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Gao Z, Xu Q, Zhang F, Hong Y, Hu Q, Yu Q, Fu S, Gong Q. The implementation of low instantaneous dose rate total body irradiation with linear accelerator in small-size treatment rooms. J Appl Clin Med Phys 2024:e14502. [PMID: 39231180 DOI: 10.1002/acm2.14502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 06/28/2024] [Accepted: 07/30/2024] [Indexed: 09/06/2024] Open
Abstract
PURPOSE This paper describes the implementation of an instantaneous low-dose-rate total body irradiation (TBI) technique using block-filtered 6 MV X-rays with a linear accelerator (LINAC) to reduce pulmonary toxicity. METHODS In the absence of dedicated TBI-specific meter-set dose rates in LINAC and sufficient treatment room size, a 2-cm-thick transmission block was used together with a 200-cm source-to-surface distance (SSD) to reduce the instantaneous dose rates of 6 MV x-rays down to 10 cGy/min, thus alteration to the beam properties. A TBI-specific dose calculation model was built with data acquired at the treatment planning system (TPS)-permitted maximum 140-cm SSD and was validated in phantoms at a 180-cm SSD. As for planning strategies, we adopted large anterior-to-posterior/posterior-to-anterior (AP/PA) open fields with multi-leaf collimator shielding for lungs to achieve target coverage, lung protection, and efficient dose delivery. A custom-designed sliding couch (Patent No. ZL202123085880.1) was manufactured to support patients during treatment. Measures to control the quality and safety of TBI treatment include machine interlocks, pretreatment checklists, and in-vivo dose monitoring. RESULTS The instantaneous dose rate of block-filtered 6MV X-ray was reduced to approximately 7.0 cGy/min at 12.5-7.5 cm depth with a 185-200 cm SSD. The dose calculated by TPS differs from the measurements by 0.15%-1.55% in the homogeneous phantom and 1.2%-4.85% in the CIRS thorax phantom. The open-field TBI technique achieved V90% (PTV) ≈ 96.8% and MLD = 6.6 Gy with 1-h planning and 50-min beam delivery in a single fraction. From February 2021 to July 2023, 30 patients received TBI treatments in our center, and in-vivo monitoring results differed from TPS calculations by -1.49%-2.10%. After 6-12 months of follow-ups, all the patients treated in our center showed no pulmonary toxicities of grade 2 or higher. CONCLUSION A low instantaneous dose rate TBI technique can be implemented in the clinic.
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Affiliation(s)
- Zhengxin Gao
- Department of Radiation Oncology, Shanghai Concord Medical Cancer center, Shanghai, China
- Proton & Heavy Ion Medical Research Center, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Soochow, Jiangsu, China
| | - Qiuyi Xu
- Department of Radiation Oncology, Shanghai Concord Medical Cancer center, Shanghai, China
- Proton & Heavy Ion Medical Research Center, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Soochow, Jiangsu, China
| | - Fengjiao Zhang
- Department of Radiation Oncology, Shanghai Concord Medical Cancer center, Shanghai, China
- Proton & Heavy Ion Medical Research Center, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Soochow, Jiangsu, China
| | - Yaling Hong
- Department of Radiation Oncology, Shanghai Concord Medical Cancer center, Shanghai, China
- Proton & Heavy Ion Medical Research Center, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Soochow, Jiangsu, China
| | - Qiaoying Hu
- Department of Radiation Oncology, Shanghai Concord Medical Cancer center, Shanghai, China
- Proton & Heavy Ion Medical Research Center, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Soochow, Jiangsu, China
| | - Qi Yu
- Department of Radiation Oncology, Shanghai Concord Medical Cancer center, Shanghai, China
- Proton & Heavy Ion Medical Research Center, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Soochow, Jiangsu, China
| | - Shen Fu
- Department of Radiation Oncology, Shanghai Concord Medical Cancer center, Shanghai, China
- Proton & Heavy Ion Medical Research Center, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Soochow, Jiangsu, China
| | - Qing Gong
- Department of Radiation Oncology, Shanghai Concord Medical Cancer center, Shanghai, China
- Proton & Heavy Ion Medical Research Center, State Key Laboratory of Radiation Medicine and Protection, Soochow University, Soochow, Jiangsu, China
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Down JD, Cornwall-Brady MR, Huang W, Hurwitz M, Floyd SR, Yilmaz OH. Selecting the Most Relevant Mouse Strains for Evaluating Radiation-Induced Multiple Tissue Injury after Leg-Shielded Partial-Body Gamma Irradiation. Radiat Res 2024; 202:510-522. [PMID: 39066627 DOI: 10.1667/rade-24-00058.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 05/24/2024] [Indexed: 07/28/2024]
Abstract
Animal studies are needed that best simulate a large-scale, inhomogeneous body exposure after a radiological or nuclear incident and that provides a platform for future development of medical countermeasures. A partial-body irradiation (PBI) model using 137Cs gamma rays with hind limb (tibia) shielding was developed and assessed for the sequalae of radiation injuries to gastrointestinal tract, bone marrow (BM) and lung and among different genetic mouse strains (C57BL/6J, C57L/J, CBA/J and FVB/NJ). In this case, a marginal level of BM shielding (∼2%) provided adequate protection against lethality from infection and hemorrhage and enabled escalation of radiation doses with evaluation of both acute and delayed radiation syndromes. A steep radiation dose-dependent body weight loss was observed over the first 5 days attributed to enteritis with C57BL/6J mice appearing to be the most sensitive strain. Peripheral blood cell analysis revealed significant depression and recovery of leukocytes and platelets over the first month after PBI and were comparable among the four different mouse strains. Latent pulmonary injury was observed on micro-CT imaging at 4 months in C57L/J mice and confirmed histologically as severe pneumonitis that was lethal at 12 Gy. The lethality and radiological densitometry (HUs) dose responses were comparable to previous studies on C57L/J mice after total-body irradiation (TBI) and BM transplant rescue as well as after localized whole-thorax irradiation (WTI). Indeed, the lethal radiation doses and latency appeared similar for pneumonitis appearing in rhesus macaques after WTI or PBI as well as predicted for patients given systemic radiotherapy. In contrast, PBI treatment of C57BL/6 mice at a higher dose of 14 Gy had far longer survival times and developed extreme and debilitating pIeural effusions; an anomaly as similarly reported in previous thorax irradiation studies on this mouse strain. In summary, a radiation exposure model that delivers PBI to unanesthetized mice in a device that provides consistent shielding of the hind limb BM was developed for 137Cs gamma rays with physical characteristics and relevance to relatively high photon energies expected from the detonation of a nuclear device or accidental release of ionizing radiation. Standard strains such as C57BL/6J mice may be used reliably for early GI or hematological radiation syndromes while the C57L/J mouse strain stands out as the most appropriate for evaluating the delayed pulmonary effects of acute radiation exposure and recapitulating this disease in humans.
