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Bouchez Q, Vandenbroucke D, Pittomvils G, Boterberg T, van Eijkeren M, Leblans P, Vanderstraeten B. Computed chest radiography for total body irradiation: image quality and clinical feasibility. Biomed Phys Eng Express 2024; 10:045032. [PMID: 38788700 DOI: 10.1088/2057-1976/ad5018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/24/2024] [Indexed: 05/26/2024]
Abstract
Objective.In myeloablative total body irradiation (TBI), lung shielding blocks are used to reduce the dose to the lungs and hence decrease the risk of radiation pneumonitis. Some centers are still using mega-Volt (MV) imaging with dedicated silver halide-based films during simulation and treatment for lung delineation and position verification. However, the availability of these films has recently become an issue. This study examines the clinical performance of a computed radiography (CR) solution in comparison to radiographic films and potential improvement of image quality by filtering and post-processing.Approach.We compared BaFBrI-based CR plates to radiographic films. First, images of an aluminum block were analyzed to assess filter impact on scatter reduction. Secondly, a dedicated image quality phantom was used to assess signal linearity, signal-to-noise ratio (SNR), contrast and spatial resolution. Ultimately, a clinical performance study involving two impartial observers was conducted on an anthropomorphic chest phantom, employing visual grading analysis (VGA). Various filter materials and positions as well as post-processing were examined, and the workflow between CR and film was compared.Main results.CR images exhibited high SNR and linearity but demonstrated lower spatial and contrast resolution when compared to film. However, filtering improved contrast resolution and SNR, while positioning filters inside the cassette additionally enhanced sharpness. Image processing improved VGA scores, while additional filtering also resulted in higher spine visibility scores. CR shortened TBI simulation by over 10 minutes for one patient, alongside a dose reduction by order of 0.1 Gy.Significance.This study highlights potential advantages of shifting from conventional radiographic film to CR for TBI. Overall, CR with the incorporation of processing and filtering proves to be suitable for TBI chest imaging. When compared to radiographic film, CR offers advantages such as reduced simulation time and dose delivery, re-usability of image plates and digital workflow integration.
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Affiliation(s)
- Quentin Bouchez
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
| | | | - Geert Pittomvils
- Department of Radiotherapy-Oncology, Ghent University Hospital, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
| | - Tom Boterberg
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
- Department of Radiotherapy-Oncology, Ghent University Hospital, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
| | - Marc van Eijkeren
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
- Department of Radiotherapy-Oncology, Ghent University Hospital, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
| | - Paul Leblans
- R&D Imaging, Agfa N.V., Septestraat 27, B-2640 Mortsel, Belgium
| | - Barbara Vanderstraeten
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
- Department of Radiotherapy-Oncology, Ghent University Hospital, Corneel Heymanslaan 10, B-9000 Ghent, Belgium
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de Lima MR, Campbell DCDP, da Cunha-Madeira MR, Bomfim BCM, de Paula Ayres-Silva J. Animal Welfare in Radiation Research: The Importance of Animal Monitoring System. Vet Sci 2023; 10:651. [PMID: 37999474 PMCID: PMC10674294 DOI: 10.3390/vetsci10110651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 11/25/2023] Open
Abstract
Long-term research into radiation exposure significantly expanded following World War II, driven by the increasing number of individuals falling ill after the detonation of two atomic bombs in Japan. Consequently, researchers intensified their efforts to investigate radiation's effects using animal models and to study disease models that emerged post-catastrophe. As a result, several parameters have been established as essential in these models, encompassing radiation doses, regimens involving single or multiple irradiations, the injection site for transplantation, and the quantity of cells to be injected. Nonetheless, researchers have observed numerous side effects in irradiated animals, prompting the development of scoring systems to monitor these animals' well-being. The aim of this review is to delve into the historical context of using animals in radiation research and explore the ethical considerations related to animal welfare, which has become an increasingly relevant topic in recent years. These concerns have prompted research groups to adopt measures aimed at reducing animal suffering. Consequently, for animal welfare, the implementation of a scoring system for clinical and behavioral monitoring is essential. This represents one of the primary challenges and hurdles in radiation studies. It is concluded that implementing standardized criteria across all institutions is aimed at ensuring result reproducibility and fostering collaboration within the scientific community.
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Affiliation(s)
- Monique Ribeiro de Lima
- Center for Animal Experimentation, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro 21041-250, Brazil; (M.R.d.L.)
| | - Daiani Cotrim de Paiva Campbell
- Center for Animal Experimentation, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro 21041-250, Brazil; (M.R.d.L.)
| | | | - Barbara Cristina Marcollino Bomfim
- Laboratory of Experimental Medicine and Health, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro 21041-250, Brazil
| | - Jackline de Paula Ayres-Silva
- Laboratory of Experimental Medicine and Health, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro 21041-250, Brazil
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Lonski P, MacManus M, Campbell BA, Wheeler G, Ungureanu E, Kron T. Assessment of lung doses in patients undergoing total body irradiation for haematological malignancies with and without lung shielding. J Med Imaging Radiat Oncol 2023; 67:684-690. [PMID: 37343142 DOI: 10.1111/1754-9485.13550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 06/05/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Total body irradiation (TBI) practices vary considerably amongst centres, and the risk of treatment related toxicities remains unclear. We report lung doses for 142 TBI patients who underwent either standing TBI with lung shield blocks or lying TBI without blocks. METHODS Lung doses were calculated for 142 TBI patients treated between June 2016 and June 2021. Patients were planned using Eclipse (Varian Medical Systems) using AAA_15.6.06 for photon dose calculations and EMC_15.6.06 for electron chest wall boost fields. Mean and maximum lung doses were calculated. RESULTS Thirty-seven patients (26.2%) were treated standing using lung shielding blocks with 104 (73.8%) treated lying down. Lowest relative mean lung doses were achieved using lung shielding blocks in standing TBI, reducing the mean lung doses to 75.2% of prescription (9.9 Gy), ±4.1% (range 68.6-84.1%) for a prescribed dose of 13.2 Gy in 11 fractions, including contributions from electron chest wall boost fields, compared to 12 Gy in 6 fraction lying TBI receiving 101.6% mean lung dose (12.2 Gy) ±2.4% (range 95.2-109.5%) (P ≪ 0.05). Patients treated lying down with 2 Gy single fraction received the highest relative mean lung dose on average, with 108.4% (2.2 Gy) ±2.6% of prescription (range 103.2-114.4%). CONCLUSION Lung doses have been reported for 142 TBI patients using the lying and standing techniques described herein. Lung shielding blocks significantly reduced mean lung doses despite the addition of electron boost fields to the chest wall.
