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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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Liang X, Li P, Wu Q. A novel AP/PA total body irradiation technique using abutting IMRT fields at extended SSD. J Appl Clin Med Phys 2024; 25:e14213. [PMID: 38425126 PMCID: PMC11005982 DOI: 10.1002/acm2.14213] [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: 06/22/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 03/02/2024] Open
Abstract
PURPOSE To develop a Total Body Irradiation (TBI) technique using IMRT at extended SSD that can be performed in any size Linac room. METHODS Patients studied were placed on a platform close to the floor, directly under the gantry with cranial-caudal axis parallel to the gantry rotation plane and at SSD ∼200 cm. Two abutting fields with the same external isocenter at gantry angles of ±21˚, collimator angle of 90˚, and field size of 25 × 40 cm2 are employed for both supine and prone positions. An iterative optimization algorithm was developed to generate a uniform dose at the patient mid-plane with adequate shielding to critical organs such as lungs and kidneys. The technique was validated in both phantom and patient CT images for treatment planning, and dose measurement and QA were performed in phantom. RESULTS A uniform dose distribution in the mid-plane within ±5% of the prescription dose was reached after a few iterations. This was confirmed with ion-chamber measurements in phantom. The mean dose to lungs and kidneys can be adjusted according to clinical requirements and can be as low as ∼25% of the prescription dose. For a typical prescription dose of 200 cGy/fraction, the total MU was ∼2400/1200 for the superior/inferior field. The overall treatment time for both supine/prone positions was ∼54 min to meet the maximum absorbed dose rate criteria of 15 cGy/min. IMRT QA with portal dosimetry shows excellent agreement. CONCLUSIONS We have developed a promising TBI technique using abutting IMRT fields at extended SSD. The patient is in a comfortable recumbent position with good reproducibility and less motion during treatment. An additional benefit of this technique is that full 3D dose distribution is available from the TPS with a DVH summary for organs of interest. The technique allows precise sparing of lungs and kidneys and can be executed in any linac room.
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Affiliation(s)
- Xiaomin Liang
- Medical Physics Graduate ProgramDuke Kunshan UniversityKunshanJiangsuChina
| | - Peixiong Li
- Medical Physics Graduate ProgramDuke Kunshan UniversityKunshanJiangsuChina
| | - Qiuwen Wu
- Department of Radiation OncologyDuke University Medical CenterDurhamNorth CarolinaUSA
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Burmeister JW, Bossenberger T, Nalichowski A, Hammoud A, Baran G, Dominello MM. Total body irradiation delivered using a dedicated Co-60 TBI unit: Evaluation of dosimetric uniformity and dose verification. J Appl Clin Med Phys 2024; 25:e14188. [PMID: 37910646 PMCID: PMC10860458 DOI: 10.1002/acm2.14188] [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: 07/12/2023] [Revised: 10/03/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023] Open
Abstract
This work presents the dosimetric characteristics of Total Body Irradiation (TBI) delivered using a dedicated Co-60 TBI unit. We demonstrate the ability to deliver a uniform dose to the entire patient without the need for a beam spoiler or patient-specific compensation. Full dose distributions are calculated using an in-house Monte Carlo treatment planning system, and cumulative dose distributions are created by deforming the dose distributions within two different patient orientations. Sample dose distributions and profiles are provided to illustrate the plan characteristics, and dose and DVH statistics are provided for a heterogeneous cohort of patients. The patient cohort includes adult and pediatric patients with a range of 132-198 cm in length and 16.5-37.5 cm in anterior-posterior thickness. With the exception of the lungs, a uniform dose of 12 Gy is delivered to the patient with nearly the entire volume receiving a dose within 10% of the prescription dose. Mean lung doses (MLDs) are maintained below the estimated threshold for radiation pneumonitis, with MLDs ranging from 7.3 to 9.3 Gy (estimated equivalent dose in 2 Gy fractions (EQD2 ) of 6.2-8.5 Gy). Dose uniformity is demonstrated across five anatomical locations within the patient for which mean doses are all within 3.1% of the prescription dose. In-vivo dosimetry demonstrates excellent agreement between measured and calculated doses, with 78% of measurements within ±5% of the calculated dose and 99% within ±10%. These results demonstrate a state-of-the-art TBI planning and delivery system using a dedicated TBI unit and hybrid in-house and commercial planning techniques which provide comprehensive dosimetric data for TBI treatment plans that are accurately verified using in-vivo dosimetry.
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Affiliation(s)
- Jay W. Burmeister
- Department of OncologyWayne State University School of MedicineDetroitMichiganUSA
- Gershenson Radiation Oncology CenterBarbara Ann Karmanos Cancer InstituteDetroitMichiganUSA
| | - Todd Bossenberger
- Gershenson Radiation Oncology CenterBarbara Ann Karmanos Cancer InstituteDetroitMichiganUSA
| | - Adrian Nalichowski
- Department of OncologyWayne State University School of MedicineDetroitMichiganUSA
- Gershenson Radiation Oncology CenterBarbara Ann Karmanos Cancer InstituteDetroitMichiganUSA
| | - Ahmad Hammoud
- Gershenson Radiation Oncology CenterBarbara Ann Karmanos Cancer InstituteDetroitMichiganUSA
| | - Geoff Baran
- Gershenson Radiation Oncology CenterBarbara Ann Karmanos Cancer InstituteDetroitMichiganUSA
| | - Michael M. Dominello
- Department of OncologyWayne State University School of MedicineDetroitMichiganUSA
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Parsons D, Lim TY, Teruel JR, Galavis P, Agostinelli S, Liang J, Mancosu P, Cherpak A, Stanley DN, Ahn KH, Guo B, Gonzalez Y, Burmeister J, Wong JY, Gu X, Kim GGY. Considerations for intensity modulated total body or total marrow and lymphoid irradiation. Clin Transl Radiat Oncol 2023; 43:100674. [PMID: 37753462 PMCID: PMC10518336 DOI: 10.1016/j.ctro.2023.100674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
We compiled a sampling of the treatment techniques of intensity-modulated total body irradiation, total marrow irradiation and total marrow and lymphoid irradiation utilized by several centers across North America and Europe. This manuscript does not serve as a consensus guideline, but rather is meant to serve as a convenient reference for centers that are considering starting an intensity-modulated program.
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Affiliation(s)
- David Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tze Yee Lim
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose R. Teruel
- Department of Radiation Oncology, New York University Langone Health, New York, NY, USA
| | - Paulina Galavis
- Department of Radiation Oncology, New York University Langone Health, New York, NY, USA
| | | | - Jieming Liang
- Department of Radiation Oncology, City of Hope National Medical Center City of Hope National Medical Center, Duarte, CA, USA
| | - Pietro Mancosu
- IRCCS Humanitas Research Hospital, Medical Physics Unit, Rozzano, Milan, Italy
| | - Amanda Cherpak
- Department of Radiation Oncology and Department of Medical Physics, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Dennis N. Stanley
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kang-Hyun Ahn
- Department of Radiation Oncology, University of Illinois, Chicago, IL and Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA
| | - Bingqi Guo
- Department of Radiation Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Yesenia Gonzalez
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jay Burmeister
- Department of Oncology, Wayne State University School of Medicine, Karmanos Cancer Center, Detroit, MI, USA
| | - Jeffrey Y.C. Wong
- Department of Radiation Oncology, City of Hope National Medical Center City of Hope National Medical Center, Duarte, CA, USA
| | - Xuejun Gu
- Department of Radiation Oncology, Stanford University, Palo Alto, CA, USA
| | - Grace Gwe-Ya Kim
- Radiation Medicine and Applied Science, University of California San Diego, La Jolla, CA, USA
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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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Köksal M, Baumert J, Jazmati D, Schoroth F, Garbe S, Koch D, Scafa D, Sarria GR, Leitzen C, Massoth G, Delis A, Heine A, Holderried T, Brossart P, Müdder T, Schmeel LC. Whole body irradiation with intensity-modulated helical tomotherapy prior to haematopoietic stem cell transplantation: analysis of organs at risk by dose and its effect on blood kinetics. J Cancer Res Clin Oncol 2023; 149:7007-7015. [PMID: 36856852 PMCID: PMC10374741 DOI: 10.1007/s00432-023-04657-7] [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: 01/25/2023] [Accepted: 02/15/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Intensity-modulated helical tomotherapy (HT) is a promising technique in preparation for bone marrow transplantation. Nevertheless, radiation-sensitive organs can be substantially compromised due to suboptimal delivery techniques of total body irradiation (TBI). To reduce the potential burden of radiation toxicity to organs at risk (OAR), high-quality coverage and homogeneity are essential. We investigated dosimetric data from kidney, lung and thorax, liver, and spleen in relation to peripheral blood kinetics. To further advance intensity-modulated total body irradiation (TBI), the potential for dose reduction to lung and kidney was considered in the analysis. PATIENTS AND METHODS 46 patients undergoing TBI were included in this analysis, partially divided into dose groups (2, 4, 8, and 12 Gy). HT was performed using a rotating gantry to ensuring optimal reduction of radiation to the lungs and kidneys and to provide optimal coverage of other OAR. Common dosimetric parameters, such as D05, D95, and D50, were calculated and analysed. Leukocytes, neutrophils, platelets, creatinine, GFR, haemoglobin, overall survival, and graft-versus-host disease were related to the dosimetric evaluation using statistical tests. RESULTS The mean D95 of the lung is 48.23%, less than half the prescribed and unreduced dose. The D95 of the chest is almost twice as high at 84.95%. Overall liver coverage values ranged from 96.79% for D95 to 107% for D05. The average dose sparing of all patients analysed resulted in an average D95 of 68.64% in the right kidney and 69.31% in the left kidney. Average D95 in the spleen was 94.28% and D05 was 107.05%. Homogeneity indexes ranged from 1.12 for liver to 2.28 for lung. The additional significance analyses conducted on these blood kinetics showed a significant difference between the 2 Gray group and the other three groups for leukocyte counts. Further statistical comparisons of the dose groups showed no significant differences. However, there were significant changes in the dose of OAR prescribed with dose sparing (e.g., lung vs. rib and kidney). CONCLUSION Using intensity-modulated helical tomotherapy to deliver TBI is a feasible method in preparation for haematopoietic stem cell transplantation. Significant dose sparing in radiosensitive organs such as the lungs and kidneys is achievable with good overall quality of coverage. Peripheral blood kinetics support the positive impact of HT and its advantages strongly encourage its implementation within clinical routine.