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Affiliation(s)
- Julian D Down
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Milton R Cornwall-Brady
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Wei Huang
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Martina Hurwitz
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Scott R Floyd
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Omer H Yilmaz
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts
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Groves AM, Paris ND, Johnston CJ, Hernady E, Finkelstein J, Lawrence P, Marples B. Mitigating Viral Impact on the Radiation Response of the Lung. Radiat Res 2024; 202:552-564. [PMID: 39048109 DOI: 10.1667/rade-24-00103.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 06/11/2024] [Indexed: 07/27/2024]
Abstract
Inflammation is a key factor in both influenza and radiation-induced lung pathophysiology. This implies a commonality of response to pulmonary damage from these insults and suggests exacerbated pathology may occur after combined exposure. We therefore tested the hypothesis that past inflammation from viral infection alters the lung microenvironment and lowers tolerance for radiation injury. Mice were inoculated with influenza A virus (IAV) and three weeks later, after virus clearance, mice received total-body irradiation (TBI). Survival as well as systemic and local lung inflammation were assessed, and strategies to mitigate pulmonary injury were investigated. After IAV infection alone, body condition recovered within 3 weeks, however inflammatory pathways remained active for 15 weeks. IAV infection exacerbated subsequent TBI responses, evident by increased lethality, enhanced histologically evident lung injury and an altered lung macrophage phenotype. To mitigate this enhanced sensitivity, captopril [an angiotensin converting enzyme inhibitor (ACEi)] was administered to limit tissue inflammation, or inflammatory monocyte-derived macrophage recruitment was blocked with a C-C chemokine receptor type 2 (CCR2) inhibitor. Both treatments abrogated the changes in circulating immune cells observed 4 weeks after TBI, and attenuated pro-inflammatory phenotypes in lung alveolar macrophages, appearing to shift immune cell dynamics towards recovery. Histologically apparent lung injury was not improved by either treatment. We show that latent lung injury from viral infection exacerbates radiation morbidity and mortality. Although strategies that attenuate proinflammatory immune cell phenotypes can normalize macrophage dynamics, this does not fully mitigate lung injury. Recognizing that past viral infections can enhance lung radiosensitivity is of critical importance for patients receiving TBI, as it could increase the incidence of adverse outcomes.
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Affiliation(s)
- Angela M Groves
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Nicole D Paris
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Carl J Johnston
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - Eric Hernady
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jacob Finkelstein
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - Paige Lawrence
- Department of Environmental Medicine, University of Rochester, Rochester, New York
| | - Brian Marples
- Department of Radiation Oncology, University of Rochester, Rochester, New York
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4
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Seravalli E, Bosman ME, Han C, Losert C, Pazos M, Engström PE, Engellau J, Fulcheri CPL, Zucchetti C, Saldi S, Ferrer C, Ocanto A, Hiniker SM, Clark CH, Hussein M, Misson-Yates S, Kobyzeva DA, Loginova AA, Hoeben BAW. Technical recommendations for implementation of Volumetric Modulated Arc Therapy and Helical Tomotherapy Total Body Irradiation. Radiother Oncol 2024; 197:110366. [PMID: 38830537 DOI: 10.1016/j.radonc.2024.110366] [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: 01/25/2024] [Revised: 05/10/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Abstract
As a component of myeloablative conditioning before allogeneic hematopoietic stem cell transplantation (HSCT), Total Body Irradiation (TBI) is employed in radiotherapy centers all over the world. In recent and coming years, many centers are changing their technical setup from a conventional TBI technique to multi-isocenter conformal arc therapy techniques such as Volumetric Modulated Arc Therapy (VMAT) or Helical Tomotherapy (HT). These techniques allow better homogeneity and control of the target prescription dose, and provide more freedom for individualized organ-at-risk sparing. The technical design of multi-isocenter/multi-plan conformal TBI is complex and should be developed carefully. A group of early adopters with conformal TBI experience using different treatment machines and treatment planning systems came together to develop technical recommendations and share experiences, in order to assist departments wishing to implement conformal TBI, and to provide ideas for standardization of practices.
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Affiliation(s)
- Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mirjam E Bosman
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Chunhui Han
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Christoph Losert
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Per E Engström
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Jacob Engellau
- Department of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Claudio Zucchetti
- Section of Medical Physics, Perugia General Hospital, Perugia, Italy
| | - Simonetta Saldi
- Section of Radiation Oncology, Perugia General Hospital, Perugia, Italy
| | - Carlos Ferrer
- Department of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Abrahams Ocanto
- Department of Radiation Oncology, San Francisco de Asís University Hospital, GenesisCare, Madrid, Spain
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Catharine H Clark
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK; Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK; Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK; Medical Physics and Bioengineering Department, University College London, London, UK
| | - Mohammad Hussein
- Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK
| | - Sarah Misson-Yates
- Medical Physics Department, Guy's and St Thomas' Hospital, London, UK; UK School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK; National Physical Laboratory, Metrology for Medical Physics Centre, London, UK
| | - Daria A Kobyzeva
- Deptartment of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Deptartment of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
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Nelson G, Sarkar V, Szegedi M, Molineu A, Olch AJ, Kunz JN, Zhao H, Huang YJ, Pillai S, Rassiah P. Validation of Acuros for total body irradiation at extended distance. J Appl Clin Med Phys 2024:e14468. [PMID: 39023298 DOI: 10.1002/acm2.14468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/23/2024] [Accepted: 06/20/2024] [Indexed: 07/20/2024] Open
Abstract
PURPOSE Standardized and accurately reported doses are essential in conventional total body irradiation (TBI), especially lung doses. This study evaluates the accuracy of the Acuros algorithm in predicting doses for extended-distance TBI. METHODS Measurements and calculations were done with both 6 and 18 MV. Tissue Maximum Ratio (TMR), output and off axis ratios (OAR) were measured at 200 and 500 cm source to detector distance and compared to Acuros calculated values. Two end-to-end tests were carried out, one with an in-house phantom (solid water and Styrofoam) with inserted ion chambers and the other was with the Imaging and Radiation Oncology Core (IROC) TBI anthropomorphic phantom equipped with TLDs. The end-to-end test was done for 6 and 18 MV both with and without lung blocks. The source to midplane distance for both phantoms were at 518 and 508 cm respectively. Lung blocks were placed at the phantom surface and a beam spoiler was positioned 30 cm from the surface of the phantoms as per our clinical set up. RESULTS The agreement between measured and calculated TMR, output and off axis ratios for both 6 and 18 MV were within 2%. Ion chamber measurements in both the Styrofoam and solid water for both energies carried out with and without lung blocks were within 2% of calculated values. TLD measured doses for both 6 and 18 MV in the IROC phantom were within 5% of calculated doses which is within the uncertainty of the TLD measurement. CONCLUSIONS The results indicate that the clinical beam model for Acuros 16.1 commissioned at standard clinical distances is capable of calculating doses accurately at extended distances up to 500 cm.