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Affiliation(s)
- Peta Lonski
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael MacManus
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Belinda A Campbell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Greg Wheeler
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Elena Ungureanu
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tomas Kron
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
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Hoeben BAW, Pazos M, Seravalli E, Bosman ME, Losert C, Albert MH, Boterberg T, Ospovat I, Mico Milla S, Demiroz Abakay C, Engellau J, Jóhannesson V, Kos G, Supiot S, Llagostera C, Bierings M, Scarzello G, Seiersen K, Smith E, Ocanto A, Ferrer C, Bentzen SM, Kobyzeva DA, Loginova AA, Janssens GO. ESTRO ACROP and SIOPE recommendations for myeloablative Total Body Irradiation in children. Radiother Oncol 2022; 173:119-133. [PMID: 35661674 DOI: 10.1016/j.radonc.2022.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Myeloablative Total Body Irradiation (TBI) is an important modality in conditioning for allogeneic hematopoietic stem cell transplantation (HSCT), especially in children with high-risk acute lymphoblastic leukemia (ALL). TBI practices are heterogeneous and institution-specific. Since TBI is associated with multiple late adverse effects, recommendations may help to standardize practices and improve the outcome versus toxicity ratio for children. MATERIAL AND METHODS The European Society for Paediatric Oncology (SIOPE) Radiotherapy TBI Working Group together with ESTRO experts conducted a literature search and evaluation regarding myeloablative TBI techniques and toxicities in children. Findings were discussed in bimonthly virtual meetings and consensus recommendations were established. RESULTS Myeloablative TBI in HSCT conditioning is mostly performed for high-risk ALL patients or patients with recurring hematologic malignancies. TBI is discouraged in children <3-4 years old because of increased toxicity risk. Publications regarding TBI are mostly retrospective studies with level III-IV evidence. Preferential TBI dose in children is 12-14.4 Gy in 1.6-2 Gy fractions b.i.d. Dose reduction should be considered for the lungs to <8 Gy, for the kidneys to ≤10 Gy, and for the lenses to <12 Gy, for dose rates ≥6 cGy/min. Highly conformal techniques i.e. TomoTherapy and VMAT TBI or Total Marrow (and/or Lymphoid) Irradiation as implemented in several centers, improve dose homogeneity and organ sparing, and should be evaluated in studies. CONCLUSIONS These ESTRO ACROP SIOPE recommendations provide expert consensus for conventional and highly conformal myeloablative TBI in children, as well as a supporting literature overview of TBI techniques and toxicities.
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Affiliation(s)
- Bianca A W Hoeben
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - Montserrat Pazos
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Enrica Seravalli
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Mirjam E Bosman
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Christoph Losert
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Michael H Albert
- Dept. of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Germany
| | - Tom Boterberg
- Dept. of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Inna Ospovat
- Dept. of Radiation Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Soraya Mico Milla
- Dept. of Radiation Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Candan Demiroz Abakay
- Dept. of Radiation Oncology, Uludag University Faculty of Medicine Hospital, Bursa, Turkey
| | - Jacob Engellau
- Dept. of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Gregor Kos
- Dept. of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Stéphane Supiot
- Dept. of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Camille Llagostera
- Dept. of Medical Physics, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Marc Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Giovanni Scarzello
- Dept. of Radiation Oncology, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | | | - Ed Smith
- Dept. of Radiation Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Abrahams Ocanto
- Dept. of Radiation Oncology, La Paz University Hospital, Madrid, Spain
| | - Carlos Ferrer
- Dept. of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Søren M Bentzen
- Dept. of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, United States
| | - Daria A Kobyzeva
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Geert O Janssens
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Hoeben BAW, Wong JYC, Fog LS, Losert C, Filippi AR, Bentzen SM, Balduzzi A, Specht L. Total Body Irradiation in Haematopoietic Stem Cell Transplantation for Paediatric Acute Lymphoblastic Leukaemia: Review of the Literature and Future Directions. Front Pediatr 2021; 9:774348. [PMID: 34926349 PMCID: PMC8678472 DOI: 10.3389/fped.2021.774348] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/03/2021] [Indexed: 12/13/2022] Open
Abstract
Total body irradiation (TBI) has been a pivotal component of the conditioning regimen for allogeneic myeloablative haematopoietic stem cell transplantation (HSCT) in very-high-risk acute lymphoblastic leukaemia (ALL) for decades, especially in children and young adults. The myeloablative conditioning regimen has two aims: (1) to eradicate leukaemic cells, and (2) to prevent rejection of the graft through suppression of the recipient's immune system. Radiotherapy has the advantage of achieving an adequate dose effect in sanctuary sites and in areas with poor blood supply. However, radiotherapy is subject to radiobiological trade-offs between ALL cell destruction, immune and haematopoietic stem cell survival, and various adverse effects in normal tissue. To diminish toxicity, a shift from single-fraction to fractionated TBI has taken place. However, HSCT and TBI are still associated with multiple late sequelae, leaving room for improvement. This review discusses the past developments of TBI and considerations for dose, fractionation and dose-rate, as well as issues regarding TBI setup performance, limitations and possibilities for improvement. TBI is typically delivered using conventional irradiation techniques and centres have locally developed heterogeneous treatment methods and ways to achieve reduced doses in several organs. There are, however, limitations in options to shield organs at risk without compromising the anti-leukaemic and immunosuppressive effects of conventional TBI. Technological improvements in radiotherapy planning and delivery with highly conformal TBI or total marrow irradiation (TMI), and total marrow and lymphoid irradiation (TMLI) have opened the way to investigate the potential reduction of radiotherapy-related toxicities without jeopardising efficacy. The demonstration of the superiority of TBI compared with chemotherapy-only conditioning regimens for event-free and overall survival in the randomised For Omitting Radiation Under Majority age (FORUM) trial in children with high-risk ALL makes exploration of the optimal use of TBI delivery mandatory. Standardisation and comprehensive reporting of conventional TBI techniques as well as cooperation between radiotherapy centres may help to increase the ratio between treatment outcomes and toxicity, and future studies must determine potential added benefit of innovative conformal techniques to ultimately improve quality of life for paediatric ALL patients receiving TBI-conditioned HSCT.