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Affiliation(s)
- Mümtaz Köksal
- Radiation Oncology, University Hospital Bonn, Bonn, Germany.
| | | | - Danny Jazmati
- Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Felix Schoroth
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Stephan Garbe
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - David Koch
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Davide Scafa
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | | | | | - Gregor Massoth
- Anaesthesiology, Perioperative and Pain Medicine, University Hospital Bonn, Bonn, Germany
| | - Achilles Delis
- Anaesthesiology, Perioperative and Pain Medicine, University Hospital Bonn, Bonn, Germany
| | - Annkristin Heine
- Internal Medicine-Oncology, Haematology and Rheumatology, University Hospital Bonn, Bonn, Germany
| | - Tobias Holderried
- Internal Medicine-Oncology, Haematology and Rheumatology, University Hospital Bonn, Bonn, Germany
| | - Peter Brossart
- Internal Medicine-Oncology, Haematology and Rheumatology, University Hospital Bonn, Bonn, Germany
| | - Thomas Müdder
- Radiation Oncology, University Hospital Bonn, Bonn, Germany
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Gruber I, Koelbl O, Treutwein M, Zeman F, Herr W, Holler E, Edinger M, Wolff D. Analysis of long-term mortality after total body irradiation-based and melphalan-based chemotherapy conditioning for acute myeloid leukemia. Ann Hematol 2023:10.1007/s00277-023-05318-y. [PMID: 37347269 DOI: 10.1007/s00277-023-05318-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment option for selected patients with acute myeloid leukemia. Yet, the influence of total body irradiation (TBI)-based conditioning as compared to non-TBI-based conditioning on long-term mortality is unclear. We retrospectively evaluated outcomes after TBI-based (n = 91) and non-TBI-based conditioning (melphalan-based, n = 248) for 1st allo-HSCT patients transplanted at the University Hospital Regensburg between 1999 and 2020. TBI was performed with an average dose rate of 4 cGy/min. Median follow-up was 8.3 years (interquartile range, 4.8-12.9 years). Cumulative incidence rates of 5-year non-relapse mortality (NRM) were 17% (95% confidence interval, CI, 10-25) and 33% (95% CI, 27-40) after TBI- and non-TBI-based conditioning (P < 0.001). Five-year cumulative incidences of relapse (CIR) were 42% (95% CI, 32-52) and 29% (95% CI, 23-35) after TBI- and non-TBI-based conditioning (P = 0.030). The 5-year OS was 54% (95% CI, 43-64) and 55% (95% CI, 48-62) after TBI- and non-TBI-based conditioning. Both groups had similar 100-day acute graft-versus-host disease (aGVHD, 43% vs. 40%) and 5-year chronic GVHD (34% vs. 36%). The multivariable regression models found no associations of TBI with the outcomes NRM, CIR, PFS, OS, aGVHD, and cGVHD. TBI was no risk factor for NRM, even including mortality caused by secondary malignancies. NRM was influenced by patient age, advanced disease status, and the use of female donors for male recipients. TBI- and non-TBI-based conditioning appear to be equally effective and tolerable for AML patients eligible for 1st allo-HSCT.
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Affiliation(s)
- Isabella Gruber
- Department of Radiation Oncology, University Hospital Regensburg, Regensburg, Germany.
| | - Oliver Koelbl
- Department of Radiation Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Marius Treutwein
- Department of Radiation Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Wolfgang Herr
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Edinger
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
- Leibniz Institute for Immunotherapy, Regensburg, Germany
| | - Daniel Wolff
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
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Reilly M, Dandapani SV, Kumar KA, Constine L, Fogh SE, Roberts KB, Small W, Schechter NR. ACR-ARS Practice Parameter for the Performance of Total Body Irradiation. Am J Clin Oncol 2023; 46:185-192. [PMID: 36907934 DOI: 10.1097/coc.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
OBJECTIVES This practice parameter was revised collaboratively by the American College of Radiology (ACR) and the American Radium Society (ARS). This practice parameter provides updated reference literature regarding both clinical-based conventional total body irradiation and evolving volumetric modulated total body irradiation. METHODS This practice parameter was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website ( https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards ) by the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ARS. RESULTS This practice parameter provides a comprehensive update to the reference literature regarding conventional total body irradiation and modulated total body irradiation. Dependence on dose rate remains an active area of ongoing investigation in both the conventional setting (where instantaneous dose rate can be varied) and in more modern rotational techniques, in which average dose rate is the relevant variable. The role of imaging during patient setup and the role of inhomogeneity corrections due to computer-based treatment planning systems are included as evolving areas of clinical interest notably surrounding the overall dose inhomogeneity. There is increasing emphasis on the importance of evaluating mean lung dose as it relates to toxicity during high-dose total body irradiation regimens. CONCLUSIONS This practice parameter can be used as an effective tool in designing and evaluating a total body irradiation program that successfully incorporates the close interaction and coordination among the radiation oncologists, medical physicists, dosimetrists, nurses, and radiation therapists.
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Affiliation(s)
| | | | - Kiran A Kumar
- UT Southwestern Medical Center 5323 Harry Hines Blvd, Dallas, TX
| | - Louis Constine
- University of Rochester Medical Center 601 Elmwood Ave, Rochester, NY
| | - Shannon E Fogh
- Department of Radiation Oncology, University of California San Francisco, CA
| | | | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago Loyola University Medical Center Department of Radiation Oncology Maguire Center - Room 2944 2160 S. 1st Ave. Maywood, IL
| | - Naomi R Schechter
- South Florida Proton Therapy Institute and Rakuten-Medical, Inc., Delray Beach, FL
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Strolin S, Paolani G, Santoro M, Cercenelli L, Bortolani B, Ammendolia I, Cammelli S, Cicoria G, Win PW, Morganti AG, Marcelli E, Strigari L. Improving total body irradiation with a dedicated couch and 3D-printed patient-specific lung blocks: A feasibility study. Front Oncol 2023; 12:1046168. [PMID: 36741733 PMCID: PMC9893493 DOI: 10.3389/fonc.2022.1046168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/16/2022] [Indexed: 01/20/2023] Open
Abstract
Introduction Total body irradiation (TBI) is an important component of the conditioning regimen in patients undergoing hematopoietic stem cell transplants. TBI is used in very few patients and therefore it is generally delivered with standard linear accelerators (LINACs) and not with dedicated devices. Severe pulmonary toxicity is the most common adverse effect after TBI, and patient-specific lead blocks are used to reduce mean lung dose. In this context, online treatment setup is crucial to achieve precise positioning of the lung blocks. Therefore, in this study we aim to report our experience at generating 3D-printed patient-specific lung blocks and coupling a dedicated couch (with an integrated onboard image device) with a modern LINAC for TBI treatment. Material and methods TBI was planned and delivered (2Gy/fraction given twice a day, over 3 days) to 15 patients. Online images, to be compared with planned digitally reconstructed radiographies, were acquired with the couch-dedicated Electronic Portal Imaging Device (EPID) panel and imported in the iView software using a homemade Graphical User Interface (GUI). In vivo dosimetry, using Metal-Oxide Field-Effect Transistors (MOSFETs), was used to assess the setup reproducibility in both supine and prone positions. Results 3D printing of lung blocks was feasible for all planned patients using a stereolithography 3D printer with a build volume of 14.5×14.5×17.5 cm3. The number of required pre-TBI EPID-images generally decreases after the first fraction. In patient-specific quality assurance, the difference between measured and calculated dose was generally<2%. The MOSFET measurements reproducibility along each treatment and patient was 2.7%, in average. Conclusion The TBI technique was successfully implemented, demonstrating that our approach is feasible, flexible, and cost-effective. The use of 3D-printed patient-specific lung blocks have the potential to personalize TBI treatment and to refine the shape of the blocks before delivery, making them extremely versatile.
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Affiliation(s)
- Silvia Strolin
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Paolani
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,*Correspondence: Giulia Paolani, ; Lidia Strigari,
| | - Miriam Santoro
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Laura Cercenelli
- eDIMES Lab-Laboratory of Bioengineering, Department of Experimental Diagnostic and Specialty Medicine, (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Barbara Bortolani
- eDIMES Lab-Laboratory of Bioengineering, Department of Experimental Diagnostic and Specialty Medicine, (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Ilario Ammendolia
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gianfranco Cicoria
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Phyo Wai Win
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessio G. Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Emanuela Marcelli
- eDIMES Lab-Laboratory of Bioengineering, Department of Experimental Diagnostic and Specialty Medicine, (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,*Correspondence: Giulia Paolani, ; Lidia Strigari,
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Köksal M, Baumert J, Schoroth F, Scafa D, Koch D, Leitzen C, Sarria GR, Giordano FA, Chatzikonstantinou G, Schmeel LC. Lung sparing and ribcage coverage in total body irradiation delivered by helical tomotherapy. Eur J Med Res 2022; 27:287. [PMID: 36496388 PMCID: PMC9737733 DOI: 10.1186/s40001-022-00918-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Helical tomotherapy (HT) is a viable method for delivering total body irradiation (TBI) when preparing patients for allogenic stem cell or bone-marrow transplantation. TBI can be planned to reduce the amount of radiation delivered to organs at risk, such as the lungs, with the aim of decreasing toxicity. However, it is important for the ribcage to receive the prescribed radiation dose in preparation for bone-marrow transplantation. In this retrospective study, we analyzed radiation dose coverage of the lungs and ribcage in patients who underwent TBI delivered by HT to achieve lung dose sparing. METHODS Thirty-five patients were included in the analysis and divided into three groups based on their prescribed radiation dose (4, 8, or 12 Gy). HT was performed using a rotating gantry to reduce radiation to the lungs. Dosimetric parameters for the lungs and ribcage as well as dose-volume histograms were calculated. RESULTS The mean lung D95 was 60.97%, 54.77%, and 37.44% of the prescribed dose for patients receiving 4 Gy, 8 Gy, and 12 Gy, respectively. Ribcage coverage was most optimal for patients receiving 4 Gy, with a D95 of 91.27% and mean homogeneity index of 1.17, whereas patients receiving 12 Gy had a mean D95 of 78.65% and homogeneity index of 1.37, which is still within the range recommended by treatment guidelines. CONCLUSIONS Using HT to achieve lung tissue sparing is a viable approach to minimizing pulmonic complications in patients undergoing TBI. As this planning adjustment does not compromise the dose and quality of coverage received by the ribcage, it is a feasible tool within conditioning regimens for allogeneic bone-marrow transplantation.