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Affiliation(s)
- Geoffrey Nelson
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | - Vikren Sarkar
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | - Martin Szegedi
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | - Andrea Molineu
- Imaging and Radiation Oncology Core, Houston QA Center, MD Anderson Cancer Center, Houston, Texas, USA
| | - Arthur J Olch
- Department of Radiation Oncology, University of Southern California and Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Jeremy N Kunz
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | - Hui Zhao
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | - Y Jessica Huang
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | | | - Prema Rassiah
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
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Ehler ED, Turcotte LM, Skamene S, Baker KS, Das SK, Constine LS, Yuan J, Dusenbery KE. Idiopathic Pneumonitis Syndrome After Total Body Irradiation in Pediatric Patients Undergoing Myeloablative Hematopoietic Stem Cell Transplantation: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:625-639. [PMID: 36973099 DOI: 10.1016/j.ijrobp.2023.02.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/17/2023] [Accepted: 02/16/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Pulmonary complications, especially idiopathic pneumonitis syndrome (IPS), are potentially life altering or fatal sequelae of hematopoietic cell transplantation (HCT). Total body irradiation (TBI) as part of the conditioning regimen has been implicated in IPS. A comprehensive PENTEC (Pediatric Normal Tissues in the Clinic) review was performed to increase our understanding of the role of TBI in the development of acute, noninfectious IPS. METHODS AND MATERIALS A systematic literature search was conducted using the MEDLINE, PubMed, and Cochrane library databases for articles describing pulmonary toxicity in children treated with HCT. Data pertaining to TBI and pulmonary endpoints were extracted. Risk of IPS was analyzed in relation to patient age, TBI dose, fractionation, dose rate, lung shielding, timing, and type of transplant, with the goal to better understand factors associated with this complication in children undergoing HCT. A logistic regression model was developed using a subset of studies with comparable transplant regimens and sufficient TBI data. RESULTS Six studies met criteria for modeling of the correlation of TBI parameters with IPS; all consisted of pediatric patients undergoing allogeneic HCT with a cyclophosphamide-based chemotherapy regimen. IPS was variably defined, but all studies that reported IPS were included in this analysis. The mean incidence of post-HCT IPS was 16% (range, 4%-41%). Mortality from IPS, when it occurred, was high (median, 50%; range, 45%-100%). Fractionated TBI prescription doses encompassed a narrow range of 9 to 14 Gy. Many differing TBI methods were reported, and there was an absence of 3-dimensional dose analysis of lung blocking techniques. Thus, a univariate correlation between IPS and total TBI dose, dose fractionation, dose rate, or TBI technique could not be made. However, a model, built from these studies based on prescribed dose using a normalized dose parameter of equivalent dose in 2-Gy fractions (EQD2), adjusted for dose rate, suggested correlation with the development of IPS (P = .0004). The model-predicted odds ratio for IPS was 24.3 Gy-1 (95% confidence interval, 7.0-84.3). Use of TBI lung dose metrics (eg, midlung point dose) could not be successfully modeled, potentially because of dosimetric uncertainties in the actual delivered volumetric lung dose and imperfections in our modeling process. CONCLUSIONS This PENTEC report is a comprehensive review of IPS in pediatric patients receiving fractionated TBI regimens for allogenic HCT. IPS was not clearly associated with 1 single TBI factor. Modeling using dose-rate adjusted EQD2 showed a response with IPS for allogeneic HCT using a cyclophosphamide-based chemotherapy regimen. Therefore, this model suggests IPS mitigation strategies can focus on not just the dose and dose per fraction but also the dose rate used in TBI. More data are needed to confirm this model and to determine the influence of chemotherapy regimens and contribution from graft-versus-host disease. The presence of confounding variables (eg, systemic chemotherapies) that affect risk, the narrow range of fractionated TBI doses found in the literature, and limitations of other reported data (eg, lung point dose) may have prevented a more straightforward link between IPS and total dose from being observed.
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Affiliation(s)
| | | | - Sonia Skamene
- Division of Radiation Oncology, McGill University, Montreal, Quebec, Canada
| | - K Scott Baker
- Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, Seattle, Washington
| | - Shiva K Das
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Louis S Constine
- Department of Radiation Oncology, James P. Wilmot Cancer Institute, University of Rochester, Rochester, New York
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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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8
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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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Endothelial Dysfunction Syndromes after Allogeneic Stem Cell Transplantation. Cancers (Basel) 2023; 15:cancers15030680. [PMID: 36765638 PMCID: PMC9913851 DOI: 10.3390/cancers15030680] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only therapy with a curative potential for a variety of malignant and non-malignant diseases. The major limitation of the procedure is the significant morbidity and mortality mainly associated with the development of graft versus host disease (GVHD) as well as with a series of complications related to endothelial injury, such as sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD), transplant-associated thrombotic microangiopathy (TA-TMA), etc. Endothelial cells (ECs) are key players in the maintenance of vascular homeostasis and during allo-HSCT are confronted by multiple challenges, such as the toxicity from conditioning, the administration of calcineurin inhibitors, the immunosuppression associated infections, and the donor alloreactivity against host tissues. The early diagnosis of endothelial dysfunction syndromes is of paramount importance for the development of effective prophylactic and therapeutic strategies. There is an urgent need for the better understanding of the pathogenetic mechanisms as well as for the identification of novel biomarkers for the early diagnosis of endothelial damage. This review summarizes the current knowledge on the biology of the endothelial dysfunction syndromes after allo-HSCT, along with the respective therapeutic approaches, and discusses the strengths and weaknesses of possible biomarkers of endothelial damage and dysfunction.
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10
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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
| | - 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
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11
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Milot MC, Bélissant-Benesty O, Dumulon-Perreault V, Ait-Mohand S, Geha S, Richard PO, Rousseau É, Guérin B. Theranostic 64Cu-DOTHA 2-PSMA allows low toxicity radioligand therapy in mice prostate cancer model. Front Oncol 2023; 13:1073491. [PMID: 36741017 PMCID: PMC9889868 DOI: 10.3389/fonc.2023.1073491] [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: 10/18/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023] Open
Abstract
Introduction We have previously shown that copper-64 (64Cu)-DOTHA2-PSMA can be used for positron emission tomography (PET) imaging of prostate cancer. Owing to the long-lasting, high tumoral uptake of 64Cu-DOTHA2-PSMA, the objective of the current study was to evaluate the therapeutic potential of 64Cu-DOTHA2-PSMA in vivo. Methods LNCaP tumor-bearing NOD-Rag1nullIL2rgnull (NRG) mice were treated with an intraveinous single-dose of 64Cu-DOTHA2-PSMA at maximal tolerated injected activity, natCu-DOTHA2-PSMA at equimolar amount (control) or lutetium-177 (177Lu)-PSMA-617 at 120 MBq to assess their impact on survival. Weight, well-being and tumor size were followed until mice reached 62 days post-injection or ethical limits. Toxicity was assessed through weight, red blood cells (RBCs) counts, pathology and dosimetry calculations. Results Survival was longer with 64Cu-DOTHA2-PSMA than with natCu-DOTHA2-PSMA (p < 0.001). Likewise, survival was also longer when compared to 177Lu-PSMA-617, although it did not reach statistical significance (p = 0.09). RBCs counts remained within normal range for the 64Cu-DOTHA2-PSMA group. 64Cu-DOTHA2-PSMA treated mice showed non-pathological fibrosis and no other signs of radiation injury. Human extrapolation of dosimetry yielded an effective dose of 3.14 × 10-2 mSv/MBq, with highest organs doses to gastrointestinal tract and liver. Discussion Collectively, our data showed that 64Cu-DOTHA2-PSMA-directed radioligand therapy was effective for the treatment of LNCaP tumor-bearing NRG mice with acceptable toxicity and dosimetry. The main potential challenge is the hepatic and gastrointestinal irradiation.
