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Procedure · Radiation

Total skin electron beam therapy (TSEB)

TSEBT; total skin electron beam radiotherapy; total skin electron irradiation. Stanford technique.

TSEB delivers low-energy electrons (typically 4–6 MeV) to the entire skin surface while sparing the underlying bone marrow and viscera. It is the most effective single skin-directed therapy for advanced mycosis fungoides (the commonest cutaneous T-cell lymphoma) and for erythrodermic CTCL. Two contemporary regimens are in clinical use: conventional 30–36 Gy (high response rates, marked acute toxicity, single course) and low-dose 10–12 Gy (similar response rates with much lower acute toxicity and the option of repeat courses). Provided in the UK at supraregional cutaneous lymphoma centres.

UK supraregional CTCL service practice and national guidance are the primary frame of reference; see about the author.

CurrentLast reviewed 27 April 2026

Indications

  • Guideline Mycosis fungoides stage IB–IIA (generalised patch / plaque disease) refractory to skin-directed therapy.
  • Mycosis fungoides stage IIB–III (tumour stage, erythroderma) — widely accepted indication.
  • Sézary syndrome — as a component of multi-modal therapy; rapid skin disease control while systemic therapy is established.
  • Primary cutaneous CD30+ lymphoproliferative disorders (multifocal pcALCL); occasionally for diffuse cutaneous B-cell lymphoma.
  • Palliation of extensive symptomatic skin disease at end-stage.
  • Refer to the supraregional cutaneous T-cell lymphoma service for assessment.

Contraindications and cautions

  • Pregnancy (absolute).
  • Severe baseline xerosis or chronic actinic damage (relative; will be exacerbated).
  • Inability to maintain the standing positions required (consider modified single-position technique for the immobile).
  • Caution with previous radiotherapy to overlapping fields — cumulative skin dose limits.

Technique

Stanford six-position dual-field technique

The internationally adopted standard. The patient stands at a distance of approximately 3–4 metres from a linear accelerator delivering 4–6 MeV electrons. Six positions are used over each treatment day:

  1. Anterior-posterior — arms abducted and elbows flexed.
  2. Posterior-anterior — same.
  3. Right anterior oblique.
  4. Left anterior oblique.
  5. Right posterior oblique.
  6. Left posterior oblique.

Two cycles of three positions per day on alternating days deliver a uniform dose distribution to the skin. The electron energy is degraded to ~4 MeV at the skin so penetration is limited to ~1 cm — sparing bone marrow, viscera and gonads.

Boost fields

Underdosed areas (perineum, soles, scalp vertex, inframammary folds) receive small boost fields to bring them to the target dose. Eyes and nails are routinely shielded; gonads may be shielded in patients of reproductive age.

Conventional regimen (30–36 Gy)

  • 1–2 Gy per fraction, four fractions per week.
  • Total 30–36 Gy over 8–10 weeks.
  • The historical Stanford reference dose for advanced mycosis fungoides.

Low-dose regimen (10–12 Gy)

  • 1 Gy per fraction, four fractions per week.
  • Total 10–12 Gy over 3 weeks.
  • Designed to retain efficacy while reducing acute toxicity and allowing repeat courses for relapse.
  • Increasingly the preferred regimen in many UK centres for patients likely to need repeated skin-directed therapy.

Outcomes

  • Trial Conventional TSEB (30–36 Gy): complete response 60–90% in T2–T3 mycosis fungoides; partial response in most of the remainder. Median duration of response approximately 12–24 months — most patients eventually relapse; adjuvant maintenance is the rule rather than the exception.
  • Trial Low-dose TSEB (10–12 Gy, Hoppe 2015): overall response 88%, complete response 27–30% in pooled series; duration of response slightly shorter than conventional but repeatable. Trade-off of efficacy vs toxicity is widely viewed as favourable.
  • Best outcomes in patch / plaque disease; tumour-stage and erythrodermic disease have lower complete-response rates and shorter duration.
  • TSEB is not curative for CTCL but produces durable skin disease control and major symptom relief, often allowing systemic therapy to be deferred or reduced.

Adverse events

Acute (during and within weeks of treatment)

  • Generalised erythema, brisk in conventional-dose regimens.
  • Pruritus, xerosis, fine desquamation.
  • Patchy alopecia (scalp); usually recovers, may be permanent in places.
  • Loss of fingernails / toenails — usually regrow.
  • Anhidrosis (loss of sweating); can persist for months.
  • Acute oedema of hands and feet.
  • Conjunctival irritation if eye shielding suboptimal.

Late

  • Skin atrophy and telangiectasia.
  • Persistent xerosis and intolerance to sun.
  • Pigmentary change (hypo- or hyperpigmentation).
  • Second cutaneous malignancy in the irradiated field after long latency — consideration with cumulative repeat low-dose courses.
  • Sterility risk minimal with gonad shielding; counselling required.

Practical considerations

  • Provided in the UK at supraregional cutaneous lymphoma centres: The Christie (Manchester), UCLH / Guy's (London) and the regional CTCL services. Referral via the CTCL MDT.
  • Photographic mapping at baseline; modified Severity-Weighted Assessment Tool (mSWAT) at baseline and follow-up for response assessment.
  • Patient preparation: skin care education, sun avoidance during and after treatment; emollients and topical steroids for treatment-related dermatitis.
  • Maintenance therapy after TSEB — topical steroids, PUVA / UVB, low-dose total skin electron re-treatment, or systemic therapy (e.g. interferon, bexarotene, brentuximab vedotin, mogamulizumab) per the CTCL MDT plan.
  • Patients who relapse can often receive repeat low-dose TSEB with similar response rates; conventional-dose retreatment is more constrained by cumulative skin toxicity.

References

  1. Hoppe RT. Mycosis fungoides: radiation therapy. Dermatol Ther 2003;16:347–54.
  2. Hoppe RT, Harrison C, Tavallaee M et al. Low-dose total skin electron beam therapy as an effective modality to reduce disease burden in patients with mycosis fungoides: results of a pooled analysis from 3 phase II clinical trials. J Am Acad Dermatol 2015;72:286–92.
  3. Kim YH, Tavallaee M, Sundram U et al. Phase II investigator-initiated study of brentuximab vedotin in mycosis fungoides and Sézary syndrome with variable CD30 expression. J Clin Oncol 2015;33:3750–8.
  4. Trautinger F, Eder J, Assaf C et al. European Organisation for Research and Treatment of Cancer consensus recommendations for the treatment of mycosis fungoides / Sézary syndrome — Update 2017. Eur J Cancer 2017;77:57–74.
  5. Specht L, Dabaja B, Illidge T et al. Modern radiation therapy for primary cutaneous lymphomas: field and dose guidelines from the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys 2015;92:32–9.

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