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Affiliation(s)
- Mümtaz Köksal
- grid.15090.3d0000 0000 8786 803XDepartment of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Jonathan Baumert
- grid.15090.3d0000 0000 8786 803XDepartment of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Felix Schoroth
- grid.15090.3d0000 0000 8786 803XDepartment of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Davide Scafa
- grid.15090.3d0000 0000 8786 803XDepartment of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - David Koch
- grid.15090.3d0000 0000 8786 803XDepartment of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Christina Leitzen
- grid.15090.3d0000 0000 8786 803XDepartment of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Gustavo R. Sarria
- grid.15090.3d0000 0000 8786 803XDepartment of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Frank A. Giordano
- grid.411778.c0000 0001 2162 1728Department of Radiation Oncology, University Medical Centre Mannheim, Mannheim, Germany
| | - Georgios Chatzikonstantinou
- grid.411088.40000 0004 0578 8220Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt, Germany
| | - Leonard C. Schmeel
- grid.15090.3d0000 0000 8786 803XDepartment of Radiation Oncology, University Hospital Bonn, Bonn, Germany
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11
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Kavak AG, Surucu M, Ahn KH, Pearson E, Aydogan B. Impact of respiratory motion on lung dose during total marrow irradiation. Front Oncol 2022; 12:924961. [PMID: 36330489 PMCID: PMC9622752 DOI: 10.3389/fonc.2022.924961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/16/2022] [Indexed: 11/21/2022] Open
Abstract
We evaluated the impact of respiratory motion on the lung dose during linac-based intensity-modulated total marrow irradiation (IMTMI) using two different approaches: (1) measurement of doses within the lungs of an anthropomorphic phantom using thermoluminescent detectors (TLDs) and (2) treatment delivery measurements using ArcCHECK where gamma passing rates (GPRs) and the mean lung doses were calculated and compared with and without motion. In the first approach, respiratory motions were simulated using a programmable motion platform by using typical published peak-to-peak motion amplitudes of 5, 8, and 12 mm in the craniocaudal (CC) direction, denoted here as M1, M2, and M3, respectively, with 2 mm in both anteroposterior (AP) and lateral (LAT) directions. TLDs were placed in five selected locations in the lungs of a RANDO phantom. Average TLD measurements obtained with motion were normalized to those obtained with static phantom delivery. The mean dose ratios were 1.01 (0.98–1.03), 1.04 (1.01–1.09), and 1.08 (1.04–1.12) for respiratory motions M1, M2, and M3, respectively. To determine the impact of directional respiratory motion, we repeated the experiment with 5-, 8-, and 12-mm motion in the CC direction only. The differences in average TLD doses were less than 1% when compared with the M1, M2, and M3 motions indicating a minimal impact from CC motion on lung dose during IMTMI. In the second experimental approach, we evaluated extreme respiratory motion 15 mm excursion in only the CC direction. We placed an ArcCHECK device on a commercial motion platform and delivered the clinical IMTMI plans of five patients. We compared, with and without motion, the dose volume histograms (DVHs) and mean lung dose calculated with the ArcCHECK-3DVH tool as well as GPR with 3%, 5%, and 10% dose agreements and a 3-mm constant distance to agreement (DTA). GPR differed by 11.1 ± 2.1%, 3.8 ± 1.5%, and 0.1 ± 0.2% with dose agreement criteria of 3%, 5%, and 10%, respectively. This indicates that respiratory motion impacts dose distribution in small and isolated parts of the lungs. More importantly, the impact of respiratory motion on the mean lung dose, a critical indicator for toxicity in IMTMI, was not statistically significant (p > 0.05) based on the Student’s t-test. We conclude that most patients treated with IMTMI will have negligible dose uncertainty due to respiratory motion. This is particularly reassuring as lung toxicity is the main concern for future IMTMI dose escalation studies.
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Affiliation(s)
- Ayse Gulbin Kavak
- Department of Radiation Oncology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Murat Surucu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, United States
| | - Kang-Hyun Ahn
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
- Department of Radiation Oncology, University of Illinois at Chicago Medical Center, Chicago, IL, United States
| | - Erik Pearson
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Bulent Aydogan
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
- Department of Radiation Oncology, University of Illinois at Chicago Medical Center, Chicago, IL, United States
- *Correspondence: Bulent Aydogan, ;
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12
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Wong JY, Liu A, Han C, Dandapani S, Schultheiss T, Palmer J, Yang D, Somlo G, Salhotra A, Hui S, Al Malki MM, Rosenthal J, Stein A. Total marrow irradiation (TMI): Addressing an unmet need in hematopoietic cell transplantation - a single institution experience review. Front Oncol 2022; 12:1003908. [PMID: 36263219 PMCID: PMC9574324 DOI: 10.3389/fonc.2022.1003908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/12/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose TMI utilizes IMRT to deliver organ sparing targeted radiotherapy in patients undergoing hematopoietic cell transplantation (HCT). TMI addresses an unmet need, specifically patients with refractory or relapsed (R/R) hematologic malignancies who have poor outcomes with standard HCT regimens and where attempts to improve outcomes by adding or dose escalating TBI are not possible due to increased toxicities. Over 500 patients have received TMI at this center. This review summarizes this experience including planning and delivery, clinical results, and future directions. Methods Patients were treated on prospective allogeneic HCT trials using helical tomographic or VMAT IMRT delivery. Target structures included the bone/marrow only (TMI), or the addition of lymph nodes, and spleen (total marrow and lymphoid irradiation, TMLI). Total dose ranged from 12 to 20 Gy at 1.5-2.0 Gy fractions twice daily. Results Trials demonstrate engraftment in all patients and a low incidence of radiation related toxicities and extramedullary relapses. In R/R acute leukemia TMLI 20 Gy, etoposide, and cyclophosphamide (Cy) results in a 1-year non-relapse mortality (NRM) rate of 6% and 2-year overall survival (OS) of 48%; TMLI 12 Gy added to fludarabine (flu) and melphalan (mel) in older patients (≥ 60 years old) results in a NRM rate of 33% comparable to flu/mel alone, and 5-year OS of 42%; and TMLI 20 Gy/flu/Cy and post-transplant Cy (PTCy) in haplo-identical HCT results in a 2-year NRM rate of 13% and 1-year OS of 83%. In AML in complete remission, TMLI 20 Gy and PTCy results in 2-year NRM, OS, and GVHD free/relapse-free survival (GRFS) rates of 0%, 86·7%, and 59.3%, respectively. Conclusion TMI/TMLI shows significant promise, low NRM rates, the ability to offer myeloablative radiation containing regimens to older patients, the ability to dose escalate, and response and survival rates that compare favorably to published results. Collaboration between radiation oncology and hematology is key to successful implementation. TMI/TMLI represents a paradigm shift from TBI towards novel strategies to integrate a safer and more effective target-specific radiation therapy into HCT conditioning beyond what is possible with TBI and will help expand and redefine the role of radiotherapy in HCT.
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Affiliation(s)
- Jeffrey Y.C. Wong
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | - An Liu
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | - Chunhui Han
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | - Savita Dandapani
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | | | - Joycelynne Palmer
- Department Computational and Quantitative Medicine, City of Hope, Duarte, CA, United States
| | - Dongyun Yang
- Department Computational and Quantitative Medicine, City of Hope, Duarte, CA, United States
| | - George Somlo
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, United States
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, United States
| | - Susanta Hui
- Departments of Radiation Oncology, City of Hope, Duarte, CA, United States
| | - Monzr M. Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, United States
| | - Joseph Rosenthal
- Department of Pediatrics, City of Hope, Duarte, CA, United States
| | - Anthony Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, United States
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13
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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: 3] [Impact Index Per Article: 1.5] [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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14
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Loginova AA, Tovmasian DA, Lisovskaya AO, Kobyzeva DA, Maschan MA, Chernyaev AP, Egorov OB, Nechesnyuk AV. Optimized Conformal Total Body Irradiation methods with Helical TomoTherapy and Elekta VMAT: Implementation, Imaging, Planning and Dose Delivery for Pediatric Patients. Front Oncol 2022; 12:785917. [PMID: 35359412 PMCID: PMC8960917 DOI: 10.3389/fonc.2022.785917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Optimized conformal total body irradiation (OC-TBI) is a highly conformal image guided method for irradiating the whole human body while sparing the selected organs at risk (OARs) (lungs, kidneys, lens). This study investigated the safety and feasibility of pediatric OC-TBI with the helical TomoTherapy (TomoTherapy) and volumetric modulated arc (VMAT) modalities and their implementation in routine clinical practice. This is the first study comparing the TomoTherapy and VMAT modalities in terms of treatment planning, dose delivery accuracy, and toxicity for OC-TBI in a single-center setting. The OC-TBI method with standardized dosimetric criteria was developed and implemented with TomoTherapy. The same OC-TBI approach was applied for VMAT. Standardized treatment steps, namely, positioning and immobilization, contouring, treatment planning strategy, plan evaluation, quality assurance, visualization and treatment delivery procedure were implemented for 157 patients treated with TomoTherapy and 52 patients treated with VMAT. Both modalities showed acceptable quality of the planned target volume dose coverage with simultaneous OARs sparing. The homogeneity of target irradiation was superior for TomoTherapy. Overall assessment of the OC-TBI dose delivery was performed for 30 patients treated with VMAT and 30 patients treated with TomoTherapy. The planned and delivered (sum of doses for all fractions) doses were compared for the two modalities in groups of patients with different heights. The near maximum dose values of the lungs and kidneys showed the most significant variation between the planned and delivered doses for both modalities. Differences in the patient size did not result in statistically significant differences for most of the investigated parameters in either the TomoTherapy or VMAT modality. TomoTherapy-based OC-TBI showed lower variations between planned and delivered doses, was less time-consuming and was easier to implement in routine practice than VMAT. We did not observe significant differences in acute and subacute toxicity between TomoTherapy and VMAT groups. The late toxicity from kidneys and lungs was not found during the 2.3 years follow up period. The study demonstrates that both modalities are feasible, safe and show acceptable toxicity. The standardized approaches allowed us to implement pediatric OC-TBI in routine clinical practice.
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Affiliation(s)
- Anna Anzorovna Loginova
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
- *Correspondence: Anna Anzorovna Loginova,
| | - Diana Anatolievna Tovmasian
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
- Faculty of Physics, Federal State Budget Educational Institution of Higher Education, M.V. Lomonosov Moscow State University, Moscow, Russia
| | | | - Daria Alexeevna Kobyzeva
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | | | - Alexander Petrovich Chernyaev
- Faculty of Physics, Federal State Budget Educational Institution of Higher Education, M.V. Lomonosov Moscow State University, Moscow, Russia
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15
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Kobyzeva D, Shelikhova L, Loginova A, Kanestri F, Tovmasyan D, Maschan M, Khismatullina R, Ilushina M, Baidildina D, Myakova N, Nechesnyuk A. Optimized Conformal Total Body Irradiation Among Recipients of TCRαβ/CD19-Depleted Grafts in Pediatric Patients With Hematologic Malignancies: Single-Center Experience. Front Oncol 2022; 11:785916. [PMID: 34976825 PMCID: PMC8716385 DOI: 10.3389/fonc.2021.785916] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Total body irradiation (TBI) in combination with chemotherapy is widely used as a conditioning regimen in pediatric and adult hematopoietic stem cell transplantation (HSCT). The combination of TBI with chemotherapy has demonstrated superior survival outcomes in patients with acute lymphoblastic and myeloid leukemia when compared with conditioning regimens based only on chemotherapy. The clinical application of intensity-modulated radiation therapy (IMRT)-based methods (volumetric modulated arc therapy (VMAT) and TomoTherapy) seems to be promising and has been actively used worldwide. The optimized conformal total body irradiation (OC-TBI) method described in this study provides selected dose reduction for organs at risk with respect to the most significant toxicity (lungs, kidneys, lenses). This study included 220 pediatric patients who received OC-TBI with subsequent chemotherapy and allogenic HSCT with TCRαβ/CD19 depletion. A group of 151 patients received OC-TBI using TomoTherapy, and 40 patients received OC-TBI using the Elekta Synergy™ linac with an Agility-MLC (Elekta, Crawley, UK) using volumetric modulated arc therapy (VMAT). Twenty-nine patients received OC-TBI with supplemental simultaneous boost to bone marrow-(SIB to BM) up to 15 Gy: 28 patients (pts)-TomoTherapy; one patient-VMAT. The follow-up duration ranged from 0.3 to 6.4 years (median follow-up, 2.8 years). Overall survival (OS) for all the patients was 63% (95% CI: 56-70), and event-free survival (EFS) was 58% (95% CI: 51-65). The cumulative incidence of transplant-related mortality (TRM) was 10.7% (95% CI: 2.2-16) for all patients. The incidence of early TRM (<100 days) was 5.0% (95% CI: 1.5-8.9), and that of late TRM (>100 days) was 5.7 (95% CI: 1.7-10.2). The main causes of death for all the patients were relapse and infection. The concept of OC-TBI using IMRT VMAT and helical treatment delivery on a TomoTherapy treatment unit provides maximum control of the dose distribution in extended targets with simultaneous dose reduction for organs at risk. This method demonstrated a low incidence of severe side effects after radiation therapy and predictable treatment effectiveness. Our initial experience demonstrates that OC-TBI appears to be a promising technique for the treatment of pediatric patients.