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Affiliation(s)
- Marie-Christine Milot
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ophélie Bélissant-Benesty
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Samia Ait-Mohand
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Sameh Geha
- Department of Pathology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Patrick O. Richard
- Department of Surgery, Division of urology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Étienne Rousseau
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada,Sherbrooke Molecular Imaging Center (CIMS), Centre de recherche du CHUS, Sherbrooke, QC, Canada
| | - Brigitte Guérin
- Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada,Sherbrooke Molecular Imaging Center (CIMS), Centre de recherche du CHUS, Sherbrooke, QC, Canada,*Correspondence: Brigitte Guérin,
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12
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Konishi T, Ogawa H, Najima Y, Hashimoto S, Kito S, Atsuta Y, Wada A, Adachi H, Konuma R, Kishida Y, Nagata A, Yamada Y, Kaito S, Mukae J, Marumo A, Noguchi Y, Shingai N, Toya T, Igarashi A, Shimizu H, Kobayashi T, Ohashi K, Doki N, Murofushi KN. Outcomes of allogeneic haematopoietic stem cell transplantation with intensity-modulated total body irradiation by helical tomotherapy: a 2-year prospective follow-up study. Ann Med 2022; 54:2616-2625. [PMID: 36254468 PMCID: PMC9624256 DOI: 10.1080/07853890.2022.2125171] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/02/2022] [Accepted: 09/11/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Intensity-modulated radiation therapy (IMRT) helps achieve good radiation dose conformity and precise dose evaluation. We conducted a single-centre prospective study to assess the safety and feasibility of total body irradiation with IMRT (IMRT-TBI) using helical tomotherapy in allogeneic haematopoietic stem cell transplantation (allo-HSCT). PATIENTS AND METHODS Thirty-nine adult patients with haematological malignancy (acute lymphoblastic leukaemia [n = 21], chronic myeloid leukaemia [n = 6], mixed phenotype acute leukaemia [n = 5], acute myeloid leukaemia [n = 4], and malignant lymphoma [n = 3]) who received 12 Gy IMRT-TBI were enrolled with a median follow-up of 934.5 (range, 617-1254) d. At the time of transplantation, 33 patients (85%) achieved complete remission. The conditioning regimen used IMRT-TBI (12 Gy in 6 fractions twice daily, for 3 d) and cyclophosphamide (60 mg/kg/d, for 2 d), seven patients were combined with cytarabine, and five with etoposide. We set dose constraints for the lungs, kidneys and lens as the organs at risk. RESULTS The mean doses for the lungs and kidneys were 7.50 and 9.11 Gy, respectively. The mean maximum dose for the lens (right/left) was 5.75/5.87 Gy. The 2-year overall survival (OS), disease-free survival (DFS), cumulative incidence of relapse (CIR) and non-relapse mortality (NRM) were 69, 64, 18 and 18%, respectively. Thirty-six patients developed early adverse events (AEs) (including four patients with Grade 3/4 toxicities), most of which were reversible oral mucositis and may partially have been related to IMRT-TBI. However, the incidence of toxicity was comparable to conventional TBI-based conditioning transplantation. None of the patients developed primary graft failure, or Grade III-IV acute graft-versus-host disease (GVHD). In late complications, chronic kidney disease was observed in six patients, a lower incidence compared to conventional TBI-based conditioning transplantation. No radiation pneumonitis or cataracts were observed in any of the patients. CONCLUSIONS IMRT-TBI is safe and feasible for haematological malignancies with acceptable clinical outcomes.KEY MESSAGESIMRT-TBI-helical tomotherapy aids in accurate dose calculation and conformity.It could be used without any considerable increase in the rate of TBI-related AEs.Allo-HSCT with IMRT-TBI may be an alternative to conventional TBI for clinical use.
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Affiliation(s)
- Tatsuya Konishi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hiroaki Ogawa
- Department of Radiology, Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Shinpei Hashimoto
- Department of Radiology, Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Satoshi Kito
- Department of Radiology, Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuya Atsuta
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Atsushi Wada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hiroto Adachi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Ryosuke Konuma
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuya Kishida
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Akihito Nagata
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuta Yamada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Satoshi Kaito
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Junichi Mukae
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Atsushi Marumo
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuma Noguchi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Naoki Shingai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Aiko Igarashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hiroaki Shimizu
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Keiko Nemoto Murofushi
- Department of Radiology, Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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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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14
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Abraham U, Romaguera T, Tolakanahalli R, Gutierrez AN, Hall M. Fractionated Total Body Irradiation on an Infant Using Tomotherapy. Cureus 2022; 14:e28143. [PMID: 36148186 PMCID: PMC9482450 DOI: 10.7759/cureus.28143] [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] [Accepted: 08/08/2022] [Indexed: 11/26/2022] Open
Abstract
Total body irradiation (TBI) is used with chemotherapy to induce immunosuppression for hematopoietic cell transplantation and is often administered using lead blocks to minimize lung dose in adults and children. This technique is challenging in infants and young children. A 13-month-old female with acute lymphoblastic leukemia (ALL) was treated with fractionated TBI to a dose of 12 Gy in eight fractions delivered twice daily. Multiple TBI techniques for delivering treatment were considered. Ultimately, treatment using helical tomotherapy was selected in order to spare and accurately quantify the dose to the lung, meet lung dose constraints, and ensure adequate TBI dose coverage. With anesthesia, this technique provided a comfortable and reproducible set-up for the young child. The treatment plan was delivered with intensity-modulated radiotherapy, where 96.4% of the target volume received a prescription dose with a total beam-on time of 16.8 minutes. The mean lung dose was 7.7 Gy for a total lung volume of 245cc. This report describes the challenges faced during the treatment planning and delivery, and how they were resolved.
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15
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Total body irradiation using volumetric modulated arc therapy, experience of a cancer hospital in Pakistan. JOURNAL OF RADIOTHERAPY IN PRACTICE 2022. [DOI: 10.1017/s1460396922000097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Introduction:
To report the planning parameters, efficacy and toxicity of total body irradiation using volumetric modulated arc therapy (VMAT).
