In February, 2012, a 36-year-old woman visited our outpatient department due to the progression of a skin disease for several months. Eight months before visiting, she found a pruritic, noduloplaque skin rash over her trunk and extremities. Concurrently, a growing, fungating lesion 15 cm in diameter was in the left lateral chest wall. She visited one of medical center in Taiwan for help. The Ga-67 study showed intense uptake in the lateral left chest wall that was corroborated by the clinical appearance. A whole abdominal computer tomography (CT) showed several subcentimeter lymph nodes in the bilateral inguinal areas, and a biopsy was done. The pathology reports showed cutaneous CD4+ T-cell lymphoma, T3N0M0B0, and stage IIB without lymph node metastasis. Many medium- to large-sized atypical lymphoid cells infiltrated diffusely into the superficial and deep dermis (Figure 1(a)). Most of the atypical lymphoid cells were positive for CD3 (Figure 1(b)) and CD4 (Figure 1(c)). Only a small portion of them were positive for CD8 (Figure 1(d)), CD79a (Figure 1(e)), and CD56 (Figure 1(f)). They were all negative for CD30 (Figure 1(g)).
The prescriptions were interferon alpha, psoralen plus ultraviolet A photochemotherapy, and Accutane (Isotretinoin). In addition, local electron radiotherapy was delivered to the left chest wall and right axillary area with 50 Gray (Gy) in 25 fractions, respectively. After local radiotherapy, the producing newly-formed plaques over the trunk and buttock outside the radiation field were noted. Oral methotrexate (2.5 mg) 5 mg twice per day was prescribed immediately but disease progressed. The patient was referred to our hospital for total skin irradiation.
HITS with dose painting techniques were applied from head to toe and avoided the previously treated areas. (Figures 2(a) and 2(b)) The patient was dressed with the diving suit (3 mm thick) to increase the superficial dose. The Polyflex II tissue equivalent material (Sammons Preston, Warrenville, IL, USA) was used as bolus for lesions over ears, fingers, and toes. The conformal bolus (R.P.D., Albertville, MN, USA) was used to cover the lesions in trunk. BlueBag immobilization system (Medical Intelligence, Germany) and thermoplastic fixation were used to fix head and neck, main trunk, and extremities. For tomotherapy treatment planning, a computed tomography (CT) image set of the whole body was required. The patients were scanned in a large bore (75 cm) CT scanner (GE, Discovery VCT PET/CT Imaging System) from head to toe. The level at 15 cm above knee was used as a reference point to separate the upper and lower set. The geometric edges of both fields were abutted at the HT treatment's 50% isodose plane. 
Both image sets were using the Philips Pinnacle3 treatment planning system for contouring. After that, the plan was transferred to the Tomotherapy Hi Art Planning system (v. 4.0.4. Tomotherapy, Inc., Madison, Wisconsin, USA). The clinical target volume (CTV) included the entire body surface system with subcutaneous 0.5 cm. To account for setup variability and respiratory motion, a planning target volume (PTV) was generated with a 0.5 cm margin at first. After 4 days treatment, the data of MVCT showed 0.5 cm for PTV was insufficient for some parts of body, such as shoulder, chest, abdomen, and pelvis. Therefore, the margins for PTV in these areas were changed accordingly. The anterior margin of the chest and abdomen was 1.0 cm with two-dimensional expansion and the shoulder was 0.8 cm with three-dimensional expansion, respectively. The CTV and PTV were sepacrated into five parts of head, chest, abdomen, pelvis, and upper extremities for the body plan. The hypothetical bolus was 1.0-1.5 cm in thickness from skin surface. Five mm was setting on the outer layer of PTV as hypothetical boluses during HITS plan to avoid the overhit of the inverse planning. Due to the different PTV margin used in the different part of body, the thicknesses of hypothetical boluses were variable. A central core complete block (CCCB) 2.5 cm away from PTV in HT planning system was used to restrict the photon beams to be an oblique incidence for increasing the superficial dose and reducing the internal organ dose (Figure 2(c)). 
Thirty Gy with 40 fractions interrupted at 20 fractions with one week resting, 4 times per week were prescribed. Total doses of 30 Gy to 95% of the PTV were delivered to the total skin area and tumor part, respectively. The normal tissue dose constraints utilized were based on the results of the survey of the clinical outcome of the target dose and dose limits to various organs at risk (OARs). The field width, pitch, and modulation factor (MF) used for the treatment planning optimization were 2.5, 0.287 cm, and 3.5, respectively. The dose volume histograms (DVHs) were calculated for the target and individual OARs. Toxicity of treatment was scored according to the Common Terminology Criteria for Adverse Events v4.0 (CTCAE v4.0).
Daily check of patient positioning was performed by the megavoltage CT (MVCT) system integrated in the tomotherapy machine. MVCT scan from head to thigh were performed to check the patient's whole body alignment. Image fusions were evaluated by the attending physician and physicist. Any translational shifts suggested by the image fusion results were applied to the final patient setup before treatment delivery. The tolerance of setup error allowed only a 5 mm difference in any of the three translation directions and 1  of difference in roll. Additional selected MVCT scans were performed after treatment to verify patient immobilization.
Radiochromic EBT2 film (International Specialty Products Inc. Wayne, NJ, USA) with thickness of 0.234 mm and effective measurement depth of 0.153 mm in a layer was used for dose measurements during HITS. Each film sheet was cut into smaller pieces as 5 x 5 cm that were placed on the lesions, head, chest, abdomen, pelvis, back, and extremities for calibration and measurement. The starting day in first period, 128 EBT2 films were measured (Figure 2(d)). In the starting day of second period, only 69 EBT2 films were putting on the important area of body to confirm the previous data. An Epson Perfection V700 flatbed scanner (Epson Seiko Corporation, Epson Seiko Corporation, Nagano, Japan) with the software of ImageJ Version 1.43 (National Institute of Health, Bethesda, MD, http://rsb.info.nih.gov/ij/) was used to scan all of the films at least 24 hours after film exposure. Films were scanned at a central scanner location and with the same orientation. The settings used were 48 bit color and 150 dpi (0.017 cm per pixel). Calibration was performed by irradiating each calibration film individually in a plastic water phantom perpendicularly to a 6 MV beam at dose levels from 0 to 150 cGy. The calibration curve was fitted using a polynomial function with the pixel value (PV) for each measurement film converted to dose accordingly (Figure 3). According to the calibration curve, the dose of the exposued EBT2 films can be measured.