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Affiliation(s)
- Daria Kobyzeva
- Department of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Larisa Shelikhova
- Department of Hematopoietic Cell Transplantation, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Loginova
- Department of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Francheska Kanestri
- Department of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Diana Tovmasyan
- Department of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Michael Maschan
- Department of Hematopoietic Cell Transplantation, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Rimma Khismatullina
- Department of Hematopoietic Cell Transplantation, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Mariya Ilushina
- Department of Hematopoietic Cell Transplantation, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Dina Baidildina
- Department of Pediatric Hematology and Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Natalya Myakova
- Department of Onco-hematology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Alexey Nechesnyuk
- Department of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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16
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Hansen AT, Rose HK, Yates ES, Hansen J, Petersen JB. Two compound techniques for total body irradiation. Tech Innov Patient Support Radiat Oncol 2021; 21:1-7. [PMID: 34977366 PMCID: PMC8683645 DOI: 10.1016/j.tipsro.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/10/2021] [Accepted: 11/30/2021] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Total body irradiation (TBI) is an important treatment modality that is used in combination with chemotherapy in many stem cell transplantation protocols. Therefore, the quality of the irradiation is important. Two techniques for planning and delivering TBI are presented and compared. METHODS AND MATERIALS The technique named ExIMRT is a combination of manually shaped conventional fields from an extended SSD and isocentric IMRT fields. The technique named ExVMAT is a combination of conventional and IMRT fields from an extended SSD and isocentric VMAT fields. Dosimetric data from 32 patients who were planned and treated according to one of the two techniques were compared. RESULTS When comparing the two techniques, it is determined that the ExVMAT technique is able to significantly reduce the mean total volume overdosed by 120% from 408 to 12 cm3. The dose covering 98% of the total lung volume is significantly increased by this technique from a mean of 9.7 Gy to 10.3 Gy. Additionally, the dose covering 2% of the total kidney volume is significantly decreased from a mean of 12.8 to 12.5 Gy. Furthermore, the population-based variance of the median dose to the total lung volume, the heart and the volume of the body prescribed to 12.5 Gy is significantly reduced. The results are obtained without compromising overall treatment quality as treatment time or dose rate to the lungs. CONCLUSION Using the ExVMAT technique, a superior dose distribution can be delivered both from a patient and a population perspective compared to the ExIMRT technique.
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Affiliation(s)
- Anders T. Hansen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark,Corresponding author at: Department of Medical Physics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - Hanne K. Rose
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Esben S. Yates
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Jolanta Hansen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
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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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Volumetric Modulated Arc Therapy Enabled Total Body Irradiation (VMAT-TBI): Six-year Clinical Experience and Treatment Outcomes. Transplant Cell Ther 2021; 28:113.e1-113.e8. [PMID: 34775145 DOI: 10.1016/j.jtct.2021.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/23/2022]
Abstract
Total body irradiation is an important part of the conditioning regimens frequently used to prepare patients for allogeneic hematopoietic stem cell transplantation (SCT). Volumetric-modulated arc therapy enabled total body irradiation (VMAT-TBI), an alternative to conventional TBI (cTBI), is a novel radiotherapy treatment technique that has been implemented and investigated in our institution. The purpose of this study is to (1) report our six-year clinical experience in terms of treatment planning strategy and delivery time and (2) evaluate the clinical outcomes and toxicities in our cohort of patients treated with VMAT-TBI. This is a retrospective single center study. Forty-four patients at our institution received VMAT-TBI and chemotherapy conditioning followed by allogeneic SCT between 2014 and 2020. Thirty-two patients (73%) received standard-dose TBI (12-13.2 Gy in 6-8 fractions twice daily), whereas 12 (27%) received low-dose TBI (2-4 Gy in one fraction). Treatment planning, delivery, and treatment outcome data including overall survival (OS), relapse-free survival (RFS), and toxicities were analyzed. The developed VMAT-TBI planning strategy consistently generated plans satisfying our dose constraints, with planning target volume coverage >90%, mean lung dose ∼50% to 75% of prescription dose, and minimal hotspots in critical organs. Most of the treatment deliveries were <100 minutes (range 33-147, mean 72). The median follow-up was 26 months. At the last follow-up, 34 of 44 (77%) of patients were alive, with 1- and 2-year OS of 90% and 79% and RFS of 88% and 71%, respectively. The most common grade 3+ toxicities observed were mucositis (31 patients [71%]) and nephrotoxicity (6 patients [13%]), both of which were deemed multifactorial in cause. Four patients (9%) in standard-dose cohort developed grade 3+ pneumonitis, with 3 cases in the setting of documented respiratory infection and only 1 (2%) deemed likely related to radiation alone. VMAT-TBI provides a safe alternative to cTBI. The dose modulation capability of VMAT-TBI may lead to new treatment strategies, such as simultaneous boost and further critical organ sparing, for better malignant cell eradication, immune suppression, and lower toxicities.
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Oertel M, Martel J, Mikesch JH, Scobioala S, Reicherts C, Kröger K, Lenz G, Stelljes M, Eich HT. The Burden of Survivorship on Hematological Patients-Long-Term Analysis of Toxicities after Total Body Irradiation and Allogeneic Stem Cell Transplantation. Cancers (Basel) 2021; 13:cancers13225640. [PMID: 34830802 PMCID: PMC8616356 DOI: 10.3390/cancers13225640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Total body irradiation is an essential large-field technique enabling myeloablation before allogeneic stem cell transplantation. With its field encompassing all organs, a diverse spectrum of toxicities may arise. This work analyzes long-term pulmonary, cardiac, ocular, neurological and renal toxicities in a monocentric patient cohort and identifies possible risk factors. Both the number of patients and the duration of the follow-up period exceed those of many comparable studies in the literature. Abstract Total body irradiation is an effective conditioning modality before autologous or allogeneic stem cell transplantation. With the whole body being the radiation target volume, a diverse spectrum of toxicities has been reported. This fact prompted us to investigate the long-term sequelae of this treatment concept in a large patient cohort. Overall, 322 patients with acute leukemia or myelodysplastic syndrome with a minimum follow-up of one year were included (the median follow-up in this study was 68 months). Pulmonary, cardiac, ocular, neurological and renal toxicities were observed in 23.9%, 14.0%, 23.6%, 23.9% and 20.2% of all patients, respectively. The majority of these side effects were grades 1 and 2 (64.9–89.2% of all toxicities in the respective categories). The use of 12 Gray total body irradiation resulted in a significant increase in ocular toxicities (p = 0.013) and severe mucositis (p < 0.001). Renal toxicities were influenced by the age at transplantation (relative risk: 1.06, p < 0.001) and disease entity. In summary, total body irradiation triggers a multifaceted, but manageable, toxicity profile. Except for ocular toxicities and mucositis, a 12 Gray regimen did not lead to an increase in long-term side effects.
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Affiliation(s)
- Michael Oertel
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
- Correspondence: ; Tel.: +49-251-83-47384; Fax: +49-251-83-47355
| | - Jonas Martel
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
| | - Jan-Henrik Mikesch
- Department of Medicine A—Hematology, Hemostaseology, Oncology, Pulmonology, University Hospital Muenster, 48149 Munster, Germany; (J.-H.M.); (C.R.); (G.L.); (M.S.)
| | - Sergiu Scobioala
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
| | - Christian Reicherts
- Department of Medicine A—Hematology, Hemostaseology, Oncology, Pulmonology, University Hospital Muenster, 48149 Munster, Germany; (J.-H.M.); (C.R.); (G.L.); (M.S.)
| | - Kai Kröger
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
| | - Georg Lenz
- Department of Medicine A—Hematology, Hemostaseology, Oncology, Pulmonology, University Hospital Muenster, 48149 Munster, Germany; (J.-H.M.); (C.R.); (G.L.); (M.S.)
| | - Matthias Stelljes
- Department of Medicine A—Hematology, Hemostaseology, Oncology, Pulmonology, University Hospital Muenster, 48149 Munster, Germany; (J.-H.M.); (C.R.); (G.L.); (M.S.)
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital Muenster, 48149 Munster, Germany; (J.M.); (S.S.); (K.K.); (H.T.E.)
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The impact of different optimization strategies on the agreement between planned and delivered doses during volumetric modulated arc therapy for total marrow irradiation. Contemp Oncol (Pozn) 2021; 25:100-106. [PMID: 34667436 PMCID: PMC8506427 DOI: 10.5114/wo.2021.107742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/13/2021] [Indexed: 11/17/2022] Open
Abstract
Aim of the study To evaluate the agreement between planned and delivered doses and its potential correlation with the plans' complexity subjected to dosimetric verification. Material and methods Four isocentre volumetric modulated arc therapy for total marrow irradiation plans optimized simultaneously with (P1) and without (P2) MU reduction were evaluated dosimetrically by γ method performed in a global mode for 4 combinations of γ-index criteria (2%/2 mm, 2%/3 mm, 3%/2 mm, and 3%/3 mm). The evaluation was conducted for 4 regions (head and neck, chest, abdomen and upper pelvis, and lower pelvis and thighs) that were determined geometrically by the isocentres. The Wilcoxon test was used to detect significant differences between γ passing rate (GPR) analysis results for the P1 and P2 plans. The Pearson correlation was used to check the relationship between GPR and the plans' complexity. Results Except for the head and neck region, the P2 plans had better GPRs than the P1 plans. Only for hard combinations of γ-index criteria (i.e. 2%/3 mm, 2%/2 mm) were the GPRs differences between P1 and P2 clinically meaningful, and they were detected in the chest, abdomen and upper pelvis, and lower pelvis and thighs regions. The highest correlations between GPR and the indices describing the plans' complexity were found for the chest region. No correlation was found for the head and neck region. Conclusions The P2 plans showed better agreement between planned and delivered doses compared to the P1 plans. The GPR and the plans' complexity depend on the anatomy region and are most important for the chest region.