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Affiliation(s)
- Bianca A. W. Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Jeffrey Y. C. Wong
- Department of Radiation Oncology, City of Hope National Medical Center and Beckman Research Institute, Duarte, CA, United States
| | - Lotte S. Fog
- Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Christoph Losert
- Department of Radiation Oncology, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Andrea R. Filippi
- Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Søren M. Bentzen
- Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Adriana Balduzzi
- Stem Cell Transplantation Unit, Clinica Paediatrica Università degli Studi di Milano Bicocca, Monza, Italy
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Vogel J, Hui S, Hua CH, Dusenbery K, Rassiah P, Kalapurakal J, Constine L, Esiashvili N. Pulmonary Toxicity After Total Body Irradiation - Critical Review of the Literature and Recommendations for Toxicity Reporting. Front Oncol 2021; 11:708906. [PMID: 34513689 PMCID: PMC8428368 DOI: 10.3389/fonc.2021.708906] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/28/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Total body irradiation is an effective conditioning regimen for allogeneic stem cell transplantation in pediatric and adult patients with high risk or relapsed/refractory leukemia. The most common adverse effect is pulmonary toxicity including idiopathic pneumonia syndrome (IPS). As centers adopt more advanced treatment planning techniques for TBI, total marrow irradiation (TMI), or total marrow and lymphoid irradiation (TMLI) there is a greater need to understand treatment-related risks for IPS for patients treated with conventional TBI. However, definitions of IPS as well as risk factors for IPS remain poorly characterized. In this study, we perform a critical review to further evaluate the literature describing pulmonary outcomes after TBI. MATERIALS AND METHODS A search of publications from 1960-2020 was undertaken in PubMed, Embase, and Cochrane Library. Search terms included "total body irradiation", "whole body radiation", "radiation pneumonias", "interstitial pneumonia", and "bone marrow transplantation". Demographic and treatment-related data was abstracted and evidence quality supporting risk factors for pulmonary toxicity was evaluated. RESULTS Of an initial 119,686 publications, 118 met inclusion criteria. Forty-six (39%) studies included a definition for pulmonary toxicity. A grading scale was provided in 20 studies (17%). In 42% of studies the lungs were shielded to a set mean dose of 800cGy. Fourteen (12%) reported toxicity outcomes by patient age. Reported pulmonary toxicity ranged from 0-71% of patients treated with TBI, and IPS ranged from 1-60%. The most common risk factors for IPS were receipt of a TBI containing regimen, increasing dose rate, and lack of pulmonary shielding. Four studies found an increasing risk of pulmonary toxicity with increasing age. CONCLUSIONS Definitions of IPS as well as demographic and treatment-related risk factors remain poorly characterized in the literature. We recommend routine adoption of the diagnostic workup and the definition of IPS proposed by the American Thoracic Society. Additional study is required to determine differences in clinical and treatment-related risk between pediatric and adult patients. Further study using 3D treatment planning is warranted to enhance dosimetric precision and correlation of dose volume histograms with toxicities.
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Affiliation(s)
- Jennifer Vogel
- Department of Radiation Oncology, Bon Secours Merch Health St. Francis Cancer Center, Greenville, SC, United States
| | - Susanta Hui
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Chia-Ho Hua
- Department of Radiation Oncology, St Jude Children’s Research Hospital, Memphis, TN, United States
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, United States
| | - Premavarthy Rassiah
- Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, United States
| | - John Kalapurakal
- Department of Radiation Oncology, Northwestern University School of Medicine, Chicago, IL, United States
| | - Louis Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, United States
| | - Natia Esiashvili
- Department of Radiation Oncology, Emory School of Medicine, Atlanta, GA, United States
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Pearlman R, Hanna R, Burmeister J, Abrams J, Dominello M. Adverse Effects of Total Body Irradiation: A Two-Decade, Single Institution Analysis. Adv Radiat Oncol 2021; 6:100723. [PMID: 34195500 PMCID: PMC8237301 DOI: 10.1016/j.adro.2021.100723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose Several adverse effects have been reported in the literature associated with total body irradiation (TBI). Reports of the adverse effects of TBI have been primarily drawn from single-institution retrospective analyses. We report, to our knowledge, one of the largest cohorts of patients treated with TBI using multiple preparative chemotherapy and radiation regimens. Methods and Materials A retrospective chart review was performed for all 705 patients treated with TBI at our institution from 1995 to 2017. Based on availability of TBI records, 622 patients (88%) had sufficient evaluable documentation for analysis. Patients received 1 of 4 conditioning regimens: busulfan-fludarabine, 2 Gy (BUFLU); fludarabine-melphalan, 2 Gy (FLUMEL); cyclophosphamide, 12 Gy fractionated (CY); or etoposide, 12 Gy fractionated (VP16). Individual patients were evaluated for 13 specific recognized adverse effects based on the Common Terminology Criteria for Adverse Events, version 5.0. Results Mucositis (grade 3) was the most common serious adverse effect and occurred most frequently in the group receiving the VP16 12 Gy regimen (40% vs less than 14% in each of the other groups). Serious febrile neutropenia (grade 3-5) was less frequent (24%) among patients receiving CY than among those receiving the other conditioning regimens (more than 38% in each of the other groups). The incidence of serious lung infection was less common (5%) in patients receiving CY than in those receiving VP16 (18%). There was a higher frequency of grade 3-5 diarrhea among those receiving FLUMEL (5%) and VP16 (4%) than in the other groups (<3%) (P = .034). Otherwise, there were no detectable differences in serious toxicity by regimen for the 13 adverse effects reviewed. Only 2 secondary malignancies were reported, and both were in the BUFLU group. Cataract formation occurred in approximately 16% of patients overall, and the rates were similar across regimens. Median time to cataract formation was 1 to 4 years across regimens, with cataracts occurring earlier in the 2-Gy regimens. The overall rate of grade ≥3 pneumonitis was approximately 2% across the entire cohort. Conclusions Our nearly 20-year TBI experience showed relatively low rates of radiation-related toxicities. However, cataracts were common with a relatively short onset time.
