomes ominous, and survival is measured in terms of months [4] Unfortunately systemic chemotherapy, either single agent or combination drugs, has not been
Results
,
.
found
[4].
total
skin
effective
Thus,
in control
meaningful
electron
with for
was carried with respect
of the
assessment
irradiation
group of patients skin who survived study patients
after
would
disease
of the pertain
value
only
107
to
evaluate control
such a with TSEI.
Two
hundred
new patients
and
with
of
cosis fungoides were treated with total (TSEI) in the Lahey Clinic Radiotherapy
Voltage
Research
constant
potential
de Graaff Received
type with July
Laboratory
are
Methods
generalized
accepted
between
after
my-
1964
revision
and
1973.
overall
all 200
survival
patients.
56
for
3 years
patients
had tumors. was commonly
or longer;
had
The
survived
for
at 3 years Patients
into three subgroups by primary on the first day of TSEI. Of the
were
lesion type 200 patients,
32 patients
plaque
lesions,
had and
Fourteen
19
poor prognosis of patients with due to rapid onset of metastatic
3 years
only a irradiation,
or longer.
These
single and
patients
listed by primary lesion type shown in table 1. Table 2 shows the current status of this group patients
were
considered studied needed
ment since the initial course of TSEI. highest cure rate was demonstrated
of
“cured.” for at further
35 All
least 5 treat-
As expected, in the group
the of
30, 1978.
Presented at the annual meetina of the American Radium Society, New Orleans, April 1978. 1 Department of Radiotherapy, Lahey Clinic Foundation, Boston, Massachusetts 02215. Address reprint 2 High Voltage Research Laboratory, Massachusetts Institute of Technology, Cambridge, Massachusetts AJR 132:261-263, February 1979 © l979American Roentgen Ray Society
for
of these patients have now been years (table 3) and none of them
The
was of the Van electrons with
October
of TSEI
survived
of them
patients.
skin electron irradiation Department-MIT High
electrostatic generator used the capacity of producing
17, 1978;
cutaneous
absolute
visceral disease [5]. Among all 200 patients, 81 received course of TSEI without further electron 35
Subjects
(54%)
patients tumors
to the
group
initiation
the
erythroderma,
of
clinical disease confined to the a substantial length of time. A
out to to local
1 shows
categorized as presented
,
significantly
date
Table
261
requests 02139.
to T. C. M. Lo.
0361
-803X/79/1322-0261
$0.00
LO
262
MR:132,
ET AL.
TABLE
February
1979
1
Survival Plaque
Tumor
Total
57 32 (56)
89 56 (63)
54 19 (35)
200 107 (54)
36 (63)
25 (28)
20 (37)
81 (41)
19 (53)
13 (52)
3 (15)
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Erythroderma
Total patients Overall 3-year survival One course of TSEI: Patients studied Survived
3 years
Note-Numbers
in parentheses
TABLE Status
of 3-Year
Survivors
TABLE
2
Who Had Only One Course Erythro-
Plaque
derma
disease
6t
9
2
Died from disease
2
2
0
19
Total .
One patient died of intercurrent
disease
at 5 years
13
were
interested
long-term
survivors.
relation
between
the
with
erythroderma,
the
need for a second course of TSEI was inversely proportional to the total dose given during the initial course (table 5). Clinically this implies that for this type of lesion, high-dose irradiation would perhaps be indicated if tolerance
allowed.
However, tients
plaque
received
disease,
repeated
the
courses
percentage of TSE1
particular
to
type
of
lesion
even
with
an
with than
years
for
tumor 1,500
this
1,300
6
7
5 6 7 8 9 10
1,125 1,125 3,000 1,800 1,800 900 1,200
6 6 6 8 8 8 8
5 5 6 5 5 5 5
900 1,000
6 6
11 5
1,200
6
12
11
Plaque: 12 13
Tumor: 14 .
who rad),
analysis.
received only one
This
high-dose survived
patient
irradiation longer than
received
Specified
maximum
entry
dose.
TABLE All 3-Year Survivors
4
Who Had More Electron Course
Therapy
Than One
of TSEI Erythro-
Plaque
Tumor
43 78 5 15 28
16 84 4 6* lOt
derma
No % Spotsonly Dead Living with .
13 41 1 6 7
disease
One patient died of intercurrent
disease
(had two TSEI and one spot treatment). t One patient is NED 5 years after
(NED) 8 years after last spot irradiation
last spot
irradiation
(had
one
TSEI and
seven
treatments).
course
of TSEI
at 3 years
a second
and
is now
living
with
disease
at 5 years. Discussion
aggressive
initial approach. in patients with tumors the incidence of generalized cutaneous recurrence was directly related to total dose (table 5). Unfortunately, among the six patients (more
4
of paseemed
be relatively constant, ranging from 65% to 80% regardless of total dose given during the first course of TSE1 (table 5), suggesting a universally high relapse rate for this
12 6 5
spot
for
who
6 6 6
treat-
course of TSE1 and subserecurrence when a second among this group of 107
In patients
900 1,200 1,050
3
‘
in the
Survival (years)
2 3
1
patients with erythroderma. Of these 14 patients, 13 received a total dose of less than 2,000 rad. Unfortunately, once cutaneous disease recurred after the initial course of TSEI the chance of ‘cure” appeared to be extremely remote. Table 4 shows the outcome of the 72 3-year survivors who required further electron irradiation, either local spot treatment or TSEI or both, after the initial course of TSEI; only two patients could be considered “cured.” One patient with tumor died from an automobile accident 8 years after two courses of TSEI and one course of local “spot” irradiation, and another patient with tumor survived 5 years free of disease after one course of TSEI and seven courses of local spot treatments. We
nique (no. fields)
Erythroderma:
t One patient is now NED after a course of chlorambucil.
mont dose during the first quent generalized cutaneous course of TSEI was required
of TSEI Tech-
(NED).
