Low-Dose Radiotherapy for Primary Cutaneous Anaplastic Large-Cell Lymphoma While on Low-Dose Methotrexate

Cutis. 2016 October;98(4):253-256

October 4, 2016|Cutis

Christine M. Cornejo, MD;Roberto A. Novoa, MD;Robert E. Krisch, MD, PhD;Ellen J. Kim, MD

Primary cutaneous anaplastic large-cell lymphoma (pcALCL) is part of a spectrum of CD30⁺ primary cutaneous lymphoproliferative disorders (pcLPDs) that also includes lymphomatoid papulosis (LyP). Localized radiotherapy at doses of 34 to 44 Gy is first-line treatment of pcALCL, but the use of low-dose radiotherapy for pcALCL has not been reported. We present the case of a patient with a history of pcALCL/LyP who was treated with low-dose radiotherapy while on oral low-dose methotrexate (MTX) once weekly. This report suggests that low-dose radiotherapy can be an effective palliative treatment of pcALCL. Low-dose radiotherapy may offer certain advantages over traditional radiotherapy, such as a more economical and efficient treatment for patients, potentially fewer short-term and long-term side effects, and the potential for concomitant use with low-dose MTX.

Practice Points

Cutaneous T-cell lymphoma tumors such as primary cutaneous anaplastic large-cell lymphoma can respond to low-dose radiation therapy, which enables future retreatment of sensitive sites.
Low-dose radiation therapy requires a shorter course of therapy than traditional dosing, which is more convenient and less costly.

Comment

Local radiotherapy is considered a first-line treatment of pcALCL; however, there is limited evidence on its clinical efficacy as well as the optimal dose and technique. Although no standard dose exists for pcALCL, the National Comprehensive Cancer Network guidelines⁸ recommend doses of 12 to 36 Gy in mycosis fungoides/Sézary syndrome subtypes of cutaneous T-cell lymphoma, which are consistent with guidelines published by the European Society for Medical Oncology.⁹ High complete response rates have been demonstrated in pcALCL at doses of 34 to 44 Gy⁶; however, lesions tend to recur elsewhere on the skin in 36% to 41% of patients despite treatment.^2,10 Lower doses of radiation therapy would provide several advantages over higher-dose therapy if a complete response could be achieved without greatly increasing the local recurrence rate. In cases of local recurrence, low-dose radiation would more easily permit retreatment of lesions compared to higher doses of radiation. Similarly, in patients with multifocal pcALCL, lower doses of radiotherapy may allow for treatment of larger skin areas while limiting potential treatment risks. Furthermore, low-dose therapy would allow for treatments to be delivered more quickly and with less inconvenience to the patient who is likely to need multiple future treatments to other areas. Low-dose radiation has been described with a favorable efficacy profile for mycosis fungoides^7,11 but has not been studied in patients with CD30⁺ pcLPDs.

Our case is notable because the patient remained on MTX during radiation therapy. Because MTX can act as a radiosensitizer, current standard practice is to stop MTX while administering radiation therapy. High oncologic doses of MTX can occasionally produce severe skin reactions at the irradiated site^12-14; however, reports of the use of lower weekly doses in combination with radiation are sparse. Our patient had refractory disfiguring facial lesions that would immediately recur once MTX was stopped. Low-dose radiation therapy was administered while she remained on her weekly MTX doses. With this treatment, she achieved a complete response, developed no radiation dermatitis, and had no further new skin lesions appear.

Conclusion

We reported the use of low-dose radiation therapy for the treatment of localized pcALCL in a patient who remained on low-dose oral MTX. Additional studies will be necessary to more fully evaluate the efficacy of using low-dose radiation both as monotherapy and in combination with MTX for pcALCL.

References

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