Methods:
From July 2019 till May 2021, nine patients treated with VMAT-based total body irradiation as a part of the myeloablative regimen for homologous stem cell transplant were evaluated. The CT acquisition, planning parameters, doses to target volume and critical structures were evaluated retrospectively.
Results:
Median age was 24 with median height 172 cm. Average Mean Lung dose was 9·5 Gy, mean dose to kidney was kidney dose 8·4 Gy, planning target volume (PTV) 95% was 98 % and mean heterogeneity index of PTV was 1·2 all patients. Total fraction delivery time including setup was 3·1 h while beam on time was 23 min. Main toxicity observed was mucositis and fatigue, while no Grade 3 or more acute radiation toxicity was observed.
Conclusion:
At our institution, high dose TBI performed with multi-isocentric VMAT is now a standard procedure. Though it is cumbersome and time-consuming process but VMAT offers an advantage of increased dose homogeneity in the target volume with reduction in doses to critical organs especially lungs and kidneys in comparison to standard source to skin distance technique, longer follow-up time is necessary to evaluate our method and long-term toxicity.
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16
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Hoeben BAW, Pazos M, Seravalli E, Bosman ME, Losert C, Albert MH, Boterberg T, Ospovat I, Mico Milla S, Demiroz Abakay C, Engellau J, Jóhannesson V, Kos G, Supiot S, Llagostera C, Bierings M, Scarzello G, Seiersen K, Smith E, Ocanto A, Ferrer C, Bentzen SM, Kobyzeva DA, Loginova AA, Janssens GO. ESTRO ACROP and SIOPE recommendations for myeloablative Total Body Irradiation in children. Radiother Oncol 2022; 173:119-133. [PMID: 35661674 DOI: 10.1016/j.radonc.2022.05.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Myeloablative Total Body Irradiation (TBI) is an important modality in conditioning for allogeneic hematopoietic stem cell transplantation (HSCT), especially in children with high-risk acute lymphoblastic leukemia (ALL). TBI practices are heterogeneous and institution-specific. Since TBI is associated with multiple late adverse effects, recommendations may help to standardize practices and improve the outcome versus toxicity ratio for children. MATERIAL AND METHODS The European Society for Paediatric Oncology (SIOPE) Radiotherapy TBI Working Group together with ESTRO experts conducted a literature search and evaluation regarding myeloablative TBI techniques and toxicities in children. Findings were discussed in bimonthly virtual meetings and consensus recommendations were established. RESULTS Myeloablative TBI in HSCT conditioning is mostly performed for high-risk ALL patients or patients with recurring hematologic malignancies. TBI is discouraged in children <3-4 years old because of increased toxicity risk. Publications regarding TBI are mostly retrospective studies with level III-IV evidence. Preferential TBI dose in children is 12-14.4 Gy in 1.6-2 Gy fractions b.i.d. Dose reduction should be considered for the lungs to <8 Gy, for the kidneys to ≤10 Gy, and for the lenses to <12 Gy, for dose rates ≥6 cGy/min. Highly conformal techniques i.e. TomoTherapy and VMAT TBI or Total Marrow (and/or Lymphoid) Irradiation as implemented in several centers, improve dose homogeneity and organ sparing, and should be evaluated in studies. CONCLUSIONS These ESTRO ACROP SIOPE recommendations provide expert consensus for conventional and highly conformal myeloablative TBI in children, as well as a supporting literature overview of TBI techniques and toxicities.
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Affiliation(s)
- Bianca A W Hoeben
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - Montserrat Pazos
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Enrica Seravalli
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Mirjam E Bosman
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Christoph Losert
- Dept. of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Michael H Albert
- Dept. of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Germany
| | - Tom Boterberg
- Dept. of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Inna Ospovat
- Dept. of Radiation Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Soraya Mico Milla
- Dept. of Radiation Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Candan Demiroz Abakay
- Dept. of Radiation Oncology, Uludag University Faculty of Medicine Hospital, Bursa, Turkey
| | - Jacob Engellau
- Dept. of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Gregor Kos
- Dept. of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Stéphane Supiot
- Dept. of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Camille Llagostera
- Dept. of Medical Physics, Institut de Cancérologie de l'Ouest, Nantes St. Herblain, France
| | - Marc Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Giovanni Scarzello
- Dept. of Radiation Oncology, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | | | - Ed Smith
- Dept. of Radiation Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Abrahams Ocanto
- Dept. of Radiation Oncology, La Paz University Hospital, Madrid, Spain
| | - Carlos Ferrer
- Dept. of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Søren M Bentzen
- Dept. of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, United States
| | - Daria A Kobyzeva
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Dept. of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Geert O Janssens
- Dept. of Radiation Oncology, University Medical Center Utrecht, The Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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Patel SS, Ahn KW, Khanal M, Bupp C, Allbee-Johnson M, Majhail NS, Hamilton BK, Rotz SJ, Hashem H, Beitinjaneh A, Lazarus HM, Krem MM, Prestidge T, Bhatt NS, Sharma A, Gadalla SM, Murthy HS, Broglie L, Nishihori T, Freytes CO, Hildebrandt GC, Gergis U, Seo S, Wirk B, Pasquini MC, Savani BN, Sorror ML, Stadtmauer EA, Chhabra S. Non-infectious pulmonary toxicity after allogeneic hematopoietic cell transplantation. Transplant Cell Ther 2022; 28:310-320. [DOI: 10.1016/j.jtct.2022.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/08/2022] [Accepted: 03/13/2022] [Indexed: 10/18/2022]
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18
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Luk SMH, Wallner K, Glenn MC, Ermoian R, Phillips MH, Tseng YD, Kim M. Effect of total body irradiation lung block parameters on lung doses using three-dimensional dosimetry. J Appl Clin Med Phys 2022; 23:e13513. [PMID: 34985180 PMCID: PMC8992940 DOI: 10.1002/acm2.13513] [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: 07/09/2021] [Revised: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose Total body irradiation (TBI) is an integral part of stem cell transplant. However, patients are at risk of treatment‐related toxicities, including radiation pneumonitis. While lung dose is one of the most crucial aspects of TBI dosimetry, currently available data are based on point doses. As volumetric dose distribution could be substantially altered by lung block parameters, we used 3D dosimetry in our treatment planning system to estimate volumetric lung dose and measure the impact of various lung block designs. Materials and methods We commissioned a TBI beam model in RayStation that matches the measured tissue‐phantom ratio under our clinical TBI setup. Cerrobend blocks were automatically generated in RayStation on thoracic Computed Tomography (CT) scans from three anonymized patients using the lung, clavicle, spine, and diaphragmatic contours. The margin for block edge was varied to 0, 1, or 2 cm from the superior, lateral, and inferior thoracic borders, with a uniform margin 2.5 cm lateral to the vertebral bodies. The lung dose was calculated and compared with a prescription dose of 1200 cGy in six fractions (three with blocks and three without). Result The point dose at midplane under the block and the average lung dose are at the range of 73%–76% and 80%–88% of prescription dose respectively regardless of the block margins. In contrast, the percent lung volume receiving 10 Gy increased by nearly two‐fold, from 31% to 60% over the margins from 0 to 2 cm. Conclusions The TPS‐derived 3D lung dose is substantially different from the nominal dose assumed with HVL lung blocks. Point doses under the block are insufficient to accurately gauge the relationship between dose and pneumonitis, and TBI dosimetry could be highly variable between patients and institutions as more descriptive parameters are not included in protocols. Much progress remains to be made to optimize and standardize technical aspects of TBI, and better dosimetry could provide more precise dosimetric predictors for pneumonitis risk.
