Second cancer after total-body irradiation (TBI) in childhood

The impacts of total body irradiation on umbilical cord blood hematopoietic stem cell transplantation

Background

Umbilical cord blood hematopoietic stem cells are commonly used for hematopoietic system reconstitution in recipients after umbilical cord blood transplantation (UCBT). However, the optimal conditioning regimen for UCBT remains a topic of debate. The exact impact of total body irradiation (TBI) as a part of conditioning regimens remains unknown.

Objectives

The aim of this study was to evaluate the impacts of TBI on UCBT outcomes.

Design

This was a multi-institution retrospective study.

Methods

A retrospective analysis was conducted on the outcomes of 136 patients receiving UCBT. Sixty-nine patients received myeloablative conditioning (MAC), in which 33 underwent TBI and 36 did not, and 67 patients received reduced-intensity conditioning (RIC), in which 43 underwent TBI and 24 did not. Univariate and multivariate analyses were conducted to compare the outcomes and the post-transplant complications between patients who did and did not undergo TBI in the MAC subgroup and RIC subgroup, respectively.

Results

In the RIC subgroup, patients who underwent TBI had superior overall survival (adjusted hazard ratio [aHR] = 0.25, 95% confidence interval [CI]: 0.09-0.66, p = 0.005) and progression-free survival (aHR = 0.26, 95% CI: 0.10-0.66, p = 0.005). However, in the MAC subgroup, there were no statistically significant differences between those receiving and not receiving TBI.

Conclusion

In the setting of RIC in UCBT, TBI utilization can improve overall survival and progression-free survival. However, TBI does not show superiority in the MAC setting.

Primary immunosuppressive TNI-based conditioning regimens in pediatric patients treated with haploidentical hematopoietic cell transplantation

PURPOSE

This retrospective analysis aims to address the toxicity and efficacy of a modified total nodal irradiation (TNI)-based conditioning regimen before haploidentical hematopoietic cell transplantation (HCT) in pediatric patients.

MATERIALS AND METHODS

Patient data including long-term follow-up were evaluated of 7 pediatric patients with malignant (n = 2) and non-malignant diseases (n = 5) who were treated by a primary TNI-based conditioning regimen. TNI was performed using anterior/posterior opposing fields. All patients received 7 Gy single-dose TNI combined with systemic agents followed by an infusion of peripheral blood stem cells (n = 7). All children had haploidentical family donors.

RESULTS

Engraftment was reached in 6/7 children after a median time of 9.5 days; 1 child had primary graft failure but was successfully reconditioned shortly thereafter. After an average follow-up time of 103.5 months (range 8.8-138.5 months), event-free (EFS) and overall survival (OS) rates were 71.4% and 85.7%, respectively. One child with a non-malignant disease died 8.8 months after transplantation due to a relapse and a multiple organ failure. Follow-up data was available for 5/6 long-term survivors with a median follow-up (FU) of 106.2 months (range 54.5-138.5 months). Hypothyroidism and deficiency of sexual hormones was present in 3/5 patients each. Mean forced expiratory volume in 1 s (FEV1) after TNI was 71%; mean vital capacity (VC) was 78%. Growth failure (< 10th percentile) occurred in 2/5 patients (height) and 1/5 patient (weight). No secondary malignancies were reported.

CONCLUSION

In this group of patients, a primary single-dose 7 Gy TNI-based conditioning regimen before HCT in pediatric patients allowed sustained engraftment combined with a tolerable toxicity profile leading to long-term OS/EFS. Late toxicity after a median FU of over 9 years includes growth failure, manageable hormonal deficiencies, and acceptable decrease in lung function.

Adverse Effects of Total Body Irradiation: A Two-Decade, Single Institution Analysis

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.