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Guo B, Sheen C, Murphy E, Magnelli A, Lu L, Cho Y, Qi P, Majhail NS, Xia P. Image-guided volumetric-modulated arc therapy of total body irradiation: An efficient workflow from simulation to delivery. J Appl Clin Med Phys 2021; 22:169-177. [PMID: 34480829 PMCID: PMC8504588 DOI: 10.1002/acm2.13412] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/10/2021] [Accepted: 08/22/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Using multi‐isocenter volumetric‐modulated arc therapy (VMAT) for total body irradiation (TBI) may improve dose uniformity and vulnerable tissue protection compared with classical whole‐body field technique. Two drawbacks limit its application: (1) VMAT‐TBI planning is time consuming; (2) VMAT‐TBI plans are sensitive to patient positioning uncertainties due to beam matching. This study presents a robust planning technique with image‐guided delivery to improve dose delivery accuracy. In addition, a streamlined sim‐to‐treat workflow with automatic scripts is proposed to reduce planning time. Materials Twenty‐five patients were included in this study. Patients were scanned in supine head‐first and feet‐first directions. An automatic workflow was used to (1) create a whole‐body CT by registering two CT scans, (2) contour lungs, kidneys, and planning target volume (PTV), (3) divide PTV into multiple sub‐targets for planning, and (4) place isocenters. Treatment planning included feathered AP/PA beams for legs/feet and VMAT for the body. VMAT‐TBI was evaluated for plan quality, planning/delivery time, and setup accuracy using image guidance. Results VMAT‐TBI planning time can be reduced to a day with automatic scripts. Treatment time took around an hour per fraction. VMAT‐TBI improved dose coverage (PTV V100 increased from 76.8 ± 10.5 to 88.5 ± 2.6; p < 0.001) and reduced lung dose (lung mean dose reduced from 10.8 ± 0.7 Gy to 9.4 ± 0.8 Gy, p < 0.001) compared with classic AP/PA technique. Conclusion A VMAT‐TBI sim‐to‐treat workflow with robust planning and image‐guided delivery was proposed. VMAT‐TBI improved the plan quality compared with classical whole‐body field techniques.
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Affiliation(s)
- Bingqi Guo
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cherian Sheen
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin Murphy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anthony Magnelli
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lan Lu
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - YoungBin Cho
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Peng Qi
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Navneet S Majhail
- Department of Hematology Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ping Xia
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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22
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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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Pulmonary Toxicity after Total Body Irradiation-An Underrated Complication? Estimation of Risk via Normal Tissue Complication Probability Calculations and Correlation with Clinical Data. Cancers (Basel) 2021; 13:cancers13122946. [PMID: 34204603 PMCID: PMC8231208 DOI: 10.3390/cancers13122946] [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] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/05/2021] [Accepted: 06/09/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Total body irradiation is an integral part of many conditioning regimens prior to allogeneic stem cell transplantation. It is a large-field technique affecting all organs at risk, of which the lungs are critical for patient survival. However, the precise rates of long-term pulmonary toxicities are unknown. This analysis provides a large patient cohort with long-term follow-up investigating TBI sequelae. Additionally, we present normal tissue complication probability calculations for acute and chronic lung toxicities to enable comparison between biophysical and real-world data. To our knowledge, this is the first adaption of this model to a total-body irradiation patient cohort, which will help to evaluate the feasibility and appropriateness of this approach. Abstract Total body irradiation (TBI) is an essential part of various conditioning regimens prior to allogeneic stem cell transplantation, but is accompanied by relevant (long-term) toxicities. In the lungs, a complex mechanism induces initial inflammation (pneumonitis) followed by chronic fibrosis. The hereby presented analysis investigates the occurrence of pulmonary toxicity in a large patient collective and correlates it with data derived from normal tissue complication probability (NTCP) calculations. The clinical data of 335 hemato-oncological patients undergoing TBI were analyzed with a follow-up of 85 months. Overall, 24.8% of all patients displayed lung toxicities, predominantly pneumonia and pulmonary obstructions (13.4% and 6.0%, respectively). NTCP calculations estimated median risks to be 20.3%, 0.6% and 20.4% for overall pneumonitis (both radiological and clinical), symptomatic pneumonitis and lung fibrosis, respectively. These numbers are consistent with real-world data from the literature and further specify radiological and clinical apparent toxicity rates. Overall, the estimated risk for clinical apparent pneumonitis is very low, corresponding to the probability of non-infectious acute respiratory distress syndrome, although the underlying pathophysiology is not identical. Radiological pneumonitis and lung fibrosis are expected to be more common but require a more precise documentation by the transplantation team, radiologists and radiation oncologists.
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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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Thakur P, DeBo R, Dugan GO, Bourland JD, Michalson KT, Olson JD, Register TC, Kock ND, Cline JM. Clinicopathologic and Transcriptomic Analysis of Radiation-Induced Lung Injury in Nonhuman Primates. Int J Radiat Oncol Biol Phys 2021; 111:249-259. [PMID: 33848608 DOI: 10.1016/j.ijrobp.2021.03.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE Radiation-induced lung injury (RILI) is a progressive condition with an early phase (radiation pneumonitis) and a late phase (lung fibrosis). RILI may occur after partial-body ionizing radiation exposures or internal radioisotope exposure, with wide individual variability in timing and extent of lung injury. This study aimed to provide new insights into the pathogenesis and progression of RILI in the nonhuman primate (NHP) rhesus macaque model. METHODS AND MATERIALS We used an integrative approach to understand RILI and its evolution at clinical and molecular levels in 17 NHPs exposed to 10 Gy of whole-thorax irradiation in comparison with 3 sham-irradiated control NHPs. Clinically, we monitored respiratory rates, computed tomography (CT) scans, plasma cytokine levels, and bronchoalveolar lavage (BAL) over 8 months and lung samples collected at necropsy for molecular and histopathologic analyses using RNA sequencing and immunohistochemistry. RESULTS Elevated respiratory rates, greater CT density, and more severe pneumonitis with increased macrophage content were associated with early mortality. Radiation-induced lung fibrosis included polarization of macrophages toward the M2-like phenotype, TGF-β signaling, expression of CDKN1A/p21 in epithelial cells, and expression of α-SMA in lung stroma. RNA sequencing analysis of lung tissue revealed SERPINA3, ATP12A, GJB2, CLDN10, TOX3, and LPA as top dysregulated transcripts in irradiated animals. In addition to transcriptomic data, we observed increased protein expression of SERPINA3, TGF-β1, CCL2, and CCL11 in BAL and plasma samples. CONCLUSIONS Our combined clinical, imaging, histologic, and transcriptomic analysis provides new insights into the early and late phases of RILI and highlights possible biomarkers and potential therapeutic targets of RILI. Activation of TGF-β and macrophage polarization appear to be key mechanisms involved in RILI.
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Affiliation(s)
- Priyanka Thakur
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Ryne DeBo
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina; Provention Bio, Red Bank, New Jersey
| | - Gregory O Dugan
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - J Daniel Bourland
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Kris T Michalson
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina; Gene Therapy Program, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - John D Olson
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Thomas C Register
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Nancy D Kock
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - J Mark Cline
- Department of Pathology, Section on Comparative Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina.
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van Leeuwen RG, Verwegen D, van Kollenburg PG, Swinkels M, van der Maazen RW. Early clinical experience with a total body irradiation technique using field-in-field beams and on-line image guidance. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2021; 16:12-17. [PMID: 33458337 PMCID: PMC7807619 DOI: 10.1016/j.phro.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 08/23/2020] [Accepted: 09/21/2020] [Indexed: 01/28/2023]
Abstract
Background and purpose Total body irradiation (TBI) is a treatment used in the conditioning of patients prior to hematopoietic stem cell transplantation. We developed an extended-distance TBI technique using a conventional linac with multi-leaf collimator to deliver a homogeneous dose, and spare critical organs. Materials and methods Patients were treated either in lateral recumbent or in supine position depending on the dose level. A conventional linac was used with the patient midline at 350 cm from the beam source. A series of beams was prepared manually using a 3D treatment planning system (TPS) aiming to improve dose homogeneity, spare the organs at risk and facilitate accurate patient positioning. An optimized dose calculation model for extended-distance treatments was developed using phantom measurements. During treatment, in-vivo dosimetry was performed using electronic dosimeters, and accurate positioning was verified using a mobile megavoltage imager. We analyzed dose volume histogram parameters for 19 patients, and in-vivo measurements for 46 delivered treatment fractions. Results Optimization of the dose calculation model for TBI improved dose calculation by 2.1% at the beam axis, and 17% at the field edge. Treatment planning dose objectives and constraints were met for 16 of 19 patients. Results of in-vivo dosimetry were within the set limitations (±10%) with mean deviations of 3.7% posterior of the lungs and 0.6% for the abdomen. Conclusions We developed a TBI treatment technique using a conventional linac and TPS that can reliably be used in the conditioning regimen of patients prior to stem cell transplantation.
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Fog LS, Wirth A, MacManus M, Downes S, Grace M, Moggré A, Mugabe K, Neveri G, Nourbehesht L, Panettieri V, Pope D, Sim L, Stanton C, Steer B, Stewart A, Ungureanu E, Kron T. Total body irradiation in Australia and New Zealand: results of a practice survey. Phys Eng Sci Med 2020; 43:825-835. [DOI: 10.1007/s13246-020-00878-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
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Litoborska J, Piotrowski T, Malicki J. Evaluation of three VMAT-TMI planning methods to find an appropriate balance between plan complexity and the resulting dose distribution. Phys Med 2020; 75:26-32. [PMID: 32480353 DOI: 10.1016/j.ejmp.2020.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Evaluation of different planning methods of treatment plan preparation for volumetric modulated arc therapy during total marrow irradiation (VMAT-TMI). METHOD Three different planning methods were evaluated to establish the most appropriate VMAT-TMI technique, based on organ at risk (OAR) dose reduction, conformity and plan simplicity. The methods were: (M1) the sub-plan method, (M2) use of eight arcs optimised simultaneously and (M3) M2 with monitor unit reduction. Friedman ANOVA comparison, with Nemenyi's procedures, was used in the statistical analysis of the results. RESULTS The dosimetric results obtained for the planning target volume and for most OARs do not differ statistically between methods. The M3 method was characterized by the lowest numbers of monitor units (3259 MU vs. 4450 MU for M1 and 4216 MU for M2) and, in general, the lowest complexity. The variability of the monitor units from control points was almost half for M3 than M1 and M2 (i.e. 0.33 MU vs. 0.61 MU for M1 and 0.58 for M2). Analysing the relationship between the dose distributions obtained for the plans and their complexity, the best result was observed for the M3 method. CONCLUSION The use of eight simultaneously optimised arcs with MU reduction allows to obtain VMAT-TMI plans that are characterized by the lowest complexity, with dose distributions comparable to the plans generated by other methods.
