Hollings opens total skin electron beam therapy program; cutaneous T-cell lymphoma patients no longer need travel out of state for this treatment

October 26, 2022
a man stands on a platform and poses with one arm up and the other down while another positions him
Bradley DePaoli, M.D., demonstrates one of the treatment positions with guidance from radiation therapist Sheldon Mims. Photo by Kristin Lee

About eight out of every million people will be diagnosed with cutaneous T-cell lymphoma. It's an extraordinarily rare type of non-Hodgkin lymphoma and, until now, South Carolinians seeking a treatment known as total skin electron beam therapy had to leave the state to find it.

Now, patients can get this treatment at MUSC Hollings Cancer Center.

Joseph Roche was the first patient to undergo the therapy, in August, under the care of radiation oncologist Charlotte Rivers, M.D.

“I sat down with her, and she explained all the pros and cons, the ins and outs, what happens to your hair and stuff. But I was sold,” Roche said.

Roche was diagnosed with cutaneous T-cell lymphoma in 2018. This cancer starts in the T-cell lymphocytes, a type of white blood cell, and affects the skin. It shows up at first as a scaly red rash and then can progress to become more eczema-like, covering more of the skin area, and eventually might form hardened plaques on the skin.

In the early stages, it’s usually managed by dermatologists, said Hollings oncologist Brian Greenwell, M.D. But the transition from dermatology care to oncology care can be bumpy, and it’s always useful to get input from both specialties, which is why Greenwell teamed up with dermatologist John Maize, M.D., two years ago to open a cutaneous lymphoma clinic.

“Patients get both medical oncology and dermatology in the same room at the same time with a unified voice and recommendations and a collegial working relationship, which is a little bit unique,” Greenwell said. “In the past, patients may have driven down multiple times, once to see Dr. Maize and then a couple weeks later to see a medical oncologist. They now come down on one trip, one clinic visit, and they get both opinions and input from both sides. And so that's really been a great opportunity, and, I think, really collaborative. We're the only clinic like that in this state.”

two doctors examine the back of a man's head 
Dermatologist Jane Scribner, M.D., and oncologist Brian Greenwell, M.D., examine Joseph Roche's skin during their multidisciplinary clinic.  

Roche, who retired to South Carolina after 35 years in hospital administration in the Midwest, was interested in total skin electron beam therapy early on. But circumstances with his family meant that out-of-state travel was out of the question. Instead, he progressed through the full suite of treatments: topical creams, monoclonal antibodies, oral chemotherapy and photodynamic therapy. In each case, the cancer was controlled for a time but then returned.

Rivers said that Roche is a good example of the type of patient who can benefit from total skin electron beam therapy, which is usually intended for symptom relief when other treatments aren’t working.

“The patients who we see who are good candidates for total skin treatment have diffuse involvement of their entire skin surface, and that can become really painful and uncomfortable,” she said. “A lot of times, they get to a point where some of the other treatments aren't working quite as well, and that's when they're referred to us.”

Greenwell said patients can have a range of experiences with cutaneous T-cell lymphoma, including some who live for decades with the condition. But it’s not necessarily easy.

“It has significant day-to-day quality of life impacts, with significant itching and discomfort,” he said. “There are psychological issues from seeing it on your skin daily and being embarrassed to go out in public because of the skin lesions or ulcerations.”

Patients are also vulnerable to infections, as the lesions damage the skin barrier.

Roche said the skin plaques made it difficult even to sleep.

“It’s hard to feel like yourself,” he said.

He was fully on board with the total skin electron beam therapy, even when Rivers explained likely side effects, like losing his hair, dry skin and fatigue.

Preparing for total skin electron beam therapy

The radiation oncology team devoted two years preparing to be able to offer this therapy, channeling resources to the project and spending hours on calculations to ensure the therapy would be delivered properly.

During therapy, the patient stands in a series of six poses, called the Stanford technique, which were developed to ensure that the radiation covers the entire skin surface. The idea is for the radiation to penetrate 1 to 2 millimeters below the skin, damaging the DNA of the cancer cells within the skin but leaving organs untouched.

“We have to really think about what's happening inside the room as a whole,” said Alek Rapchak, the lead physicist for Hollings’ total skin electron beam therapy program. Radiation physicists perform the calculations to ensure that patients are getting the radiation dosage prescribed by the doctor.

Unlike typical radiation oncology calculations, which are performed with the idea of a concentrated beam of radiation focused on one spot, calculations for total skin electron beam therapy have to take into account the size of the room, the patient’s distance from the machine and the patient’s size.

“It's really just like a big spray tanning booth of electrons that get thrown out all around the room,” Rapchak explained. “We have to be able to calculate how much dose is going to the patient, how deep that dose has gone to the patient and how to make this as uniform as possible."

Although acceptable doses are considered to be within 10% of the prescribed dosage, the Hollings physicist team has been able to get the dosage within 5% of the prescription, Rapchak said.

"At an NCI-designated cancer center in an academic institution like this, we can focus on patients who have conditions that may be a little more rare, and we can dedicate the resources to treat just a few patients instead of only focusing on cancers that affect the majority of the people." 

Alek Rapchak
total skin therapy lead physicist

Patients come for five treatments over the course of a week, and the cancer cells continue to die off for a few weeks after the treatment ends.

Rivers noted that this therapy is available only because of Hollings’ robust physicist team to support it – without the team’s expertise, the therapy couldn’t be offered.

The intense calculations are one reason that this therapy isn’t widely available, in addition to the fact that it’s geared toward such a small percentage of the patient population.

“This is going to help a few patients, and it requires a lot of time and resources in order to do it. But at the end of the day, this is going to help their lives immensely,” Rapchak said.

“And I think that's one of the important things to look at – when working at an NCI-designated cancer center in an academic institution like this, we can focus on patients who have conditions that may be a little more rare, and we can dedicate the resources to treat just a few patients instead of only focusing on cancers that affect the majority of the people,” he continued. “We do that, and we do a great job. But now we can also focus on patients where we may only get 15 to 20 in a year, where other cancer centers can't allocate those resources.”

Rivers said the therapy has gotten a good reception.

“The patients that we've seen so far have been really grateful that they can do this while they're at home; that they don't have to worry about traveling,” she said.