Total body irradiation of bone marrow transplant using helical TomoTherapy with a focus on the quality of dose contribution at junction target volumes

PURPOSE

Total body irradiation (TBI) can be safely delivered on TomoTherapy (Accuray, Sunnyvale, CA, USA) in both pediatric and adult patients with proper imaging and planning despite the length constraint of 135 cm. To overcome this limitation, two CT (Computed Tomography) scans (CT1& CT2) are taken in patients above 135 cm in height. Adequate junction dose coverage is important in TBI. Presently, there is no clinical report with a focus on the quality of dose distribution at the CT junction in view of the guidelines on quality of coverage from the RTOG. Hence, our main objectives were to evaluate the dose distribution and quality of coverage at the junction in 16 patients who received TBI using TomoTherapy.

METHODS

PTV(upper) and PTV(lower) along with a junction were created on CT1 and CT2, respectively. Subsequently, the 10 cm junction in the thigh region was divided into five target volumes of 2 cm thickness with dose prescription ranging from 10 to 90% to deliver a total dose equal to 100% when fused.

RESULTS

The D₅₀ was equal to the prescribed dose in most of the cases ranging from 99.5 to 104% for PTV(upper), 100-103% for PTV(lower), and 99.5-108% for junctional PTVs (1PTV, 2PTV, 3PTV, 4PTV, and 5PTV). The average D₉₅ doses from PTV(upper) and PTV(lower) were 97 ± 1.4% and 96.7 ± 1.08%, respectively. The average D₉₅ doses for 1PTV, 2PTV, 3PTV, 4PTV, and 5PTV were 96.1 ± 1.88%, 91.6 ± 1.82%, 87.3 ± 1.5%, 91.6 ± 1.4%, and 96.2 ± 1.5% respectively. Q_RTOG values ranged between 0.85 and 1.05 and were in concordance with RTOG guidelines.

CONCLUSION

Since junction-based planning was required for most TBI patients, it is essential to evaluate the quality of dose coverage in the junction for better TBI plans.

Comparison of different TBI techniques in terms of dose homogeneity - review study

Total body irradiation (TBI) is a kind of external beam radiotherapy, used in conjunction with chemotherapy with the purpose of immunosuppression. Since the target in TBI is the whole body, so achieving uniform dose distribution throughout the entire body during TBI is necessary. As recommended by AAPM dose variation must be within ±10% of the prescription dose. With the evidences from literature there is limited substantiation to consider a treatment method better than others, but with regard to the size of the treatment room, workload of the radiotherapy department and prevalent technology used within each treatment department it is recommended to make the suitable and optimum method in each department. In this work, a review study was performed on different TBI techniques with the purpose of assessment and comparison of dose distribution homogeneity in these methods.

Advanced glycation end products and chronic inflammation in adult survivors of childhood leukemia treated with hematopoietic stem cell transplantation

BACKGROUND

Among survivors of pediatric acute lymphoblastic leukemia (ALL), those who received hematopoietic stem cell transplantation (HSCT) conditioned with total-body irradiation (TBI) show the highest risk of late complications, including cardiovascular (CV) disease. Advanced glycation end products (AGEs) have been associated with CV disease in diabetes mellitus and other clinical conditions. This study explores AGEs plasma levels, inflammatory status, and lipid profile in survivors of pediatric ALL who received HSCT conditioned with TBI.

PROCEDURE

Inclusion criteria were (a) previous diagnosis of ALL at age < 18 years, treated with HSCT conditioned with TBI; (b) age > 18 at the time of the study enrollment; (c) off-therapy for at least five years. Radiotherapy other than TBI, preexisting heart disease, glucose metabolism impairment, body mass index > 25, active graft versus host disease (GvHD), smoking, or treatment with cholesterol lowering medications were exclusion criteria. Eighteen survivors and 30 age-matched healthy controls were enrolled.