,
3
DoseS (rad)
c ass
1
with
(43)
after One Course
Tumor
2
Living
“Cure”
of TSEI
11
Cured
35
are percentages.
3
Mycosis
fungoides
lymphomatous system. The undetermined skin
means
electron
for
is
a
rare
and
chronic
form
of
malignancy arising from the cutaneous optimal treatment for this disease remains today. However, the distinct value of total irradiation,
local
control
as one
of this
of the
disease,
most
successful
is well
known.
AJR:132,
February
ELECTRON
1979
TABLE incidence
of Generalized
5
Downloaded from www.ajronline.org by 170.164.50.90 on 11/04/15 from IP address 170.164.50.90. Copyright ARRS. For personal use only; all rights reserved
(N
=
All 3-Year No. Patients
Recurrence Rate (%)
17 9 3 3
9(53) 2 (22) 0 1 (33)
28
19(68) 11 (65)
17
1,500-2,500
5
4
2,500-3,000 3,000-4,000
3 3
2 (67) 2 (67)
7
5 (71)
>1,500(1,687)
1
1(100)
Unfortunately, the prognosis becomes ominous as soon as the disease has spread beyond the cutaneous system, since response to chemotherapy has been poor [4]. Thus, we believe that meaningful assessment of the value of TSE1 would pertain only to the group of longterm survivors with disease still confined to skin. Our results are similar to those reported by others [2, 8]. In patients with generalized skin lesions, the cure after
one
single
course
of TSE1
is less
than
10%,
even when higher doses were given. Apparently TSE1 alone is not expected to be the curative mode of treatment for this disease. Many centers including ours have embarked on a program to give patients adjuvant topical nitrogen mustard after completion of TSEI. No significant improvement in long-term disease-free survival has been seen so far [9]. Others are also using a multidisciplinary approach with TSE1, total nodal photon irradiation, topical nitrogen mustard, and systemic chemotherapy. The results remain pending at present [8]. Our
results
suggest
that
in patients
with
erythroderma,
total dose during the initial course of TSE1 is inversely related to generalized recurrence rate. However, in patients with plaques or tumors, this relationship seems to be much less obvious. The Stanford group also found that while the incidence of complete regression was directly related
to treatment
dose
during
their
particularly relapse tolerance
group
of
patients
an inverse relationship tumor lesions [2].
lesions.
course
that the fungoides We
of
TSEI
rate for
believe
be
in patients is high, further
erythroderma, group
optimal dose of TSEI may vary depending that
should
with in their
with allowing TSEI
total kept
dose
generalized reserve
when
pa-
for patients on type of
during
relatively
of
the
initial
conservative, of
plaques normal
where tissue
indicated.
REFERENCES
DO, Salzman FA, Trump JG, Wright lymphoma cutis with low megavolt electron beam therapy; nine year follow-up in 200 cases. South Med J 54 : 769-776, 1961 2. Fuks ZY, Bagshaw MA, Farber EM: Prognostic signs and the management of the mycosis fungoides. Cancer 32: Fromer
KA:
6(55)
1,100-1,500
rate
skin
1.
11
in
was with
263
(80)
19):
1,10O
TSEI
FUNGOIDES
We conclude with mycosis
56):
=
MYCOSIS
there tients
Survivors
32):
1,100-1,500
Tumor(N
FOR
of
Recurrence:
SMD (rad)
Erythroderma 1,100 1,100-1,500 1,500-2,500 2,500-3,500 Plaque (N = 1,100
IRRADIATION
the first course
1385-1395,
JL, Johnston Management of
1973
3. Hare HF, Fromer JL, Trump JG, Wright KA, Anson JH: Cathode ray treatment for lymphomas involving the skin. Arch Dermatol 68 : 635-642, 1953 4. Levi JA, Wiernik PH: Management of mycosis fungoidescurrent status and future prospects. Medicine 54:73-88, 1975
Lo TCM, Salzman FA, Moschella SL, Tolman EL, Wright KA: Whole body surface electron irradiation in the treatment of mycosis fungoides: an evaluation of 200 patients. Radiology. In press, 1979 6. Smedal Ml, Johnston DO, Salzman FA, Trump JG, Wright KA: Ten year experience with low megavolt electron therapy.AJR 88:215-228, 1962 7. Trump JG, Wright KA, Evans WE, Anson JH: High energy electrons for treatment of extensive superficial malignant lesions.AJR 69:623-629, 1953 8. Wallner PE, Brady LW, Vonderheid E, Van Scott EJ: Technical considerations for a program of remission induction and maintenance of mycosis fungoides utilizing total body electrons, total nodal photons, topical nitrogen mustard and systemic chemotherapy. Presented at the annual meeting of the American Society of Therapeutic Radiologists, Denver, November 1977 9. Price NM, Hoppe RT, Constantine VS, Fuks ZY, Farber EM: The treatment of mycosis fungoides: adjuvant topical mechlorethamine after electron beam therapy. Cancer 40:28512853, 1977 5.