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Affiliation(s)
- Joanna Litoborska
- Department of Medical Physics, Greater Poland Cancer Centre, Poznań, Poland
| | - Tomasz Piotrowski
- Department of Medical Physics, Greater Poland Cancer Centre, Poznań, Poland; Department of Electroradiology, Poznań University of Medical Sciences, Poznań, Poland.
| | - Julian Malicki
- Department of Medical Physics, Greater Poland Cancer Centre, Poznań, Poland; Department of Electroradiology, Poznań University of Medical Sciences, Poznań, Poland
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Thomas DH, Miller B, Rabinovitch R, Milgrom S, Kavanagh B, Diot Q, Miften M, Schubert LK. Integration of automation into an existing clinical workflow to improve efficiency and reduce errors in the manual treatment planning process for total body irradiation (TBI). J Appl Clin Med Phys 2020; 21:100-106. [PMID: 32426947 PMCID: PMC7386186 DOI: 10.1002/acm2.12894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose To identify causes of error, and present the concept of an automated technique that improves efficiency and helps to reduce transcription and manual data entry errors in the treatment planning of total body irradiation (TBI). Methods Analysis of incidents submitted to incident learning system (ILS) was performed to identify potential avenues for improvement by implementation of automation of the manual treatment planning process for total body irradiation (TBI). Following this analysis, it became obvious that while the individual components of the TBI treatment planning process were well implemented, the manual ‘bridging’ of the components (transcribing data, manual data entry etc.) were leading to high potential for error. A C#‐based plug‐in treatment planning script was developed to remove the manual parts of the treatment planning workflow that were contributing to increased risk. Results Here we present an example of the implementation of “Glue” programming, combining treatment planning C# scripts with existing spreadsheet calculation worksheets. Prior to the implementation of automation, 35 incident reports related to the TBI treatment process were submitted to the ILS over a 6‐year period, with an average of 1.4 ± 1.7 reports submitted per quarter. While no incidents reached patients, reports ranged from minor documentation issues to potential for mistreatment if not caught before delivery. Since the implementation of automated treatment planning and documentation, treatment planning time per patient, including documentation, has been reduced; from an average of 45 min pre‐automation to <20 min post‐automation. Conclusions Manual treatment planning techniques may be well validated, but they are time‐intensive and have potential for error. Often the barrier to automating these techniques becomes the time required to “re‐code” existing solutions in unfamiliar computer languages. We present the workflow here as a proof of concept that automation may help to improve clinical efficiency and safety for special procedures.
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Affiliation(s)
- David H Thomas
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
| | - Brian Miller
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
| | - Rachel Rabinovitch
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
| | - Sarah Milgrom
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
| | - Brian Kavanagh
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
| | - Quentin Diot
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
| | - Moyed Miften
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
| | - Leah K Schubert
- Department of Radiation Oncology, University of Colorado, Aurora, CO, USA
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Frederick R, Hudson A, Balogh A, Cao JQ, Pierce G. Standardized flattening filter free volumetric modulated arc therapy plans based on anteroposterior width for total body irradiation. J Appl Clin Med Phys 2020; 21:75-86. [PMID: 32043760 PMCID: PMC7075390 DOI: 10.1002/acm2.12827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 12/17/2022] Open
Abstract
In this work, the feasibility of using flattening filter free (FFF) beams in volumetric modulated arc therapy (VMAT) total body irradiation (TBI) treatment planning to decrease protracted beam‐on times for these treatments was investigated. In addition, a methodology was developed to generate standardized VMAT TBI treatment plans based on patient physical dimensions to eliminate plan optimization time. A planning study cohort of 47 TBI patients previously treated with optimized VMAT ARC 6 MV beams was retrospectively examined. These patients were sorted into six categories depending on height and anteroposterior (AP) width at the umbilicus. Using Varian Eclipse, clinical 40 cm × 10 cm open field arcs were substituted with 6 MV FFF. Mid‐plane lateral dose profiles in conjunction with relative arc output factors (RAOF) yielded how far a given multileaf collimator (MLC) leaf must move in order to achieve a mid‐plane 100% isodose for a specific control point. Linear interpolation gave the dynamic MLC aperture for the entire arc for each patient AP width category, which was subsequently applied through Python scripting. All FFF VMAT TBI plans were then evaluated by two radiation oncologists and deemed clinically acceptable. The FFF and clinical VMAT TBI plans had similar Body–5 mm D98% distributions, but overall the FFF plans had statistically significantly increased or broader Body–5 mm D2% and mean lung dose distributions. These differences are not considered clinically significant. Median beam‐on times for the FFF and clinical VMAT TBI plans were 11.07 and 18.06 min, respectively, and planning time for the FFF VMAT TBI plans was reduced by 34.1 min. In conclusion, use of FFF beams in VMAT TBI treatment planning resulted in dose homogeneity similar to our current VMAT TBI technique. Clinical dosimetric criteria were achieved for a majority of patients while planning and calculated beam‐on times were reduced, offering the possibility of improved patient experience.
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Affiliation(s)
- Rebecca Frederick
- Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada
| | - Alana Hudson
- Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Alex Balogh
- Department of Oncology, University of Calgary, Calgary, AB, Canada.,Division of Radiation Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Jeffrey Q Cao
- Department of Oncology, University of Calgary, Calgary, AB, Canada.,Division of Radiation Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Greg Pierce
- Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada.,Department of Oncology, University of Calgary, Calgary, AB, Canada
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Xia P, Cao K, Hu X, Liu L, Yu D, Dong S, Du J, Xu Y, Liu B, Yang Y, Gao F, Sun X, Liu H. K ATP Channel Blocker Glibenclamide Prevents Radiation-Induced Lung Injury and Inhibits Radiation-Induced Apoptosis of Vascular Endothelial Cells by Increased Ca 2+ Influx and Subsequent PKC Activation. Radiat Res 2019; 193:171-185. [PMID: 31877256 DOI: 10.1667/rr15381.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Radiation-induced lung injury (RILI) is a common and severe side effect of thoracic radiotherapy, which compromises patients' quality of life. Recent studies revealed that early vascular injury, especially microvascular damage, played a central role in the development of RILI. For this reason, early vascular protection is essential for RILI therapy. The ATP-sensitive K+ (KATP) channel is an ATP-dependent K+ channel with multiple subunits. The protective role of the KATP channel in vascular injury has been demonstrated in some published studies. In this work, we investigated the effect of KATP channel on RILI. Our findings confirmed that the KATP channel blocker glibenclamide, rather than the KATP channel opener pinacidil, remitted RILI, and in particular, provided protection against radiation-induced vascular injury. Cytology experiments verified that glibenclamide enhanced cell viability, increased the potential of proliferation after irradiation and attenuated radiation-induced apoptosis. Involved mechanisms included increased Ca2+ influx and PKC activation, which were induced by glibenclamide pretreatment. In conclusion, the KATP channel blocker glibenclamide remitted RILI and inhibited the radiation-induced apoptosis of vascular endothelial cells by increased Ca2+ influx and subsequent PKC activation.
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Affiliation(s)
- Penglin Xia
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Kun Cao
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Xuguang Hu
- Department of Gastrointestinal Surgery, Changhai Hospital, Shanghai, P.R. China
| | - Lei Liu
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Danyang Yu
- Ophthalmology Department of Kunming General Hospital of Chengdu Military Area Command, Kunming, Yunnan, China
| | - Suhe Dong
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Jicong Du
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Yang Xu
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Bin Liu
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Yanyong Yang
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Fu Gao
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Xuejun Sun
- Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
| | - Hu Liu
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
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Radiation-Related Toxicities Using Organ Sparing Total Marrow Irradiation Transplant Conditioning Regimens. Int J Radiat Oncol Biol Phys 2019; 105:1025-1033. [DOI: 10.1016/j.ijrobp.2019.08.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/16/2019] [Accepted: 08/08/2019] [Indexed: 12/22/2022]
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Dreyfuss AD, Jahangiri P, Simone CB, Alavi A. Evolving Role of Novel Quantitative PET Techniques to Detect Radiation-Induced Complications. PET Clin 2019; 15:89-100. [PMID: 31735305 DOI: 10.1016/j.cpet.2019.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Radiation-induced normal tissue toxicities vary in terms of pathophysiologic determinants and timing of disease development, and they are influenced by the dose and radiation volume the critical organs receive, and the radiosensitivity of normal tissues and their baseline rate of cell turnover. Radiation-induced lung injury is dose limiting for the treatment of lung and thoracic cancers and can lead to fibrosis and potentially fatal pneumonitis. This article focuses on pulmonary and cardiovascular complications of radiation therapy and discusses how PET-based novel quantitative techniques can be used to detect these events earlier than current imaging modalities or clinical presentation allow.
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Affiliation(s)
- Alexandra D Dreyfuss
- Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Pegah Jahangiri
- Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, 225 East 126th Street, New York, NY 10035, USA.
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Hanania AN, Mainwaring W, Ghebre YT, Hanania NA, Ludwig M. Radiation-Induced Lung Injury: Assessment and Management. Chest 2019; 156:150-162. [PMID: 30998908 PMCID: PMC8097634 DOI: 10.1016/j.chest.2019.03.033] [Citation(s) in RCA: 281] [Impact Index Per Article: 56.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/18/2019] [Accepted: 03/22/2019] [Indexed: 12/22/2022] Open
Abstract
Radiation-induced lung injury (RILI) encompasses any lung toxicity induced by radiation therapy (RT) and manifests acutely as radiation pneumonitis and chronically as radiation pulmonary fibrosis. Because most patients with thoracic and breast malignancies are expected to undergo RT in their lifetime, many with curative intent, the population at risk is significant. Furthermore, indications for thoracic RT are expanding given the advent of stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR) for early-stage lung cancer in nonsurgical candidates as well as oligometastatic pulmonary disease from any solid tumor. Fortunately, the incidence of serious pulmonary complications from RT has decreased secondary to advances in radiation delivery techniques. Understanding the temporal relationship between RT and injury as well as the patient, disease, and radiation factors that help distinguish RILI from other etiologies is necessary to prevent misdiagnosis. Although treatment of acute pneumonitis is dependent on clinical severity and typically responds completely to corticosteroids, accurately diagnosing and identifying patients who may progress to fibrosis is challenging. Current research advances include high-precision radiation techniques, an improved understanding of the molecular basis of RILI, the development of small and large animal models, and the identification of candidate drugs for prevention and treatment.