RESULTS

AGEs plasma levels were markedly higher in ALL survivors than in healthy subjects (2.15 ± 2.21 vs 0.29 ± 0.15 pg/mL, P < 0.01). Survivors also showed higher levels of high-sensitivity C-reactive protein (2.32 ± 1.70 vs 0.88 ± 1.09 mg/dL, P < 0.05), IL-1β (7.04 ± 1.52 vs 4.64 ± 2.02 pg/mL, P < 0.001), IL17 (37.44 ± 3.51 vs 25.19 ± 6.34 pg/mL, P < 0.001), an increased glutathione/reduced glutathione ratio (0.085 ± 0.07 vs 0.041 ± 0.036, P < 0.05) and slight alterations in their lipid profile.

CONCLUSIONS

Our data show AGEs accumulation and chronic inflammation in ALL survivors who received HSCT conditioned with TBI. These alterations may contribute to the increased risk of CV disease reported in these subjects.

The impact of severe late-effects after 12 Gy fractionated total body irradiation and allogeneic stem cell transplantation for childhood leukemia (1988-2010)

This study consists of a retrospective study including 71 childhood leukemia survivors (36 females) treated with allo-HSCT 12 Gy fractionated total body irradiation (fTBI) conditioning, with a median age of 25.0 y at time of follow-up and a median delay of 14.8 y since the graft. The recovery ratio was 90%. The number of severe late-effects was specified for each patient: 21 with growth deficiency (final height <162.5 cm for 12/35 men and <152.0 cm for 9/36 women - Growth deficiency was correlated to young age at the time of the allograft); 5 with sclerodermic chronic graft vs. host disease; 9 with osteonecrosis; risk of impaired fertility for 25 women and 28 men (only 2 women had a child); 8 with diabetes; 5 with pulmonary late-effects including 1 death; 5 with chronic renal insufficiency including 1 death; 2 with cardiac late-effects; 2 with arterial high blood pressure; 11 (8 women) declared 14 subsequent cancers (7 with thyroid carcinomas, 3 with multiple squamous cell carcinomas, 2 with epidermoïdis carcinomas of the tongue or the lip, 1 with bone sarcoma, and 1 with carcinoma of the breast); 6 with chelating treatments of hemochromatosis; 14 with important educational underachievement; 11 with depression at adult age; 1 with hepatitis B virus infection; 4 with other severe late-effects, including 2 with blindness. The average number of severe late-effects was 2.3 with a positive correlation according to delay from fTBI (p < 0.0002). Two-thirds had at least 2 late-effects. These results emphasize the urgent abandonment of conditioning by TBI in children.

Immunosuppressive Total Nodal Irradiation-Based Reconditioning Regimens After Graft Rejection or Graft Failure in Pediatric Patients Treated With Myeloablative Allogeneic Hematopoietic Cell Transplantation

PURPOSE

This retrospective analysis aimed to address the efficacy of total nodal irradiation (TNI)-based reconditioning regimens in pediatric patients with graft failure/rejection after allogeneic hematopoietic cell transplantation.

METHODS AND MATERIALS

Thirty-three pediatric patients with malignant (n = 25) and nonmalignant diseases (n = 8) were treated with a TNI-based reconditioning regimen. All patients received a 7-Gy single dose combined with anti-T lymphocyte antibody OKT3 (n = 16), anti-thymocyte globulin (n = 24), fludarabine (n = 31), and/or thiotepa (n = 28), followed by an infusion of peripheral blood stem cells (n = 31) or bone marrow transplant (n = 2). Twenty-eight of 33 patients had haploidentical family donors.