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Affiliation(s)
- Samuel M H Luk
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA.,Department of Radiation Oncology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Mallory C Glenn
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Ralph Ermoian
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Mark H Phillips
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson cancer Research Center, Seattle, Washington, USA
| | - Minsun Kim
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
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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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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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21
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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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22
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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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23
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Naessig M, Hernandez S, Astorga NR, McCulloch J, Saenz D, Myers P, Rasmussen K, Stathakis S, Ha CS, Papanikolaou N, Ford J, Kirby N. A customizable aluminum compensator system for total body irradiation. J Appl Clin Med Phys 2021; 22:36-44. [PMID: 34432944 PMCID: PMC8504611 DOI: 10.1002/acm2.13393] [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: 07/10/2020] [Revised: 07/15/2021] [Accepted: 07/28/2021] [Indexed: 11/08/2022] Open
Abstract
Purpose To develop a simplified aluminum compensator system for total body irradiation (TBI) that is easy to assemble and modify in a short period of time for customized patient treatments. Methods The compensator is composed of a combination of 0.3 cm thick aluminum bars, two aluminum T‐tracks, spacers, and metal bolts. The system is mounted onto a plexiglass block tray. The design consists of 11 fixed sectors spanning from the patient's head to feet. The outermost sectors utilize 7.6 cm wide aluminum bars, while the remaining sectors use 2.5 cm wide aluminum bars. There is a magnification factor of 5 from the compensator to the patient treatment plane. Each bar of aluminum is interconnected at each adjacent sector with a tongue and groove arrangement and fastened to the T‐track using a metal washer, bolt, and nut. Inter‐bar leakage of the compensator was tested using a water tank and diode. End‐to‐end measurements were performed with an ion chamber in a solid water phantom and also with a RANDO phantom using internal and external optically stimulated luminescent detectors (OSLDs). In‐vivo patient measurements from the first 20 patients treated with this aluminum compensator were compared to those from 20 patients treated with our previously used lead compensator system. Results The compensator assembly time was reduced to 20–30 min compared to the 2–4 h it would take with the previous lead design. All end‐to‐end measurements were within 10% of that expected. The median absolute in‐vivo error for the aluminum compensator was 3.7%, with 93.8% of measurements being within 10% of that expected. The median error for the lead compensator system was 5.3%, with 85.1% being within 10% of that expected. Conclusion This design has become the standard compensator at our clinic. It allows for quick assembly and customization along with meeting the Task Group 29 recommendations for dose uniformity.
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Affiliation(s)
- Madison Naessig
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Department of Nuclear Engineering, Texas A&M University, College Station, Texas, USA
| | - Soleil Hernandez
- Department of Nuclear Engineering, Texas A&M University, College Station, Texas, USA
| | - Nestor Rodrigo Astorga
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - James McCulloch
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Daniel Saenz
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Pamela Myers
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Karl Rasmussen
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Sotirios Stathakis
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Chul S Ha
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Niko Papanikolaou
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - John Ford
- Department of Nuclear Engineering, Texas A&M University, College Station, Texas, USA
| | - Neil Kirby
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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24
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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: 24] [Impact Index Per Article: 8.0] [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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25
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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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26
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Haraldsson A, Wichert S, Engström PE, Lenhoff S, Turkiewicz D, Warsi S, Engelholm S, Bäck S, Engellau J. Organ sparing total marrow irradiation compared to total body irradiation prior to allogeneic stem cell transplantation. Eur J Haematol 2021; 107:393-407. [PMID: 34107104 DOI: 10.1111/ejh.13675] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Total body irradiation (TBI) is commonly used prior to hematopoietic stem cell transplantation (HSCT) in myeloablative conditioning regimens. However, TBI may be replaced by total marrow irradiation (TMI) at centres with access to Helical TomoTherapy, a modality that has the advantage of delivering intensity-modulated radiotherapy to long targets such as the entire bone marrow compartment. Toxicity after organ sparing TMI prior to HSCT has not previously been reported compared to TBI or with regard to engraftment data. METHODS We conducted a prospective observational study on 37 patients that received organ sparing TMI prior to HSCT and compared this cohort to retrospective data on 33 patients that received TBI prior to HSCT. RESULTS The 1-year graft-versus-host disease-free, relapse-free survival (GRFS) was 67.5% for all patients treated with TMI and 80.5% for patients with matched unrelated donor and treated with TMI, which was a significant difference from historical data on TBI patients with a hazard ratio of 0.45 (P = .03) and 0.24 (P < .01). Engraftment with a platelet count over 20 [K/µL] and 50 [K/µL] was significantly shorter for the TMI group, and neutrophil recovery was satisfactory in both treatment cohorts. There was generally a low occurrence of other treatment-related toxicities. CONCLUSIONS Despite small cohorts, some significant differences were found; TMI as part of the myeloablative conditioning yields a high 1-year GRFS, fast and robust engraftment, and low occurrence of acute toxicity.
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Affiliation(s)
- André Haraldsson
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Department of medical radiation physics, Clinical Sciences, Lund university, Lund, Sweden
| | - Stina Wichert
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per E Engström
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Stig Lenhoff
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Dominik Turkiewicz
- Department of Pediatric Oncology and Hematology, Skåne University Hospital, Lund, Sweden
| | - Sarah Warsi
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Division of Molecular Medicine and Gene Therapy, Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Silke Engelholm
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Sven Bäck
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Department of medical radiation physics, Clinical Sciences, Lund university, Lund, Sweden
| | - Jacob Engellau
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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Isobe A, Usui K, Hara N, Sasai K. The effects of rotational setup errors in total body irradiation using helical tomotherapy. J Appl Clin Med Phys 2021; 22:93-102. [PMID: 34028944 PMCID: PMC8292714 DOI: 10.1002/acm2.13271] [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: 01/14/2021] [Revised: 04/04/2021] [Accepted: 04/10/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose Helical tomotherapy (HT) is a form of intensity‐modulated radiation therapy that is employed in total body irradiation (TBI). Because TBI targets the whole body, accurate setup positioning at the edge of the treatment volume is made difficult by the whole‐body rotational posture. The purpose of this study is to clarify the tolerance for rotational setup error (SE) in the vertical direction. In addition, we perform a retrospective analysis of actually irradiated dose distributions using previous patients’ irradiation data. Methods To clarify the effects of rotational SE on the dose distribution, the planned CT images of 10 patients were rotated by 1–5° in the vertical (pitch) direction to create a pseudo‐rotational SE image. Then, the effect of the magnitude of the rotational SE on the dose distribution was simulated. In addition, the irradiated dose to the patients was analyzed by obtaining recalculated dose distributions using megavoltage CT images acquired before treatment. Results The simulation results showed that the average value of the lung volume receiving at least 10 Gy did not exceed the allowable value when the SE value was ≤2°. When the rotational SE was ≤3°, it was possible to maintain the clinical target volume dose heterogeneity within ±10% of the prescribed dose, which is acceptable according to the guidelines. A retrospective analysis of previous patients’ irradiation data showed their daily irradiation dose distribution. The dose to the clinical target volume was reduced by up to 3.4% as a result of the residual rotational SE. Although whole‐course retrospective analyses showed a statistically significant increase in high‐dose areas, the increase was only approximately 1.0%. Conclusions Dose errors induced by rotational SEs of ≤2° were acceptable in this study.
