Leading the Way in Total Skin Electron Beam Therapy

By Achy Yahalom, MD,

Tuesday, June 16, 2015

Joachim Yahalom, MD, FACR

High-quality, modern radiotherapy is critical for the curative and palliative treatment of many lymphomas. At Memorial Sloan Kettering Cancer Center (MSK), we have a full-time radiation oncology service solely dedicated to lymphoma. This dedicated service is an integral component of our multimodality team approach and serves to widen the effective therapeutic options we can offer to patients. We are privileged to provide one of the largest and most comprehensive services in lymphoma radiation oncology in the world.

There are several unique conceptual themes in lymphoma radiation oncology applied at MSK. We aim to use the lowest possible effective radiation dose, individually tailored to the clinical pathological situation. We reduce the area exposed to radiation using sophisticated imaging and radiation equipment. And we seek to integrate radiotherapy (RT) into the chemotherapy and transplant regimens, applying a multidisciplinary treatment approach.

International Lymphoma Radiation Oncology Group

As a founder and chairman of the International Lymphoma Radiation Oncology Group (ILROG) — a collaboration between lymphoma radiation oncology leaders from 12 countries and more than 20 cancer centers around the globe — I am proud that MSK has become an epicenter for research, policy, and technology. Modern guidelines for lymphoma treatment recently developed, harmonized, and published by ILROG have already been incorporated into the National Comprehensive Cancer Network guidelines and adopted by many lymphoma and radiation oncology international organizations. These guidelines reflect, in many ways, the practices established at MSK and other world-class centers.

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State-of-the-Art Technology

At MSK, we utilize state-of-the-art radiation technology to optimize the delivery of radiotherapy. In fact, intensity modulation radiation therapy (IMRT) for challenging radiation fields was developed here. Treatment planning using a PET-CT simulator provides real-time disease activity and anatomic information to determine the treatment position for the most accurate and safe radiation field design. In addition, Deep Inspiration Breast Hold (DIBH) technology allows us to deliver radiation during the optimal time in the respiratory cycle, protecting the normal organs in the chest. MSK is one of few radiation oncology centers in the country that has the capability to offer Total Skin Electron Beam (TSEB) radiation, a unique arrangement of the radiation facility and accelerators to provide highly effective treatment to patients with extensive infiltration of the skin with lymphoma, such as mycosis fungoides.

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Unique Clinical Programs

Highlights of our unique clinical programs for lymphoma patients include:

  • Using a mini, low dose of radiation to effectively control indolent lymphomas such as follicular lymphomas and marginal zone lymphomas. In this “boom-boom” radiation treatment, only two low-dose fractions of radiation are delivered to provide long-lasting disease control in 70 percent of selected patients who often have relapsed after other therapies. We are currently studying molecular predictors of response to this treatment. More than 100 patients have already been treated at MSK with this method — most successfully.
  • Extra-nodal Marginal Zone Lymphomas (MALT lymphoma). In 1992, MSK introduced organ-specific conformal RT of MALT lymphoma in the stomach as an alternative to gastrectomy. Over the last 25 years, we have treated hundreds of patients with MALT lymphoma effectively and safely in a variety of organ sites including the eyes, skin, lung, meninges, thyroid, salivary glands, breast and more.
  • In 1985, we pioneered the concept of using radiotherapy as a major component for the salvage of patients with relapsed or refractory Hodgkin and non-Hodgkin lymphomas. We designed RT fields that individually address the sites of most concern, and integrated accelerated hyper-fractionated radiotherapy after salvage chemotherapy and prior to the high-dose chemotherapy and stem cell rescue. These patients—numbering more than 450 with Hodgkin disease—have been treated on prospective protocols and all are published, including recently (Moskowitz et al. Lancet Oncology 2015). Our results compare favorably with other large salvage programs, with a low-toxicity profile and excellent short- and long-term safety records.
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International Symposium

In May 2015, MSK hosted a two-day international symposium in collaboration with ILROG devoted entirely to modern radiotherapy of lymphoma. The symposium was co-sponsored and endorsed by the largest radiation oncology organizations in North America (ASTRO) and Europe (ESTRO).

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