Clinical implementation of total skin electron

beam (TSEB) therapy: A review of the relevant

literature
Presented by: Sehrish Inam
Trainee Medical Physicist
Date : May13,2014
Contents
Abstract
Introduction
Equipment requirement
Physical requirement
Single scattered electron beam therapy
Other techniques of skin therapy
Stanford technique
Dose rates
Setup problems
Dose prescription
Dosimetric setup
Dosimetric problems
Clinically acceptance objectives
Conclusion


Abstract:
Total skin electron beam therapy has been in medical service since
the middle of the last century in order to confront rare skin
malignancies. Since then various techniques have been developed,
all aiming at better clinical results in conjunction with less post-
irradiation complications. In this article every available technique is
presented in addition to physical parameters of technique
establishment and common dose fractionation. This study also
revealed the preference of the majority of institutes the last 20
years in six dual field technique at a high dose rate, which is a safe
and effective treatment.
Introduction
Total skin electron beam is treatment modality for
T-cell lymphoma
Mycosis
Fungoides
Kaposi sarcoma
Low penetration electron beam
Linear accelerator capable of producing large 200 cm 80
cm uniform fields with extended SSD.
Equipment Requirement
Linear accelerator that can be modified in order to
deliver a homogeneous electron field at a large
distance from its source (2-7 m).
Beam degrader which ensures superficial beam
penetration into tissue.
Large treatment room for large SSD.
ventilation that removes O3 produced by electron
air interactions .
Auxiliary equipment for the proper and repeatable
positioning.
Dosimetry equipments.
Shielding to avoid sensitivity (eyes & nails)
Physical requirements
3steps of dosimetric checks
1. Physical specification of field dimensions, nominal
SSD, electron beam energies, field at treatment plane
and dose distributions, dose rate and photon
contamination.
2. Dose distribution and rate for dose from electrons
and photons.
3. Clinical aspects that arises dose prescription, dose
fractionation, boost fields for underdosed areas,
shielding design


Requires a linear accelerator that can provide a
homogenous electron field at an SSD of 700 cm.
Energy degrader for beam flattening patient is
irradiated in standing position.
Requires a large treatment room
Single scattered horizontal beam
Other techniques of skin therapy
Static large
electron
fields with
patient in
standing
position.
Static electron
field, rotated
the standing
patient over
360.
Static
electron field
with patient
translated in
lying position
Stanford technique
Developed in 1973 at Stanford university
Patient rotates in 60 steps standing at
treatment positions
Beam energy and shape modulators are used.
Easily achievable in small treatment rooms.
2 central axes of beam pointing outward
patients body ,so x-ray contamination can be
avoided
Stanford technique
Stanford technique
Six dual field techniques or Stanford technique

Stanford technique
Six dual field technique

Dose rates
High dose rate 2500-3000 cGy/min at dmax .
Daily treatment time reduced to 9.5min to
15min.
HDR is a treatment modality in mycosis
fungodis with good results and less time
consuming
Setup problems
Room size
Ventilation of ozone
Skin sensitivity
Eye nail shielding
Dose prescription
27Gy 40Gy(mean dose 35-36Gy) at HDR in an
average of 9weeks,4 days per week.
HDR provides low toxicity ,better tolerance &
reduces treatment time.
For under dosed areas boost fields of 4-26Gy
are prescribed.
For vertex of scalp angled lead reflector is
provided.

Dosimetric setup
Dosimeter (TLDs, ionization chambers,
gafchromic films)
Solid water phantom or anthromorphic
phantom.
Scanning and evaluation of gafchromic
by Epson10000xl

Dosimetric problems
On extended SSD;
Combination of partial beams in order to
create a large field that cover patient
dimensions.
Beam energy degrdading, because lowest
energy provided in electron mode is 6MeV.
Thickness of degrader can vary from 3mm
to 18mm.
If air volume is not sufficient use acraylic
sheet for secondary scattering.

Clinically acceptance objectives
+5% of dose at dmax in a phantom on the central ray
for atleast 80% of the nominal field area.
In Stanford technique dose homogeneity varies from 4%
to 10%.
Prefer dosimetry by gafchromic.


Conclusion
Total skin electron beam irradiation is an effective
treatment for various skin malignancies.
Toxicity can be reduced by HDR & appropriate shielding.
All techniques require linear accelerator with electron
mode & large SSD.
Dosimetric technique should be carried out to ensure
treatment quality.
Prescribed doses differ according to personalized
patient needs and treatment schedules.
36-40 Gy dose delivered in 4 days per week for 9
weeks at HDR.