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Affiliation(s)
- Akira Isobe
- Department of Radiation Oncology Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Keisuke Usui
- Department of Radiation Oncology Graduate School of Medicine, Juntendo University, Tokyo, Japan.,Department of Radiological Technology Faculty of Health Science, Juntendo University, Tokyo, Japan
| | - Naoya Hara
- Department of Radiology, Juntendo University Hospital, Tokyo, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology Graduate School of Medicine, Juntendo University, Tokyo, Japan
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28
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Durie E, Nicholson E, Anthias C, Dunne EM, Potter M, Ethell M, Messiou C, Brennan J, Eagle S, Talbot J, Smyth G, Ingram W, Saran F, Mandeville HC. Determining the incidence of interstitial pneumonitis and chronic kidney disease following full intensity haemopoetic stem cell transplant conditioned using a forward-planned intensity modulated total body irradiation technique. Radiother Oncol 2021; 158:97-103. [PMID: 33636231 DOI: 10.1016/j.radonc.2021.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 02/01/2021] [Accepted: 02/15/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE/OBJECTIVE Total body irradiation (TBI) remains a key component of conditioning for allogeneic haemopoietic stem cell transplant (HSCT), with interstitial pneumonitis (IP) and chronic kidney disease (CKD) important late sequelae. We undertook a retrospective service evaluation of TBI patients treated with a forward-planned intensity modulated radiotherapy technique (FP IMRT). MATERIAL/METHODS 74 adult patients were identified; all received step and shoot FP IMRT TBI, 14.4 Gy in 8 fractions over 4 days. Mean doses to the lungs and kidneys were 12-12.5 Gy. Toxicities were defined as per CTCAE v4.0: IP as multilobar infiltrates on CT with symptoms of dyspnoea, and renal dysfunction as an Estimated Glomerular Filtration rate (eGFR) < 60 ml/min/1.73 m2 for > 3 months. Secondary endpoints were overall survival (OS), progression free survival (PFS), cumulative incidence of non-relapse mortality (NRM), relapse risk and of acute and chronic GvHD. RESULTS Patients received treatment for the following diagnosis: ALL/LBL (n = 37); AML (n = 33), CML-BC (n = 2) and High grade NHL (n = 2). The rate of IP due to any cause was 30%; positive microbiological evidence in 73% (16 /22). Idiopathic IP was seen in 8%, with only 4% (n = 3) having IP Grade ≥ 3. Two (4%) of 52 long term survivors developed CKD, one with thrombotic microangiopathy. 4 year NRM was 16% (CI 11-32%); no treatment related deaths in matched sibling or umbilical cord blood HSCT. CONCLUSION FP IMRT TBI, reducing dose to the lungs and kidneys, has lower rates of idiopathic IP and CKD compared to the literature. This technique is safe and effective conditioning for full intensity HSCT.
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Affiliation(s)
- Emily Durie
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Emma Nicholson
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Chloe Anthias
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Emma M Dunne
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Mike Potter
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Mark Ethell
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Christina Messiou
- Radiology Department, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Joy Brennan
- Haemato-Oncology Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Sally Eagle
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - James Talbot
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Gregory Smyth
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Westley Ingram
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Frank Saran
- Department of Radiotherapy, Auckland City Hospital, New Zealand
| | - Henry C Mandeville
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, United Kingdom; The Institute of Cancer Research, Sutton, United Kingdom.
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29
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Terasaki Y, Terasaki M, Shimizu A. Protective Effects of Hydrogen against Irradiation. Curr Pharm Des 2021; 27:679-686. [PMID: 33463456 DOI: 10.2174/1381612827666210119103545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/19/2020] [Indexed: 11/22/2022]
Abstract
Radiation-induced lung injury is characterized by an acute pneumonia phase followed by a fibrotic phase. At the time of irradiation, a rapid, short-lived burst of reactive oxygen species (ROS) such as hydroxyl radicals (•OH) occurs, but chronic radiation-induced lung injury may occur due to excess ROS such as H2O2, O2•-, ONOO-, and •OH. Molecular hydrogen (H2) is an efficient antioxidant that quickly diffuses cell membranes, reduces ROS such as •OH and ONOO-, and suppresses damage caused by oxidative stress in various organs. In 2011, through the evaluation of electron-spin resonance and fluorescent indicator signals, we had reported that H2 can eliminate •OH and can protect against oxidative stress-related apoptotic damage induced by irradiation of cultured lung epithelial cells. We had explored for the first time the radioprotective effects of H2 treatment on acute and chronic radiation-induced lung damage in mice by inhaled H2 gas (for acute) and imbibed H2-enriched water (for chronic). Thus, we had proposed that H2 be considered a potential radioprotective agent. Recent publications have shown that H2 directly neutralizes highly reactive oxidants and indirectly reduces oxidative stress by regulating the expression of various genes. By regulating gene expression, H2 functions as an anti-inflammatory and anti-apoptotic molecule and promotes energy metabolism. The increased evidence obtained from cultured cells or animal experiments reveal a putative place for H2 treatment and its radioprotective effect clinically. This review focuses on major scientific advances in the treatment of H2 as a new class of radioprotective agents.