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Affiliation(s)
- Richard Pearlman
- Detroit Medical Center, Detroit, Michigan
- Corresponding author: Richard Pearlman, MD
| | - Renee Hanna
- Michigan State University College of Human Medicine, Lansing, Michigan
| | - Jay Burmeister
- Wayne State University, Detroit, Michigan
- Karmanos Cancer Institute, Detroit, Michigan
- Corresponding author: Richard Pearlman, MD
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Esiashvili N, Lu X, Ulin K, Laurie F, Kessel S, Kalapurakal JA, Merchant TE, Followill DS, Sathiaseelan V, Schmitter MK, Devidas M, Chen Y, Wall DA, Brown PA, Hunger SP, Grupp SA, Pulsipher MA. Higher Reported Lung Dose Received During Total Body Irradiation for Allogeneic Hematopoietic Stem Cell Transplantation in Children With Acute Lymphoblastic Leukemia Is Associated With Inferior Survival: A Report from the Children's Oncology Group. Int J Radiat Oncol Biol Phys 2019; 104:513-521. [PMID: 30807822 PMCID: PMC6548591 DOI: 10.1016/j.ijrobp.2019.02.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 01/14/2019] [Accepted: 02/14/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To examine the relationship between lung radiation dose and survival outcomes in children undergoing total body irradiation (TBI)-based hematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukemia on the Children's Oncology Group trial. METHODS AND MATERIALS TBI (1200 or 1320 cGy given twice daily in 6 or 8 fractions) was used as part of 3 HSCT preparative regimens, allowing institutional flexibility regarding TBI techniques, including lung shielding. Lung doses as reported by each participating institution were calculated for different patient setups, with and without shielding, with a variety of dose calculation techniques. The association between lung dose and transplant-related mortality, relapse-free survival, and overall survival (OS) was examined using the Cox proportional hazards regression model controlling for the following variables: TBI dose rate, TBI fields, patient position during TBI, donor type, and pre-HSCT minimal residual disease level. RESULTS Of a total of 143 eligible patients, 127 had lung doses available for this analysis. The TBI techniques were heterogeneous. The mean lung dose was reported as 904.5 cGy (standard deviation, ±232.3). Patients treated with lateral fields were more likely to receive lung doses ≥800 cGy (P < .001). The influence of lung dose ≥800 cGy on transplant-related mortality was not significant (hazard ratio [HR], 1.78; P = .21). On univariate analysis, lung dose ≥800 cGy was associated with inferior relapse-free survival (HR, 1.76; P = .04) and OS (HR, 1.85; P = .03). In the multivariate analysis, OS maintained statistical significance (HR, 1.85; P = .04). CONCLUSIONS The variability in TBI techniques resulted in uncertainty with reported lung doses. Lateral fields were associated with higher lung dose, and thus they should be avoided. Patients treated with lung dose <800 cGy in this study had better outcomes. This approach is currently being investigated in the Children's Oncology Group AALL1331 study. Additionally, the Imaging and Radiation Oncology Core Group is evaluating effects of TBI techniques on lung doses using a phantom.
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Affiliation(s)
| | - Xiaomin Lu
- Children's Oncology Group Data Center, Biostatistics, University of Florida, Gainesville, Florida
| | - Ken Ulin
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - Fran Laurie
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - Sandy Kessel
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - John A Kalapurakal
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois
| | | | - David S Followill
- Imaging and Radiation Oncology Rhode Island QA Center, Houston, Texas
| | | | - Mary K Schmitter
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - Meenakshi Devidas
- Children's Oncology Group Data Center, Biostatistics, University of Florida, Gainesville, Florida
| | - Yichen Chen
- Children's Oncology Group Data Center, Biostatistics, University of Florida, Gainesville, Florida
| | - Donna A Wall
- Manitoba Blood and Marrow Transplant Program, Winnipeg, Manitoba, Canada
| | - Patrick A Brown
- Johns Hopkins University Kimmel Cancer Center, Baltimore, Maryland
| | - Stephen P Hunger
- Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephan A Grupp
- Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Pulsipher
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
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Byun HK, Yoon HI, Cho J, Kim HJ, Min YH, Lyu CJ, Cheong JW, Kim JS, Kim HS, Kim SJ, Yang AJ, Lee BM, Lee WH, Lee J, Ahn KJ, Suh CO. Factors associated with pulmonary toxicity after myeloablative conditioning using fractionated total body irradiation. Radiat Oncol J 2017; 35:257-267. [PMID: 29037020 PMCID: PMC5647754 DOI: 10.3857/roj.2017.00290] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 11/05/2022] Open
Abstract
Purpose Pulmonary toxicities, including infectious pneumonia (IP) and idiopathic pneumonia syndrome (IPS), are serious side effects of total body irradiation (TBI) used for myeloablative conditioning. This study aimed to evaluate clinical factors associated with IP and IPS following TBI. Materials and Methods Fifty-eight patients with hematologic malignancies who underwent TBI before allogeneic hematopoietic stem cell transplantation between 2005 and 2014 were reviewed. Most patients (91%) received 12 Gy in 1.5 Gy fractions twice a day. Pulmonary toxicities were diagnosed based on either radiographic evidence or reduced pulmonary function, and were subdivided into IP and IPS based on the presence or absence of concurrent infection. Results Pulmonary toxicities developed in 36 patients (62%); 16 (28%) had IP and 20 (34%) had IPS. IP was significantly associated with increased treatment-related mortality (p = 0.028) and decreased survival (p = 0.039). Multivariate analysis revealed that the risk of developing IPS was significantly higher in patients who received stem cells from a matched unrelated donor than from a matched sibling donor (p = 0.021; hazard ratio [HR] = 12.67; 95% confidence interval [CI], 1.46–110.30). Combining other conditioning agents with cyclophosphamide produced a higher tendency to develop IP (p = 0.064; HR = 6.19; 95% CI, 0.90–42.56). Conclusion IP and IPS involve different risk factors and distinct pathogeneses that should be considered when planning treatments before and after TBI.