RESULTS

After a median of 11 days, engraftment was seen in 32 of 33 children. Two children died 34 days after retransplantation because of either disease relapse or treatment-related multiple organ failure. Severe acute toxicity was reported in only 1 child (systemic inflammatory response syndrome-like reaction; recovery after cortisone treatment). The average follow-up was 60.2 months (range, 1.1-162.5 months). Event-free and overall survival rates at 2/5 years follow-up were 62.0%/58.6% and 65.1%/61.7%, respectively. Despite sustained engraftment, 12 patients died from disease relapse (n = 3), Moschkowitz syndrome (n = 1), or multiple organ failure (n = 8). Follow-up data were available for 18 of 21 survivors, with a median follow-up of 92.8 months (range, 3.6-162.5 months). Hypothyroidism was present in 78.6% of patients, and sex/growth hormonal insufficiencies were reported for 37.5%. Mean forced expiratory volume in 1 second after TNI was 84%; mean vital capacity was 79%. Severe growth failure (<3rd percentile) occurred in 28.6% (height) and 35.7% (weight) of patients. No secondary malignancies were reported.

CONCLUSIONS

In the high-risk group of patients with graft failure/rejection after allogeneic hematopoietic cell transplantation, the TNI-based reconditioning regimen seems to allow sustained engraftment combined with a favorable toxicity profile, leading to long-term event-free and overall survival. Late toxicity after a median follow-up of over 7.5 years includes growth failure, manageable hormonal deficiencies, and a low risk of decrease of lung function.

Curative therapies: Allogeneic hematopoietic cell transplantation from matched related donors using myeloablative, reduced intensity, and nonmyeloablative conditioning in sickle cell disease

Sickle cell disease (SCD) chronically damages multiple organs over the lifetime of affected individuals. Allogeneic hematopoietic cell transplantation (allo-HCT) is the most studied curative intervention. Fully matched related marrow, peripheral blood derived, or cord blood HCT have the best transplant outcome for symptomatic patients with SCD. For patients with asymptomatic or milder disease who have this donor option available, risks and benefits of HCT should be discussed among the patient, family, treating hematologist, and transplant physician, and decision to proceed to HCT should be individualized. Myeloablative conditioning with busulfan, cyclophosphamide, and ATG has been a commonly employed regimen for children and young adults. Recently, low intensity conditioning with low dose total body irradiation and alemtuzumab is emerging as an efficacious and safe regimen for adults, young adults, and possibly children. Mixed donor chimerism (minimum ≥20% myeloid cells), from myeloablative or nonmyeloablative conditioning regimen, produces robust normal donor erythropoiesis and is sufficient to provide a clinical cure. The proportion of patients remaining on immunosuppression beyond 2 years post-HCT is likely <10% with either myeloablative or low intensity regimens. Late effects from myeloablative or reduced intensity conditioning, or from several more months of immunosuppression in low intensity conditioning may be less common than those observed in HCT for malignant indications. Nonmyeloablative approaches with low toxicities should be the focus of future research efforts. Prevention of GVHD is a shared goal in all approaches of allo-HCT in SCD.

Treatment of graft failure with TNI-based reconditioning and haploidentical stem cells in paediatric patients

Graft failure is a life‐threatening complication after allogeneic haematopoietic stem cell transplantation (HSCT). We report a cohort of 19 consecutive patients (median age: 8·5 years) with acute leukaemias (n = 14) and non‐malignant diseases (n = 5) who experienced graft failure after previous HSCT from matched (n = 3) or haploidentical donors (n = 16) between 2003 and 2012. After total nodal irradiation (TNI)‐based reconditioning combined with fludarabine, thiotepa and anti‐T cell serotherapy, all patients received T cell‐depleted peripheral blood stem cell grafts from a second, haploidentical donor. Median time between graft failure and retransplantation was 14 d (range 7–40). Sustained engraftment (median: 10 d, range 9–32) and complete donor chimerism was observed in all evaluable patients. 5 patients additionally received donor lymphocyte infusions. Graft‐versus‐host disease (GvHD) grade II and III occurred in 1 patient each (22%); no GvHD grade IV was observed. 2 patients had transient chronic GvHD. The regimen was well tolerated with transient interstitial pneumonitis in one patient. Treatment‐related mortality after one year was 11%. Event‐free survival and overall survival 3 years after retransplantation were 63% and 68%. Thus, a TNI‐based reconditioning regimen followed by transplantation of haploidentical stem cells is an option to rescue patients with graft failure within a short time span and with low toxicity.