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Affiliation(s)
- Alexander N Hanania
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Walker Mainwaring
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Yohannes T Ghebre
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX; Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX.
| | - Michelle Ludwig
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
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Effect of dose rate on pulmonary toxicity in patients with hematolymphoid malignancies undergoing total body irradiation. Radiat Oncol 2018; 13:180. [PMID: 30227866 PMCID: PMC6145366 DOI: 10.1186/s13014-018-1116-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study evaluated the effect of radiation dose rate in patients with hematolymphoid malignancies undergoing myeloablative conditioning with total body irradiation (TBI), for hematopoietic stem cell transplantation. METHODS The incidence of pulmonary toxicity (PT) and treatment efficacy were compared between the conventional (≥ 6 cGy/min) and reduced dose rate (< 6 cGy/min). Seventy-seven patients receiving once-daily TBI between 2000 and 2016 were reviewed. We compared the cumulative rate of PT, overall survival (OS), relapse, and transplantation-related mortality (TRM) between conventional (n = 54) and reduced (n = 23) groups. Factors associated with PT were assessed in the presence of competing risks. RESULTS The median follow-up time was 40.7 months, and PT occurred in 50 patients (64.9%). On multivariate analyses, the groups classified by the dose rate (P = 0.010), total dose (P = 0.025), and conditioning regimen (P = 0.029) were significant factors for the development of PT. OS was significantly reduced when PT occurred (P < 0.001). However, the OS, relapse, and TRM were not different between the two groups. CONCLUSIONS In summary, about two-thirds of the patients undergoing daily TBI experienced PT, which affected OS. Therefore, reducing the dose rate (less than 6 cGy/min) of TBI can decrease the risk of PT, without compromising the treatment efficacy.
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Influence of Total Body Irradiation Dose Rate on Idiopathic Pneumonia Syndrome in Acute Leukemia Patients Undergoing Allogeneic Hematopoietic Cell Transplantation. Int J Radiat Oncol Biol Phys 2018; 103:180-189. [PMID: 30205123 DOI: 10.1016/j.ijrobp.2018.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/24/2018] [Accepted: 09/03/2018] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine the relationship between dose rate and other factors in the development of idiopathic pneumonia syndrome (IPS) in patients with acute lymphoblastic leukemia or acute myeloid leukemia who are undergoing total body irradiation (TBI)-based myeloablative conditioning for allogeneic hematopoietic cell transplantation (HCT). METHODS AND MATERIALS From 2006 to 2016, 202 patients with acute leukemia (111 acute lymphoblastic leukemia, 91 acute myeloid leukemia) ranging in age from 1 to 57 years (median, 25 years) underwent allogeneic HCT at University of Minnesota. Pretransplantation conditioning included cyclophosphamide (120 mg/kg) with (68%) or without fludarabine (75 mg/m2) followed by 13.2 Gy TBI given in 8 twice-daily fractions of 1.65 Gy over 4 days. Dose rate varied based on linear accelerator availability and ranged from 8.7 to 19.2 cGy/min. Patients were stratified by receipt of high-dose-rate (HDR; >15 cGy/min; 56%) or low-dose-rate (LDR; ≤15 cGy/min; 44%) TBI for all 8 fractions. IPS was defined as pulmonary injury based on clinical symptoms, radiographic evidence, or pulmonary function testing within 100 days of HCT in the absence of concurrent infection. RESULTS IPS developed in 42 patients (21%) between 4 and 73 days (median, 16 days) after transplantation. HDR TBI was associated with a higher rate of IPS compared with LDR TBI (29% vs 10%; P < .01). On multiple regression analysis, HDR remained a significant predictor of IPS (hazard ratio, 2.6; 95% confidence interval, 1.2-5.3; P = .01), and this led to inferior 1-year overall survival (60% vs 76%; P = .01) and increased 1-year nonrelapse mortality (28% vs 15%; P = .02). CONCLUSIONS TBI dose rates ≤15 cGy/min reduce the risk of posttransplantation IPS and improve overall survival. LDR TBI should be strongly considered as an easily implemented parameter to improve the safety of pretransplantation TBI-based conditioning.
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Symons K, Morrison C, Parry J, Woodings S, Zissiadis Y. Volumetric modulated arc therapy for total body irradiation: A feasibility study using Pinnacle 3 treatment planning system and Elekta Agility™ linac. J Appl Clin Med Phys 2018; 19:103-110. [PMID: 29368389 PMCID: PMC5849856 DOI: 10.1002/acm2.12257] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/06/2017] [Accepted: 12/05/2017] [Indexed: 12/11/2022] Open
Abstract
A study was undertaken to explore the use of volumetric modulated arc therapy (VMAT) for total body irradiation (TBI). Five patient plans were created in Pinnacle3 using nine 6 MV photon dynamic arcs. A dose of 12 Gy in six fractions was prescribed. The planning target volume (PTV) was split into four subsections for the head, chest, abdomen, and pelvis. The head and chest beams were optimized together, followed by the abdomen and pelvis beams. The last stage of the planning process involved turning all beams on and performing a final optimization to achieve a clinically acceptable plan. Beam isocenters were shifted by 3 or 5 mm in the left-right, anterior-posterior, and superior-inferior directions to simulate the effect of setup errors on the dose distribution. Treatment plan verification consisted of ArcCheck measurements compared to calculated doses using a global 3%/3 mm gamma analysis. All five patient plans achieved the planning aim of delivering 12 Gy to at least 90% of the target. The mean dose in the PTV was 12.7 Gy. Mean lung dose was restricted to 8 Gy, and a dose reduction of up to 40% for organs such as the liver and kidneys proved feasible. The VMAT technique was found to be sensitive to patient setup errors particularly in the superior-inferior direction. The dose predicted by the planning system agreed with measured doses and had an average pass rate of 99.2% for all arcs. VMAT was found to be a viable treatment technique for total body irradiation.
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Affiliation(s)
- Kirsty Symons
- Genesis Cancer Care WADepartment of Radiation OncologyFiona Stanley HospitalMurdochWAAustralia
| | - Colm Morrison
- Genesis Cancer Care WADepartment of Radiation OncologyFiona Stanley HospitalMurdochWAAustralia
- School of PhysicsThe University of Western AustraliaPerthWAAustralia
| | - Jason Parry
- Genesis Cancer Care WADepartment of Radiation OncologyFiona Stanley HospitalMurdochWAAustralia
| | - Simon Woodings
- Genesis Cancer Care WADepartment of Radiation OncologyFiona Stanley HospitalMurdochWAAustralia
- Department of RadiotherapyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Yvonne Zissiadis
- Genesis Cancer Care WADepartment of Radiation OncologyFiona Stanley HospitalMurdochWAAustralia
- School of SurgeryThe University of Western AustraliaPerthWAAustralia
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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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Reduced incidence of interstitial pneumonitis after allogeneic hematopoietic stem cell transplantation using a modified technique of total body irradiation. Sci Rep 2016; 6:36730. [PMID: 27830767 PMCID: PMC5103225 DOI: 10.1038/srep36730] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/20/2016] [Indexed: 01/30/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation is a curative-intent treatment for patients with high-risk hematologic diseases. However, interstitial pneumonitis (IP) and other toxicities remain major concerns after total body irradiation (TBI). We have proposed using linear accelerators with rice-bag compensators for intensity modulation (IM-TBI), as an alternative to the traditional cobalt-60 teletherapy with lung-shielding technique (Co-TBI). Patients who received a TBI-based myeloablative conditioning regimen between 1995 and 2014 were recruited consecutively. Before March 2007, TBI was delivered using Co-TBI (n = 181); afterward, TBI was administered using IM-TBI (n = 126). Forty-four patients developed IP; of these cases, 19 were idiopathic. The IP-related mortality rate was 50% in the total IP cohort and 63% in the idiopathic subgroup. The 1-year cumulative incidences of IP and idiopathic IP were 16.5% and 7.4%, respectively; both rates were significantly higher in the Co-TBI group than in the IM-TBI group. Multivariate analysis revealed that Co-TBI was an independent prognostic factor for both total and idiopathic IP. In the acute myeloid leukemia subgroup, patients with different TBI techniques had similar outcomes for both overall and relapse-free survival. In conclusion, IM-TBI is an easy and effective TBI technique that could substantially reduce the complication rate of IP without compromising treatment efficacy.
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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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Peters M, Taylor B, Turner E. An Evidence-Based Review of Total Body Irradiation. J Med Imaging Radiat Sci 2015; 46:442-449. [PMID: 31052126 DOI: 10.1016/j.jmir.2015.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 09/21/2015] [Accepted: 09/23/2015] [Indexed: 12/25/2022]
Abstract
The purpose of this literature review is to investigate clinical treatment methods of total body irradiation within the context of a clinical department adopting a paediatric cohort with no existing technique. An extensive review of the literature was conducted using PubMed, Science Direct, Google Scholar, and Clinicians Knowledge Network. Articles were limited to nonhelical tomotherapy, nonparticle therapies, and those using hyperfractionated regimes. Total marrow irradiation was excluded because of national treatment and trial limitations. Of the numerous patient positioning methods present within the literature, the most comfortable and reproducible positioning methods for total body irradiation include both supine and the supine and/or prone combination. These positions increased stability and patient comfort during treatment, while also facilitating computed tomography data acquisition at the simulation stage. Ideally, dose calculations should be performed using a three-dimensional treatment planning system and quality assurance procedures that include in vivo dosimetry measurements. The available literature also suggests inhomogeneity correction factors and intensity modulation are superior to conventional open field techniques and should be implemented within developing protocols. Dynamic machine dose modulation is suggested to reduce department impact, removing the need for tissue compensators and accessory shielding devices, while providing significant improvements to treatment time and dose accuracy. Further long-term survival and intensity modulation studies are warranted, including direct comparisons of both dose modulation and treatment efficiency.
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Affiliation(s)
- Mitchell Peters
- Queensland University of Technology, Queensland, Australia; Radiation Oncology Mater Centre South Brisbane, Queensland, Australia.
| | - Beth Taylor
- Radiation Oncology Mater Centre South Brisbane, Queensland, Australia; Queensland University of Technology, Queensland, Australia
| | - Emma Turner
- Radiation Oncology Mater Centre South Brisbane, Queensland, Australia; South Bank University, London, England
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42
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Sensitive Fibre-Based Thermoluminescence Detectors for High Resolution In-Vivo Dosimetry. Sci Rep 2015; 5:13309. [PMID: 26314683 PMCID: PMC4551967 DOI: 10.1038/srep13309] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 07/20/2015] [Indexed: 12/16/2022] Open
Abstract
With interest in the potential of optical fibres as the basis of next-generation thermoluminescence dosimeters (TLDs), the development of suitable forms of material and their fabrication has become a fast-growing endeavour. Present study focuses on three types of Ge-doped optical fibres with different structural arrangements and/or shapes, namely conventional cylindrical fibre, capillary fibre, and flat fibre, all fabricated using the same optical fibre preform. For doses from 0.5 to 8 Gy, obtained at electron and photon energies, standard thermoluminescence (TL) characteristics of the optical fibres have been the subject of detailed investigation. The results show that in collapsing the capillary fibre into a flat shape, the TL yield is increased by a factor of 5.5, the yield being also some 3.2 times greater than that of the conventional cylindrical fibre fabricated from the same perform. This suggests a means of production of suitably sensitive TLD for in-vivo dosimeter applications. Addressing the associated defects generating luminescence from each of the optical fibres, the study encompasses analysis of the TL glow curves, with computerized glow curve deconvolution (CGCD) and 2nd order kinetics.
