Cutaneous T-cell lymphoma (CTCL) is a chronic, debilitating disease that has a severe impact on quality of life. We present a patient with multiple CTCL lesions on the bilateral feet, which impaired his ability to ambulate. His lesions on both feet were successfully treated with a total of 8 Gy in two fractions via high-dose-rate surface brachytherapy using the Freiburg Flap applicator. The deeper aspects of the bulkier lesions on the left foot were boosted with electron beam therapy. The radiation therapy was well tolerated, and the patient was able to regain his mobility after completing radiation therapy. To our knowledge, there are few reports utilizing brachytherapy in treating CTCL. Our case describes treatment of larger, more extensive CTCL lesions than previously reported.
Cutaneous T-cell lymphoma (CTCL) is a chronic, debilitating condition that accounts for approximately 4% of all non-Hodgkin lymphomas, with mycosis fungoides being the most common type [
A 69-year-old male presented to dermatology clinic with stage T2b mycosis fungoides, diagnosed two years prior, which manifested as a persistent, chronic rash involving both feet, and, to a lesser extent, other sites of his body. The lesions on his feet were painful and pruritic, limiting his ability to wear shoes and ambulate for the past two years. His disease showed little to no response to numerous topical agents including topical nitrogen mustard, imiquimod, clobetasol, vinegar soaks, PUVA soaks, amoxicillin, and doxycycline. Per the patient, consideration was made for amputation of the left foot below the ankle, which he refused. Subsequently, he was referred to radiation oncology.
Physical exam revealed tender, confluent, erythematous, and desquamated patches on the skin extending from the dorsal and ventral surfaces of his left foot to the ankle (Figures
(a) and (b) Left foot at presentation. (c) and (d) Left foot at follow-up 11 months later with a new 3-4 cm circular lesion that developed just proximal to the irradiated area. (e) Right foot at presentation. (f) Right foot at follow-up 11 months later.
The FF applicator consists of a planar array of 1 cm diameter silicone spheres with longitudinal channels for insertion of treatment catheters and flexible connections laterally which enable the FF to conform to highly curved and irregular surfaces. The FF is often affixed to a thermoplastic mesh (TM), commonly used in radiation therapy, to maintain a reproducible orientation relative to the patient’s anatomy.
In preparation for this patient’s left foot HDR treatment, two pieces of TM material (Extremity EMRT-8430, Bionix Inc., Toledo, OH) were heated and formed around the patient’s left foot consisting of a dorsal part and corresponding plantar portion. This two-part, clam shell construction allowed the entire foot to be tightly enveloped by TM yet provided ease of ingress and egress (Figure
(a) Two-part thermoplastic mesh encompassing the left foot with proximal border of treatment area outlined in black. (b) Complete Freiburg device consisting of a total of 39 catheters. (c) Plantar aspect of the Freiburg device. (d) Positioning of the left foot for CT scan and treatment.
For treatment planning, a CT scan was performed with the FF device firmly affixed to the patient’s foot and a thin metal marker wire attached to the TM to delineate the intended treatment borders (Figure
(a) Left foot treatment plan: 3D view of source dwell positions. (b) Left foot treatment plan: cutaneous planning treatment volume is shown in cyan, and the delivery of a highly conformal 4 Gy of radiation is shown in yellow isodose line.
The treatment was well tolerated with some mild radiation-related edema and associated left foot pain that was managed conservatively and resolved within a week of completing treatment. At one-week follow-up, his lesions were regressing with significant improvement in pain, scaling, and erythema. Four months later, the deeper aspect of the gross tumor lesions involving the left foot was boosted with 20 Gy in 10 daily fractions using 6 MeV external beam electrons. Additionally, the same brachytherapy process without EBRT was subsequently followed for the patient’s right foot, which responded well to HDR brachytherapy.
At each short-term follow-up (≤ 6 weeks) after completing his HDR brachytherapy, he reported a rewarding response with improvement of disease-related erythema, pain, and swelling in all treated areas, with near resolution of treatment related hyperpigmentation (Figures
CTCL lesions are extremely radiosensitive, with some reports suggesting that low-dose radiation therapy can achieve successful results (Table
Local cutaneous T-cell lymphoma lesions treated with low-dose radiation therapy.
| | | | | | |
---|---|---|---|---|---|---|
Neelis et al, 2009 [ | 24 | 65 | Electron beam | 8.0 Gy in 2 fractions | 5/65 (7.7%) | 9.6 months |
Thomas et al, 2013 [ | 58 | 270 | Photon or electron beam | ≥7.0 Gy in 1 fraction | 4/270 (1.5%) | 41.3 months |
DeSimone et al, 2013 [ | 10 | 23 | HDR brachytherapy | 8.0 Gy in 2 fractions | 0/23 (0%) | 6.3 months (median) |
Goddard et al, 2015 [ | 6 | 8 | HDR brachytherapy | 8.0 Gy in 2 fractions | 1/8 (12.5%) | 15.8 months |
Brachytherapy is a technique in which a radioactive source is placed directly into or adjacent to target lesions via implants or surface applicators [
While brachytherapy treatments for nonmelanoma skin cancers have been extensively studied and found to have high local control rates and excellent cosmetic outcomes [
The symptom burden of CTCL significantly impairs the quality of life for patients. Patients frequently experience intense pruritus, pain, cracking and bleeding skin, and associated insomnia, depression, and decreased self-esteem [
Cutaneous T-cell lymphoma
Gray
High-dose-rate
External beam radiation therapy
Freiburg Flap
Thermoplastic mesh
Planning treatment volume.
The authors report no conflicts of interest.