KEY POINTS
- ESTRO developed the recommendations using a three-round Delphi process involving 16 experts in radiation oncology, clinical oncology and medical physics. Consensus was predefined as >80% agreement, and all 14 technical and quality statements ultimately reached consensus.
- Reduced-dose total skin electron therapy was a major focus. Contemporary regimens used by participating centres varied substantially, with 12 Gy in 8 fractions the most commonly reported schedule, while higher-dose regimens of 24-30 Gy remained in use.
- The panel reached 100% agreement that electrons should be used for total skin irradiation, with energy selected according to the required depth-dose characteristics. A dual-angle technique was preferred, although single-angle delivery remains acceptable in selected settings.
- For repeat irradiation, the panel recommended keeping the lifetime cumulative whole-skin dose at or below 60 Gy EQD2 and cumulative local dose at or below 100 Gy EQD2, using an α/β of 10 Gy. Individual fraction size, prior response and interval from previous treatment should also influence retreatment decisions.
- Acceptable surface dose in the lower back and umbilical regions was defined as 80%-120% of the prescribed dose, with 94% agreement. Institution-specific measurements should determine treatment distance, and scatterer-degrader plates or specialized flattening filters are recommended when required for surface dose and uniformity.
- Eye and nail protection was supported by 94% of experts when these areas are uninvolved. Routine face or scalp shielding was discouraged because of relapse risk, but after three Delphi rounds 94% supported shared decision-making when patients prioritize hair preservation.
- In vivo dosimetry during implementation of a new programme and comprehensive QA including equipment calibration, patient-specific verification and end-to-end testing received 100% agreement. Local supplementary fields remain appropriate for underdosed folds, soles or residual tumorous disease.
CLINICAL TAKEAWAY
These recommendations provide a practical modern reference for centres delivering or establishing total skin electron therapy, particularly as reduced-dose regimens become more common. They should reduce technical variability across institutions, although several recommendations remain consensus-based rather than supported by comparative clinical trials.