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Modulatory effect of moringa oleifera against gamma-radiation-induced oxidative stress in rats. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.biomag.2014.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Huang Y, Liu W, Liu H, Yang Y, Cui J, Zhang P, Zhao H, He F, Cheng Y, Ni J, Cai J, Li B, Gao F. Grape seed pro-anthocyanidins ameliorates radiation-induced lung injury. J Cell Mol Med 2014; 18:1267-77. [PMID: 24758615 PMCID: PMC4124012 DOI: 10.1111/jcmm.12276] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 02/10/2014] [Indexed: 01/22/2023] Open
Abstract
Radiation-induced lung injury (RILI) is a potentially fatal and dose-limiting complication of thoracic radiotherapy. This study was to investigate the protective effects of grape seed pro-anthocyanidins (GSPs), an efficient antioxidant and anti-carcinogenic agent, on RILI. In our study, it was demonstrated that acute and late RILI was ameliorated after GSPs treatment possibly through suppressing TGF-β1/Smad3/Snail signalling pathway and modulating the levels of cytokines (interferon-γ, IL-4 and IL-13) derived from Th1/Th2 cells. In addition, a sustained high level of PGE2 was also maintained by GSPs treatment to limited fibroblast functions. As shown by electron spin resonance spectrometry, GSPs could scavenge hydroxyl radical (•OH) in a dose-dependent manner, which might account for the mitigation of lipid peroxidation and consequent apoptosis of lung cells. In vitro, GSPs radiosensitized lung cancer cell A549 while mitigating radiation injury on normal alveolar epithelial cell RLE-6TN. In conclusion, the results showed that GSPs protects mice from RILI through scavenging free radicals and modulating RILI-associated cytokines, suggesting GSPs as a novel protective agent in RILI.
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Affiliation(s)
- Yijuan Huang
- Department of Radiation Medicine, Faculty of Naval Medicine, Second Military Medical University, Shanghai, China
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Gorshkova I, Zhou T, Mathew B, Jacobson JR, Takekoshi D, Bhattacharya P, Smith B, Aydogan B, Weichselbaum RR, Natarajan V, Garcia JGN, Berdyshev EV. Inhibition of serine palmitoyltransferase delays the onset of radiation-induced pulmonary fibrosis through the negative regulation of sphingosine kinase-1 expression. J Lipid Res 2012; 53:1553-68. [PMID: 22615416 DOI: 10.1194/jlr.m026039] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The enforcement of sphingosine-1-phosphate (S1P) signaling network protects from radiation-induced pneumonitis. We now demonstrate that, in contrast to early postirradiation period, late postirradiation sphingosine kinase-1 (SphK1) and sphingoid base-1-phosphates are associated with radiation-induced pulmonary fibrosis (RIF). Using the mouse model, we demonstrate that RIF is characterized by a marked upregulation of S1P and dihydrosphingosine-1-phosphate (DHS1P) levels in the lung tissue and in circulation accompanied by increased lung SphK1 expression and activity. Inhibition of sphingolipid de novo biosynthesis by targeting serine palmitoyltransferase (SPT) with myriocin reduced radiation-induced pulmonary inflammation and delayed the onset of RIF as evidenced by increased animal lifespan and decreased expression of markers of fibrogenesis, such as collagen and α-smooth muscle actin (α-SMA), in the lung. Long-term inhibition of SPT also decreased radiation-induced SphK activity in the lung and the levels of S1P-DHS1P in the lung tissue and in circulation. In vitro, inhibition or silencing of serine palmitoyltransferase attenuated transforming growth factor-β1 (TGF-β)-induced upregulation of α-SMA through the negative regulation of SphK1 expression in normal human lung fibroblasts. These data demonstrate a novel role for SPT in regulating TGF-β signaling and fibrogenesis that is linked to the regulation of SphK1 expression and S1P-DHS1P formation.
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Affiliation(s)
- Irina Gorshkova
- Institute for Personalized Respiratory Medicine, Section of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
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Surucu M, Yeginer M, Kavak GO, Fan J, Radosevich JA, Aydogan B. Verification of dose distribution for volumetric modulated arc therapy total marrow irradiation in a humanlike phantom. Med Phys 2012; 39:281-8. [PMID: 22225298 DOI: 10.1118/1.3668055] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Volumetric modulated arc therapy (VMAT) treatment planning studies have been reported to provide good target coverage and organs at risk (OARs) sparing in total marrow irradiation (TMI). A comprehensive dosimetric study simulating the clinical situation as close as possible is a norm in radiotherapy before a technique can be used to treat a patient. Without such a study, it would be difficult to make a reliable and safe clinical transition especially with a technique as complicated as VMAT-TMI. To this end, the dosimetric feasibility of VMAT-TMI technique in terms of treatment planning, delivery efficiency, and the most importantly three dimensional dose distribution accuracy was investigated in this study. The VMAT-TMI dose distribution inside a humanlike Rando phantom was measured and compared to the dose calculated using RapidArc especially in the field junctions and the inhomogeneous tissues including the lungs, which is the dose-limiting organ in TMI. METHODS Three subplans with a total of nine arcs were used to treat the planning target volume (PTV), which was determined as all the bones plus the 3 mm margin. Thermoluminescent detectors (TLDs) were placed at 39 positions throughout the phantom. The measured TLD doses were compared to the calculated plan doses. Planar dose for each arc was verified using mapcheck. RESULTS TLD readings demonstrated accurate dose delivery, with a median dose difference of 0.5% (range: -4.3% and 6.6%) from the calculated dose in the junctions and in the inhomogeneous medium including the lungs. CONCLUSIONS The results from this study suggest that RapidArc VMAT technique is dosimetrically accurate, safe, and efficient in delivering TMI within clinically acceptable time frame.
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Affiliation(s)
- Murat Surucu
- Department of Radiation and Cellular Oncology University of Chicago, Chicago, Illinois 60637, USA
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Severe Pulmonary Toxicity After Myeloablative Conditioning Using Total Body Irradiation: An Assessment of Risk Factors. Int J Radiat Oncol Biol Phys 2011; 81:812-8. [DOI: 10.1016/j.ijrobp.2010.06.058] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 06/11/2010] [Accepted: 06/18/2010] [Indexed: 11/30/2022]
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Terasaki Y, Ohsawa I, Terasaki M, Takahashi M, Kunugi S, Dedong K, Urushiyama H, Amenomori S, Kaneko-Togashi M, Kuwahara N, Ishikawa A, Kamimura N, Ohta S, Fukuda Y. Hydrogen therapy attenuates irradiation-induced lung damage by reducing oxidative stress. Am J Physiol Lung Cell Mol Physiol 2011; 301:L415-26. [PMID: 21764987 DOI: 10.1152/ajplung.00008.2011] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Molecular hydrogen (H(2)) is an efficient antioxidant that diffuses rapidly across cell membranes, reduces reactive oxygen species (ROS), such as hydroxyl radicals and peroxynitrite, and suppresses oxidative stress-induced injury in several organs. ROS have been implicated in radiation-induced damage to lungs. Because prompt elimination of irradiation-induced ROS should protect lung tissue from damaging effects of irradiation, we investigated the possibility that H(2) could serve as a radioprotector in the lung. Cells of the human lung epithelial cell line A549 received 10 Gy irradiation with or without H(2) treatment via H(2)-rich PBS or medium. We studied the possible radioprotective effects of H(2) by analyzing ROS and cell damage. Also, C57BL/6J female mice received 15 Gy irradiation to the thorax. Treatment groups inhaled 3% H(2) gas and drank H(2)-enriched water. We evaluated acute and late-irradiation lung damage after H(2) treatment. H(2) reduced the amount of irradiation-induced ROS in A549 cells, as shown by electron spin resonance and fluorescent indicator signals. H(2) also reduced cell damage, measured as levels of oxidative stress and apoptotic markers, and improved cell viability. Within 1 wk after whole thorax irradiation, immunohistochemistry and immunoblotting showed that H(2) treatment reduced oxidative stress and apoptosis, measures of acute damage, in the lungs of mice. At 5 mo after irradiation, chest computed tomography, Ashcroft scores, and type III collagen deposition demonstrated that H(2) treatment reduced lung fibrosis (late damage). This study thus demonstrated that H(2) treatment is valuable for protection against irradiation lung damage with no known toxicity.
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Affiliation(s)
- Yasuhiro Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan.
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Mathew B, Jacobson JR, Berdyshev E, Huang Y, Sun X, Zhao Y, Gerhold LM, Siegler J, Evenoski C, Wang T, Zhou T, Zaidi R, Moreno-Vinasco L, Bittman R, Chen CT, LaRiviere PJ, Sammani S, Lussier YA, Dudek SM, Natarajan V, Weichselbaum RR, Garcia JGN. Role of sphingolipids in murine radiation-induced lung injury: protection by sphingosine 1-phosphate analogs. FASEB J 2011; 25:3388-400. [PMID: 21712494 DOI: 10.1096/fj.11-183970] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Clinically significant radiation-induced lung injury (RILI) is a common toxicity in patients administered thoracic radiotherapy. Although the molecular etiology is poorly understood, we previously characterized a murine model of RILI in which alterations in lung barrier integrity surfaced as a potentially important pathobiological event and genome-wide lung gene mRNA levels identified dysregulation of sphingolipid metabolic pathway genes. We hypothesized that sphingolipid signaling components serve as modulators and novel therapeutic targets of RILI. Sphingolipid involvement in murine RILI was confirmed by radiation-induced increases in lung expression of sphingosine kinase (SphK) isoforms 1 and 2 and increases in the ratio of ceramide to sphingosine 1-phosphate (S1P) and dihydro-S1P (DHS1P) levels in plasma, bronchoalveolar lavage fluid, and lung tissue. Mice with a targeted deletion of SphK1 (SphK1(-/-)) or with reduced expression of S1P receptors (S1PR1(+/-), S1PR2(-/-), and S1PR3(-/-)) exhibited marked RILI susceptibility. Finally, studies of 3 potent vascular barrier-protective S1P analogs, FTY720, (S)-FTY720-phosphonate (fTyS), and SEW-2871, identified significant RILI attenuation and radiation-induced gene dysregulation by the phosphonate analog, fTyS (0.1 and 1 mg/kg i.p., 2×/wk) and to a lesser degree by SEW-2871 (1 mg/kg i.p., 2×/wk), compared with those in controls. These results support the targeting of S1P signaling as a novel therapeutic strategy in RILI.
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Affiliation(s)
- Biji Mathew
- Institute for Personalized Respiratory Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, University of Illinois at Chicago, Chicago, Illinois 60612, USA
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Corvò R, Zeverino M, Vagge S, Agostinelli S, Barra S, Taccini G, Lint MTV, Frassoni F, Bacigalupo A. Helical tomotherapy targeting total bone marrow after total body irradiation for patients with relapsed acute leukemia undergoing an allogeneic stem cell transplant. Radiother Oncol 2011; 98:382-6. [DOI: 10.1016/j.radonc.2011.01.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 12/01/2010] [Accepted: 01/04/2011] [Indexed: 10/18/2022]
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