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Affiliation(s)
- Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeho Cho
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ju Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo Hong Min
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chuhl Joo Lyu
- Division of Pediatric Hemato-oncology, Department of Pediatrics, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Korea
| | - June-Won Cheong
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Sun Kim
- Division of Pediatric Hemato-oncology, Department of Pediatrics, Yonsei University Health System, Yonsei University College of Medicine, Seoul, Korea
| | - Soo-Jeong Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Andrew Jihoon Yang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Min Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hee Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Joongyo Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Jung Ahn
- Department of Radiation Oncology, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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10
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Factors Influencing Pulmonary Toxicity in Children Undergoing Allogeneic Hematopoietic Stem Cell Transplantation in the Setting of Total Body Irradiation-Based Myeloablative Conditioning. Int J Radiat Oncol Biol Phys 2016; 94:349-59. [DOI: 10.1016/j.ijrobp.2015.10.054] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 10/11/2015] [Accepted: 10/26/2015] [Indexed: 11/23/2022]
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11
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In haematopoietic SCT for acute leukemia TBI impacts on relapse but not survival: results of a multicentre observational study. Bone Marrow Transplant 2013; 48:908-14. [PMID: 23708705 DOI: 10.1038/bmt.2013.66] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 03/26/2013] [Accepted: 03/30/2013] [Indexed: 11/12/2022]
Abstract
The aim of this study was to determine whether parameters related to TBI impacted upon OS and relapse in patients with acute leukemia in CR who underwent haematopoietic SCT (HSCT) in 11 Italian Radiation Oncology Centres. Data were analysed from 507 patients (313 males; 194 females; median age 15 years; 318 with ALL; 188 with AML; 1 case not recorded). Besides 128 autologous transplants, donors included 192 matched siblings, 74 mismatched family members and 113 unrelated individuals. Autologous and allogeneic transplants were analysed separately. Median follow-up was 40.1 months. TBI schedules and HSCT type were closely related. Uni- and multi-variate analyses showed no parameter was significant for OS or relapse in autologous transplantation. Multivariate analysis showed type of transplant and disease impacted significantly on OS in allogeneic transplantation. Disease, GVHD and TBI dose were risk factors for relapse. This analysis illustrates that Italian Transplant Centre use of TBI is in line with international practice. Most Centres adopted a hyperfractionated schedule that is used worldwide (12 Gy in six fractions over 3 days), which appears to have become standard. TBI doses impacted significantly upon relapse rates.
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12
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Othman TB, Kochbati L, Abdelkefi A, Ladeb S, Torjman L, Lakhal A, Kammoun L, Hentati D, Besbes M, Abdeladhim AB, Maalej M. Effect of once-a-day fractionated total body irradiation on the risk of relapse after non-T-cell-depleted HLA-matched sibling transplantation. ACTA ACUST UNITED AC 2007; 25:407-10. [PMID: 17952545 DOI: 10.1007/s11604-007-0158-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Accepted: 05/15/2007] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to assess the impact of fractionated total body irradiation (F-TBI) on treatment-related mortality (TRM) and relapse in patients who received a non-T-cell-depleted allogeneic stem cell transplantation (ASCT) for hematological malignancies. MATERIALS AND METHODS Between March 2003 and December 2004, a total of 24 patients with HLA-identical sibling donors entered this study and received three doses of 3.33 Gy F-TBI separated by 24 h and cyclophosphamide or etoposide. RESULTS At a median follow-up of 37 months (range 29-47 months), 4 of the 24 patients (16.6%) died of TRM. Relapse occurred in 10 patients at a median of 9 months (range 2-18 months). Overall, 13 of 24 patients (54%) died. Relapse was the most common cause of death (9/13). The 2-year actuarial survival rate was 46% (+/-11%). CONCLUSION In our experience, ASCT conditioned with F-TBI was associated with low TRM but a high early relapse rate in patients with hematological malignancies.
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Affiliation(s)
- Tarek Ben Othman
- Centre National de Greffe de Moelle Osseuse, Rue Jebel Lakhdar, 1006, Bab Saadoun, Tunis, Tunisia
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13
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Prestwich RJ, Picton SV, Glaser A, Taylor RE. Fatal pneumonitis in children with metastatic rhabdomyosarcoma following whole lung radiotherapy and sequential epirubicin. Pediatr Blood Cancer 2007; 48:586-90. [PMID: 16302221 DOI: 10.1002/pbc.20660] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Interstitial pneumonitis is a recognized complication following whole lung radiotherapy. We report two cases in which fatal pneumonitis appeared to be precipitated by the administration of epirubicin-containing combination chemotherapy within 7 weeks of completion of whole lung radiotherapy. These cases highlight a potentially fatal interaction between radiotherapy and modern chemotherapy regimens.
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Affiliation(s)
- R J Prestwich
- Department of Clinical Oncology, Cookridge Hospital, Yorkshire Cancer Centre, West Yorkshire, UK.
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14
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Oya N, Sasai K, Tachiiri S, Sakamoto T, Nagata Y, Okada T, Yano S, Ishikawa T, Uchiyama T, Hiraoka M. Influence of Radiation Dose Rate and Lung Dose on Interstitial Pneumonitis after Fractionated Total Body Irradiation: Acute Parotitis May Predict Interstitial Pneumonitis. Int J Hematol 2006; 83:86-91. [PMID: 16443559 DOI: 10.1532/ijh97.05046] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study evaluated patients for the influence of the dose rate and lung dose of fractionated total body irradiation (TBI) in preparation for allogeneic bone marrow transplantation (BMT) on the subsequent development of interstitial pneumonitis (IP). Sixty-six patients at our institute were treated with TBI followed by BMT. All of the patients received a total TBI dose of 12 Gy given in 6 fractions over 3 days and were divided into 3 groups according to the radiation dose rate and lung dose: group A, lung dose of 8 Gy (n = 18); group B, lung dose of 12 Gy at 8 cGy/min (n = 25); and group C, lung dose of 12 Gy at 19 cGy/min (n = 23). The overall survival rate, the cumulative incidence of relapse, and the cumulative incidence of IP were evaluated in relation to various potential indicators of future IP. There were no significant differences in survival and relapse rates between patient group A and combined groups B and C. Clinically significant IP occurred in 13 patients. The cumulative incidence of IP was significantly higher in patients who developed acute parotitis as indicated by either an elevation in the serum amylase level or parotid pain of grade 1 to 2. There was no difference in IP incidence among groups A, B, and C. There was no significant difference in IP incidence between lung dose values of 8 Gy (with lung shielding) and 12 Gy (without lung shielding) and between dose rate values of 8 cGy/min and 19 cGy/ min, at least when TBI was given in 6 fractions. The presence of acute parotitis during or just after TBI may be a predictor of IP.
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Affiliation(s)
- Natsuo Oya
- Department of Therapeutic Radiology and Oncology, Graduate School of Medical Sciences, Kyoto University, Kyoto, Japan.