Glioblastoma Multiforme in a Post Allogeneic Stem Cell Transplant Patient. A Case Report and Literature Review of Post Transplant Neurological Tumors

Seventeen year old boy, a case of relapsed acute lymphoblastic leukemia 10 years post allogeneic transplantation, presented to us with acute onset of right hemiparesis. The imaging revealed contrast enhancing lesion in the frontal lobe, biopsy of the same was consistent with glioblastoma multiforme (GBM). He had received total body irradiation (TBI) based conditioning regimen prior to transplant. GBM was treated with left parietal craniotomy and parietal excision of tumour, followed by radiation therapy with concurrent and adjuvant chemotherapy. Disease progressed while was on adjuvant chemotherapy and patient succumbed to his illness 8 months after the diagnosis of GBM. We report here a here unusual case of GBM in a post transplant patient who received TBI based conditioning regimen.

Total Body Irradiation (TBI) using Helical Tomotherapy in children and young adults undergoing stem cell transplantation

Background

Establishing Total Body Irradiation (TBI) using Helical Tomotherapy (HT) to gain better control over dose distribution and homogeneity and to individually spare organs at risk. Because of their limited body length the technique seems especially eligible in juvenile patients.

Patients and methods

The cohort consisted of 10 patients, 6 female and 4 male, aged 4 - 22 y with acute lymphoblastic- (ALL) or acute myeloic leukemia (AML). All patients presented with high risk disease features. Body length in treatment position ranged from 110–180 cm. Two Gy single dose was applied BID to a total dose of 12 Gy. Dose volume constraint for the PTV was 95% dose coverage for 95% of the volume. The lungs were spared to a mean dose of [less than or equal to] 10 Gy. Patients were positioned in a vac-loc bag in supine position with a 3-point head mask.

Results

Average D95 to the PTV was 11.7 Gy corresponding to a mean coverage of the PTV of 97.5%. Dmean for the lungs was 9.14 Gy. Grade 3–4 side effects were not observed.

Conclusions

TBI using HT is feasible and well tolerated. A benefit could be demonstrated with regard to dose distribution and homogeneity and the selective dose-reduction to organs at risk.

Final height and body mass index after fractionated total body irradiation and allogeneic stem cell transplantation in childhood leukemia

Impaired linear growth has been reported in patients treated during childhood with allogeneic stem cell transplantation and fractionated total body irradiation (fTBI). The objective of this study was to determine the final height and body mass index (BMI) achieved. Forty-nine patients with leukemia were included and surveyed for more than 5 years. Median age at follow-up was 24.3 years (range, 18.9-35.8) and median follow-up time from allograft was 14.4 years (range, 4.5-21.9). Mean height standard deviation score (s.d.s.) at final examination (-1.1 ± 1.3,) was significantly lower than at fTBI (0.3 ± 1.2; P = .001). Final height s.d.s. was significantly correlated with age at diagnosis, age at fTBI, and target height (P = .001; P < .001; P < .001, respectively). Final height was significantly lower in children transplanted before age 5 (P = .006). Growth hormone treatment (n = 6) had only a modest effect on growth velocity. Mean BMI at follow-up was normal at 19.6 kg/m(2) for boys and 21.2 for girls, but with a significant decrease since allograft only for boys (-1.2 ± 1.5 s.d.s.) (P = .003). In conclusion, final height is decreased; BMI is normal but decreased from fTBI in boys.

Retrospective, monocentric analysis of late effects after Total Body Irradiation (TBI) in adults

PURPOSE

Total body irradiation (TBI) is a standard treatment modality within the multidisciplinary approach for allogeneous stem cell or bone marrow transplantation. However, surviving patients are at risk for developing a variety of late sequelae. This analysis aimed to retrospectively characterize late effects after TBI in adults treated in a single center.