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15
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Zaucha RE, Buckner DC, Barnett T, Holmberg LA, Gooley T, Hooper HA, Maloney DG, Appelbaum F, Bensinger WI. Modified total body irradiation as a planned second high-dose therapy with stem cell infusion for patients with bone-based malignancies. Int J Radiat Oncol Biol Phys 2006; 64:227-34. [PMID: 16169680 DOI: 10.1016/j.ijrobp.2005.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Revised: 06/07/2005] [Accepted: 06/08/2005] [Indexed: 11/29/2022]
Abstract
PURPOSE To estimate the maximum tolerated dose of hyperfractionated total marrow irradiation (TMI) as a second consolidation after high-dose chemotherapy with autologous or syngeneic blood stem cell transfusion for patients with bone/bone marrow-based malignant disease. PATIENTS AND METHODS Fifty-seven patients aged 3-65 years (median, 45 years), including 21 with multiple myeloma, 24 with breast cancer, 10 with sarcoma, and 2 with lymphoma, were treated with 1.5 Gy administered twice daily to a total dose of 12 Gy (n = 27), 13.5 Gy (n = 12), and 15 Gy (n = 18). Median time between the 2 transplants was 105 days (range, 63-162 days). RESULTS All patients engrafted neutrophils (median, Day 11; range, Day 9-23) and became platelet independent (median, Day 9; range, Day 7-36). There were 5 cases of Grade 3-4 regimen-related pulmonary toxicity, 1 at 12 Gy, and 4 at 15 Gy. Complete responses, partial responses, and stabilizations were achieved in 33%, 26%, and 41% of patients, respectively. Kaplan-Meier estimates of 5-year progression-free survival and overall survival for 56 evaluable patients are 24% and 36%, respectively. Median time of follow-up among survivors was 96 months (range, 77-136 months). CONCLUSION Total marrow irradiation as a second myeloablative therapy is feasible. The estimated maximum tolerated dose for TMI in a tandem transplant setting was 13.5 Gy. Because 20% of patients are surviving at 8 years free of disease, further studies of TMI are warranted.
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Affiliation(s)
- Renata E Zaucha
- Fred Hutchinson Cancer Research Center, University of Washington, Clinical Research Division, Seattle, WA 98109-1024, USA
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16
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Hui SK, Kapatoes J, Fowler J, Henderson D, Olivera G, Manon RR, Gerbi B, Mackie TR, Welsh JS. Feasibility study of helical tomotherapy for total body or total marrow irradiationa). Med Phys 2005; 32:3214-24. [PMID: 16279075 DOI: 10.1118/1.2044428] [Citation(s) in RCA: 162] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Total body radiation (TBI) has been used for many years as a preconditioning agent before bone marrow transplantation. Many side effects still plague its use. We investigated the planning and delivery of total body irradiation (TBI) and selective total marrow irradiation (TMI) and a reduced radiation dose to sensitive structures using image-guided helical tomotherapy. To assess the feasibility of using helical tomotherapy, (A) we studied variations in pitch, field width, and modulation factor on total body and total marrow helical tomotherapy treatments. We varied these parameters to provide a uniform dose along with a treatment times similar to conventional TBI (15-30 min). (B) We also investigated limited (head, chest, and pelvis) megavoltage CT (MVCT) scanning for the dimensional pretreatment setup verification rather than total body MVCT scanning to shorten the overall treatment time per treatment fraction. (C) We placed thermoluminescent detectors (TLDs) inside a Rando phantom to measure the dose at seven anatomical sites, including the lungs. A simulated TBI treatment showed homogeneous dose coverage (+/-10%) to the whole body. Doses to the sensitive organs were reduced by 35%-70% of the target dose. TLD measurements on Rando showed an accurate dose delivery (+/-7%) to the target and critical organs. In the TMI study, the dose was delivered conformally to the bone marrow only. The TBI and TMI treatment delivery time was reduced (by 50%) by increasing the field width from 2.5 to 5.0 cm in the inferior-superior direction. A limited MVCT reduced the target localization time 60% compared to whole body MVCT. MVCT image-guided helical tomotherapy offers a novel method to deliver a precise, homogeneous radiation dose to the whole body target while reducing the dose significantly to all critical organs. A judicious selection of pitch, modulation factor, and field size is required to produce a homogeneous dose distribution along with an acceptable treatment time. In addition, conformal radiation to the bone marrow appears feasible in an external radiation treatment using image-guided helical tomotherapy.
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Affiliation(s)
- Susanta K Hui
- Department of Therapeutic Radiology, University of Minnesota, Minneapolis, 420 Delaware Street SE, Minneapolis, Minnesota 55455, USA.
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17
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Hui SK, Das RK, Thomadsen B, Henderson D. CT-based analysis of dose homogeneity in total body irradiation using lateral beam. J Appl Clin Med Phys 2004; 5:71-9. [PMID: 15738922 PMCID: PMC5723515 DOI: 10.1120/jacmp.v5i4.1980] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A computed tomography (CT) based treatment planning system for total body irradiation (TBI) is presented and compared with the commonly practiced lateral treatment delivery. The TBI regimen has been proved to be an essential conditional regimen for patients undergoing bone marrow transplantation. The advantage of the TBI regimen with bone marrow transplantation (BMT) in hematological malignancies can be offset by toxicities arising from TBI in posttransplant complications. With the increasing survival rates, the evaluation of long‐term side effects and quality of life has become an important area of research interest. There have been several treatment techniques developed over the decades designed to achieve accurate dose delivery and dose homogeneity. This paper reports on the verification of the dose delivery for a basic lateral technique using thermoluminescent dosimeters (TLDs) placed in an anthropomorphic phantom and its correlation with CT‐based treatment planning. CT‐based treatment plans on several patients were used to evaluate the doses delivered to the whole body and critical organs. A large variation in doses delivered to the whole body was demonstrated, with some parts of the bone marrow failing to receive the prescribed dose and some critical organs, such as the lungs, receiving excessive doses. Placing the arms at the sides only partially compensates for the increased transmission of the lungs because the arms only shadow part of the lung. This study shows that CT‐based treatment planning for TBI provides precise and accurate dose calculations and allows for the correlation of clinical outcomes with the doses actually delivered to various organs. PACS numbers: 87.53.Dq, 87.66.Xa, 87.66.Sq
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Affiliation(s)
- Susanta K Hui
- Department of Human Oncology, University of Wisconsin-Madison, 600 Highland Avenue, Madison, Wisconsin 53792, USA.
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18
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Abstract
A review was undertaken of all patients treated at Royal Adelaide Hospital, South Australia with total body irradiation (TBI) for the purpose of assessing the incidence of interstitial pneumonitis (IP) and possible prognostic factors for its development. The aim was also to assess the impact of IP and other prognostic factors on long-term survival outcome following bone marrow transplantation. A total of 84 patients received TBI, with 12 Gy in six fractions delivered using two different instantaneous dose rates of 7.5 and 15 cGy min−1. This series included 26 cases of acute lymphoblastic leukaemia, 26 of multiple myeloma and 15 of acute myelogenous leukaemia. On multivariate analysis, a higher dose rate was independently significant for an increased risk of IP.
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Affiliation(s)
- S A Carruthers
- Department of Radiation Oncology, Royal Adelaide Hospital Cancer Centre, North Terrace, Adelaide, South Australia 5000, Australia.
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19
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Cui YZ, Hisha H, Yang GX, Fan TX, Jin T, Li Q, Lian Z, Ikehara S. Optimal protocol for total body irradiation for allogeneic bone marrow transplantation in mice. Bone Marrow Transplant 2002; 30:843-9. [PMID: 12476275 DOI: 10.1038/sj.bmt.1703766] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2002] [Accepted: 08/28/2002] [Indexed: 11/08/2022]
Abstract
We have previously demonstrated, using chimeric resistant MRL/lpr mice, that a fractionated total body irradiation (FTBI) (5 Gy x 2 with a 4 h interval on the day before allogeneic bone marrow transplantation (BMT)) is the best conditioning regimen for the treatment of autoimmune diseases in radiosensitive MRL/lpr mice. In the present study, using various standard strains of mice (not radiosensitive mice), we explore the best protocol for irradiation (doses and intervals) as the conditioning regimen for allogeneic BMT. Recipient mice were exposed to various irradiation regimens: a single total body irradiation (TBI) of 9.5 or 12 Gy and FTBI of (5+5) Gy to (7+7) Gy with a 1 to 24 h interval. The method generally utilized for humans ((2+2) Gy with a 4 h interval for 3 days (total 12 Gy)) was also used. One day after the last irradiation, donor BMCs from BALB/c, C3H, or C57BL/6 (B6) mice were transplanted into C3H or B6 mice. The irradiation protocol of (2+2) Gy for 3 days was found to be insufficient to enable the complete removal of recipient immunocompetent cells, since donor-reactive T cells were observed in the recipient spleens and many recipient-type NK and CD4(+) cells were also detected in the recipient hematolymphoid tissues. In all the combinations, the highest survival rate was achieved in the recipients irradiated with (6+6) or (6.5+6.5) Gy with a 4 h interval. In the surviving mice, the hematolymphoid tissues had been fully reconstituted with donor cells.
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Affiliation(s)
- Y-Z Cui
- First Department of Pathology, Kansai Medical University, Moriguchi, Osaka, Japan
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20
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Della Volpe A, Ferreri AJM, Annaloro C, Mangili P, Rosso A, Calandrino R, Villa E, Lambertenghi-Deliliers G, Fiorino C. Lethal pulmonary complications significantly correlate with individually assessed mean lung dose in patients with hematologic malignancies treated with total body irradiation. Int J Radiat Oncol Biol Phys 2002; 52:483-8. [PMID: 11872296 DOI: 10.1016/s0360-3016(01)02589-5] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE To assess the impact of lung dose on lethal pulmonary complications (LPCs) in a single-center group of patients with hematologic malignancies treated with total body irradiation (TBI) in the conditioning regimen for bone marrow transplantation (BMT). METHODS The mean lung dose of 101 TBI-conditioned patients was assessed by a thorough (1 SD around 2%) in vivo transit dosimetry technique. Fractionated TBI (10 Gy, 3.33 Gy/fraction, 1 fraction/d, 0.055 Gy/min) was delivered using a lateral-opposed beam technique with shielding of the lung by the arms. The median lung dose was 9.4 Gy (1 SD 0.8 Gy, range 7.8--11.4). The LPCs included idiopathic interstitial pneumonia (IIP) and non-idiopathic IP (non-IIP). RESULTS Nine LPCs were observed. LPCs were observed in 2 (3.8%) of 52 patients in the group with a lung dose < or = 9.4 Gy and in 7 (14.3%) of 49 patients in the >9.4 Gy group. The 6-month LPC risk was 3.8% and 19.2% (p = 0.05), respectively. A multivariate analysis adjusted by the following variables: type of malignancy (acute leukemia, chronic leukemia, lymphoma, myeloma), type of BMT (allogeneic, autologous), cytomegalovirus infection, graft vs. host disease, and previously administered drugs (bleomycin, cytarabine, cyclophosphamide, nitrosoureas), revealed a significant and independent association between lung dose and LPC risk (p = 0.02; relative risk = 6.7). Of the variables analyzed, BMT type (p = 0.04; relative risk = 6.6) had a risk predictive role. CONCLUSION The mean lung dose is an independent predictor of LPC risk in patients treated with the 3 x 3.33-Gy low-dose-rate TBI technique. Allogeneic BMT is associated with a higher risk of LPCs.
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Affiliation(s)
- Aldo Della Volpe
- Centro Trapianti di Midollo, Ospedale Maggiore di Milano IRCCS, Milano, Italy
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Chen CI, Abraham R, Tsang R, Crump M, Keating A, Stewart AK. Radiation-associated pneumonitis following autologous stem cell transplantation: predictive factors, disease characteristics and treatment outcomes. Bone Marrow Transplant 2001; 27:177-82. [PMID: 11281387 DOI: 10.1038/sj.bmt.1702771] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
High-dose therapy followed by autologous stem cell transplantation (ASCT) prolongs survival in patients with multiple myeloma and is relatively safe with treatment-related mortality rates of only 1-5%. Interstitial pneumonitis (IP) is normally an infrequent complication of ASCT with a reported incidence of 0-16%. Between 1992 and 1998, 94 myeloma patients at our center underwent ASCT using a high-dose regimen of etoposide (60 mg/kg), melphalan (160 mg/m2) and fractionated TBI 12 Gy. An unusually high incidence of IP (29/94 (31%)) was noted. Mortality in the IP patients was high at 45%. Patients developing IP were more frequently anemic than those who did not have pulmonary complications (hemoglobin <100 g/l) prior to transplant (P = 0.03) but no other pre-transplant factors were predictive (ie age, gender, smoking history, CMV status, pulmonary function, creatinine, beta2-microglobulin or C-reactive protein, prior cumulative chemotherapy or chest irradiation). A significantly lower IP rate was noted in 32 contemporaneous myeloma control patients conditioned with BU-CY without TBI at our center (3/32 (9%); P=0.03) and in 32 lymphoma control patients conditioned with the same melphalan and etoposide regimen minus the TBI (2/32 (6%); P = 0.003). In contrast, when using the same TBI-containing regimen in 32 concurrently treated lymphoma patients, an increase in IP similar to that seen in our myeloma cohort (7/32 (22%); P = 0.3) was noted. This strongly suggests that TBI is the predominant factor contributing to lung toxicity. We conclude that radiation-associated pneumonitis cannot be easily predicted by pretransplant variables. Therefore surveillance, early recognition and prompt therapy are recommended.