PATIENTS AND METHODS

Patients ≥ 18 years treated with fractionated TBI (4-12 Gy) between 1996 and 2008 were included in this study. Treatment data were collected retrospectively from the treating departments. Late effects were evaluated using the clinic charts and/or were obtained from the general practitioners using a standardized questionnaire. Analyses were performed by calculation of the cumulative incidences using the Kaplan-Meier method and the log rank test.

RESULTS

A total of 308 patients ≥ 18 years were treated including a TBI of whom 78 patients were excluded from further analysis due to death within less than 1 year after TBI. Patients suffered from leukemia in most cases. Late toxicity follow-up was available in 120 patients (mean age 46.1 years; range, 18-70 years) after a mean follow-up of 23 months (range, 12-96 months). The cumulative incidences (CI) at 3 years were 28% for pulmonary event, 8% for pulmonary toxicity, 25% for kidney toxicity, 8% for cataract, 17% for bone toxicity, and 10% for secondary malignancy. The CI of bone toxicity was higher in female than in male patients (p = 0.019).

CONCLUSION

Late effects after TBI in the context of allogeneous stem cell or bone marrow transplantation can frequently be observed. Regular follow-up examinations are advised for the early registration and treatment of adverse effects.

Cephalometric assessment of the axial inclination of upper and lower incisors in relation to the third-order angle

BACKGROUND AND AIM

Estimating incisor inclination cephalometrically by reference lines NA and NB puts the orthodontist in the difficult position of relating these axial inclination data to the bracket's third-order prescription which refers to a perpendicular to the occlusal plane. Purpose of the present study was to evaluate the relationship between the cephalometrically-assessed incisor inclination (using the lines NA and NB for reference) and the third-order angle (syn.: torque angle, TA) according to Andrews' description, and moreover to investigate the correlation between incisor inclination data and skeletal-sagittal and skeletal-vertical findings.

MATERIALS AND METHODS

The lateral cephalograms and corresponding dental casts of 67 subjects between 10 and 25 years of age (regardless of skeletal and dental relationships) were considered in the study. All subjects were Caucasian, and none had undergone orthodontic therapy. Upper (U1) and lower (L1) incisor angulations were cephalometrically assessed in reference to the NA and NB lines and compared to third-order angles obtained from dental cast measurements with an incisor inclination-recording appliance. Incisor inclination data from the two measurements were correlated to craniofacial sagittal (angles SNA, SNB, ANB) and vertical (angles NSL-NL, NSL-ML, ML-NL) findings from the radiographs.

RESULTS

The third-order angles in the upper arch measured on the dental casts were a mean of 16.2 degrees (SD = 5.3 degrees) smaller than the axial inclination according to the NA line; the lower incisor third-order data were less than those of the axial inclination according to the NB line by a mean of 27.8 degrees (SD = 4.75 degrees). In this sample, there was a range of 42.7 degrees for the U1TA variable (mean = 5.6 degrees, SD 9.73 degrees) and 47 degrees for U1NA/ degrees variable (mean = 21.71 degrees, SD = 8.67 degrees). The L1TA variable showed a range of 29 degrees (mean = -2.95 degrees, SD = 7.17 degrees), the radiographic L1NB/ degrees range was 23 degrees (mean = 24.91 degrees, SD = 5.8 degrees). We observed a highly significant correlation (r(NA) = 0.84***, r(NB) = 0.76***) between the Andrews' angle and the inclination estimated in reference to the NA and NB lines. No significant correlation between incisor inclination and craniofacial measurements was detected.

CONCLUSIONS

Dental cast measurements seem to be more precise and more valid than lateral radiographs. The method we describe enables clinicians to get a good idea precisely and quickly of how much torque potential remains in the brackets and archwires during treatment. The inclination of the incisors can also be calculated using the regression equations provided, making additional lateral cephalograms unnecessary.