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Affiliation(s)
- C I Chen
- University of Toronto Autologous Bone Marrow Transplant Program, The Princess Margaret Hospital, Ontario, Canada
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Hale GA, Tong X, Benaim E, Cunningham JM, Heslop HE, Horwiz EM, Leung W, Rochester RJ, Shearer PD, Srivastava DK, Woodard JP, Bowman LC. Allogeneic bone marrow transplantation in children failing prior autologous bone marrow transplantation. Bone Marrow Transplant 2001; 27:155-62. [PMID: 11281384 DOI: 10.1038/sj.bmt.1702765] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Twenty-three children with de novo acute myelogenous leukemia (AML) (n = 20), secondary AML (n = 1), or non-Hodgkin's lymphoma (NHL) (n = 2) underwent allogeneic bone marrow transplantation (alloBMT) for graft failure (n = 1) or recurrent malignancy (n = 22) between February 1992 and August 1999 following autologous BMT (ABMT). Induction chemotherapy was given to 14 patients and nine patients went directly to alloBMT. Five received marrow from matched siblings, 14 from matched unrelated donors and four from mismatched family members. Conditioning regimens included cyclophosphamide, cytarabine, and total body irradiation. Nine patients are alive disease-free between 627 and 2433 days (1.7-6.7 years) post BMT resulting in a 4-year DFS of 39%. Eight patients relapsed at a median of 206 days (range, 35-669 days) post alloBMT and all eventually died. Eight patients (two of whom also relapsed) died of RRT. Although RRT and relapse remain significant problems, a significant percentage of pediatric patients failing ABMT may be cured with alloBMT.
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Affiliation(s)
- G A Hale
- Department of Hematology/Oncology, St Jude Children's Research Hospital, Memphis, TN 38105-2794, USA
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Vaidya SJ, Atra A, Bahl S, Pinkerton CR, Calvagna V, Horton C, Milan S, Shepherd V, Brain C, Treleaven J, Powles R, Tait D, Meller ST. Autologous bone marrow transplantation for childhood acute lymphoblastic leukaemia in second remission - long-term follow-up. Bone Marrow Transplant 2000; 25:599-603. [PMID: 10734293 DOI: 10.1038/sj.bmt.1702214] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
From 1984 to 1996, 31 consecutive children without sibling donors, aged 5-19 years (median 8) with acute lymphoblastic leukaemia (ALL) in second complete remission (CR), received unpurged autologous bone marrow transplantation (ABMT) after melphalan and single fraction total body irradiation (TBI). ABMT was performed using fresh unmanipulated marrow harvested after standard reinduction and consolidation therapy 2-11 months (median 5) after relapse. With a median survival of 2.9 years the probability of survival for all patients in continuing second CR was 45.1% (95% CI, 24%-62%) after 5 years. Regimen-related and non-leukaemia mortality was 7% (95% CI, 2%-26%). The longest time to second relapse from ABMT was 3.1 years. Pituitary and gonadal dysfunction requiring hormonal replacement therapy occurred in the majority of long-term survivors. Twelve patients developed cataracts. ABMT with melphalan/single fraction TBI has proved an effective anti-leukaemia treatment with low regimen-related mortality but significant long-term morbidity. The current approach of allogeneic BMT from an unrelated donor when no sibling donor is available, following conditioning with cyclophosphamide/ fractionated TBI has resulted in a reduced relapse rate and improved short-term overall survival in the treatment of relapsed childhood ALL. However, long-term results are awaited.
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Affiliation(s)
- S J Vaidya
- Paediatric Oncology, The Royal Marsden NHS Trust, Sutton, UK
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Aristei C, Aversa F, Chionne F, Martelli MF, Latini P. Interstitial pneumonitis in acute leukemia patients submitted to T-depleted matched and mismatched bone marrow transplantation. Int J Radiat Oncol Biol Phys 1998; 41:651-7. [PMID: 9635716 DOI: 10.1016/s0360-3016(98)00068-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To identify factors that could contribute to interstitial pneumonitis (IP), which remains one of the major causes of morbidity and mortality after both matched and mismatched bone marrow transplantation (BMT). METHODS AND PATIENTS Ninety acute leukemia patients received an allogeneic T-depleted matched (n = 54) or mismatched (n = 36) BMT. They were preconditioned with total body irradiation (TBI), thiotepa, rabbit anti-thymocyte globulin, and cyclophosphamide. The TBI scheme was hyperfractionated in matched, and a single dose in mismatched patients. The dose to the lungs was reduced in both groups. RESULTS Five of the 54 matched patients developed IP. All cases were fatal. There were 16 cases of IP, 13 fatal, in the mismatched group. The probability of developing IP was 11.3 +/- 4.9% and 48.6 +/- 9.0%, respectively. The between-group difference was statistically significant (p < 0.0001). The type of transplant and the TBI scheme were the most important parameters for IP development in univariate analysis, whereas acute graft-versus-host disease, disease stage and sex were nonsignificant. Median follow-up was 342 days (range 17-2900). CONCLUSIONS The low incidence of IP in matched patients and the lack of idiopathic cases are evidence for the validity of the TBI schedule. In contrast, the incidence in mismatched patients remains too high; therefore, new strategies should be studied in an attempt to lower it.
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Affiliation(s)
- C Aristei
- Institute of Radiotherapy Oncology, General Hospital and Perugia University, Italy
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Shank B. The balancing act: pneumonitis vs. relapse in cytoreductive regimens containing total body irradiation. Int J Radiat Oncol Biol Phys 1996; 36:261-2. [PMID: 8823285 DOI: 10.1016/s0360-3016(96)00307-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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