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Affiliation(s)
- Yasuhiro Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Mika Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
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30
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Konishi T, Ogawa H, Najima Y, Hashimoto S, Wada A, Adachi H, Konuma R, Kishida Y, Nagata A, Yamada Y, Kaito S, Mukae J, Marumo A, Noguchi Y, Toya T, Igarashi A, Kobayashi T, Ohashi K, Doki N, Karasawa K. Safety of total body irradiation using intensity-modulated radiation therapy by helical tomotherapy in allogeneic hematopoietic stem cell transplantation: a prospective pilot study. JOURNAL OF RADIATION RESEARCH 2020; 61:969-976. [PMID: 32888029 PMCID: PMC7674702 DOI: 10.1093/jrr/rraa078] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/05/2020] [Accepted: 08/20/2020] [Indexed: 05/28/2023]
Abstract
Total body irradiation using intensity-modulated radiation therapy total body irradiation (IMRT-TBI) by helical tomotherapy in allogeneic hematopoietic stem cell transplantation (allo-HSCT) allows for precise evaluation and adjustment of radiation dosage. We conducted a single-center pilot study to evaluate the safety of IMRT-TBI for allo-HSCT recipients. Patients with hematological malignancies in remission who were scheduled for allo-HSCT with TBI-based myeloablative conditioning were eligible. The primary endpoint was the incidence of adverse events (AEs). Secondary endpoints were engraftment rate, overall survival, relapse rate, non-relapse mortality, and the incidence of acute and chronic graft-versus-host disease (aGVHD and cGVHD, respectively). Between July 2018 and November 2018, ten patients were recruited with a median observation duration of 571 days after allo-HSCT (range, 496-614). D80% for planning target volume (PTV) in all patients was 12.01 Gy. Average D80% values for lungs, kidneys and lenses (right/left) were 7.50, 9.03 and 4.41/4.03 Gy, respectively. Any early AEs (within 100 days of allo-HSCT) were reported in all patients. Eight patients experienced oral mucositis and gastrointestinal symptoms. One patient experienced Bearman criteria grade 3 regimen-related toxicity (kidney and liver). All cases achieved neutrophil engraftment. There was no grade III-IV aGVHD or late AE. One patient died of sinusoidal obstruction syndrome 67 days after allo-HSCT. The remaining nine patients were alive and disease-free at final follow-up. Thus, IMRT-TBI was well tolerated in terms of early AEs in adult patients who underwent allo-HSCT; this warrants further study with longer observation times to monitor late AEs and efficacy.
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Affiliation(s)
| | | | - Yuho Najima
- Corresponding author. Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-18-22 Hon-Komagome, Bunkyo-ku, Tokyo, Japan, 1138677, Phone: +81-3-3823-2101, Fax: +81-3-3823-5433,
| | - Shinpei Hashimoto
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Atsushi Wada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Hiroto Adachi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Ryosuke Konuma
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yuya Kishida
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Akihito Nagata
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yuta Yamada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Satoshi Kaito
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Junichi Mukae
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Atsushi Marumo
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Yuma Noguchi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Aiko Igarashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
| | - Katsuyuki Karasawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital
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31
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Mancosu P, Navarria P, Muren LP, Castagna L, Reggiori G, Clerici E, Sarina B, Bramanti S, De Philippis C, Tomatis S, Santoro A, Scorsetti M. Development of an Immobilization Device for Total Marrow Irradiation. Pract Radiat Oncol 2020; 11:e98-e105. [PMID: 32160952 DOI: 10.1016/j.prro.2020.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/24/2020] [Accepted: 02/15/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE A body frame dedicated to total marrow (lymph node) irradiation (TMI/TMLI) could minimize patient motion during the potentially extended beam-on time with this technique. We present the development of a dedicated immobilization system for TMI/TMLI using volumetric modulated arc therapy. METHODS AND MATERIALS Since 2010, 59 adult patients were treated with TMI/TMLI using a multi-isocenter volumetric modulated arc therapy technique. Two computed tomographies (CTs) were required (1 head-first supine and 1 feet-first supine) to cover the whole volume. For the first 10 patients, 2 standard commercial frames with personalized masks (with/without personalized vacuum cushion for the lower extremities) were used without specific interfixation (frame A). For the next 49 patients a homemade 3-frame immobilization system was adopted (frame B), where each frame was interlocked with the next one and thermoplastic masks used to fix the patient. The effectiveness of the 2 immobilization systems was assessed by offline/online matching between daily cone beam CT of each isocenter and the simulation CTs. RESULTS Mean offline shifts for frame A were 3 to 12 mm in anterior-posterior, 2 to 5 mm in cranilal-caudal, and 2 to 6 mm in left-right directions. Larger shifts were found for feet-first supine series (shifts up to 23 mm). In frame B, mean offline shifts were 1 to 4 mm in anterior-posterior, 1 to 4 mm in cranial-caudal, and 1 to 4 mm in left-right directions. Mean online adjustments were -1 ± 4 mm in anterior-posterior, 0 ± 2 mm in cranial-caudal, and 0 ± 4 mm in left-right directions. CONCLUSIONS The patient positioning shifts for TMI/TMLI irradiation were mitigated by a homemade immobilization system and the use of individualized masks.
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Affiliation(s)
- Pietro Mancosu
- Medical Physics Service, Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy.
| | - Pierina Navarria
- Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy
| | | | - Luca Castagna
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy
| | - Giacomo Reggiori
- Medical Physics Service, Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy
| | - Elena Clerici
- Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy
| | - Barbara Sarina
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy
| | - Stefania Bramanti
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy
| | - Chiara De Philippis
- Bone Marrow Transplantation Unit, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy
| | - Stefano Tomatis
- Medical Physics Service, Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy
| | - Armando Santoro
- Medical Oncology Department, Humanitas Clinical and Research Hospital, Milan, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Rozzano, Italy
| | - Marta Scorsetti
- Radiation Oncology Department, Humanitas Clinical and Research Hospital, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Rozzano, Italy
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32
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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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33
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Nates JL, Price KJ. Late Noninfectious Pulmonary Complications in Hematopoietic Stem Cell Transplantation. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7123191 DOI: 10.1007/978-3-319-74588-6_51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is an established therapeutic modality for a number of malignant and nonmalignant conditions. Pulmonary complications following HSCT are associated with increased mortality and morbidity. These complications may be classified into infectious versus noninfectious, and early versus late based on the time of occurrence post-transplant. Thus, exclusion of infectious etiologies is the first step in the diagnoses of pulmonary complications. Late onset noninfectious pulmonary complications typically occur 3 months post-transplant. Bronchiolitis obliterans is the major contributor to late-onset pulmonary complications, and its clinical presentation, pathogenesis, and current therapeutic approaches are discussed. Idiopathic pneumonia syndrome is another important complication which usually occurs early, although its onset may be delayed. Organizing pneumonia is important to recognize due to its responsiveness to corticosteroids. Other late onset noninfectious pulmonary complications discussed here include pulmonary venoocclusive disease, pulmonary cytolytic thrombi, pleuroparenchymal fibroelastosis, thoracic air leak syndrome, and posttransplant lymphoproliferative disorders.
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Affiliation(s)
- Joseph L. Nates
- Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Kristen J. Price
- Division of Anesthesiology, Critical Care and Pain Medicine, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX USA
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34
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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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35
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Wenger DS, Triplette M, Crothers K, Cheng GS, Hill JA, Milano F, Shahrir S, Schoch G, Vande Vusse LK. Incidence, Risk Factors, and Outcomes of Idiopathic Pneumonia Syndrome after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 26:413-420. [PMID: 31605819 PMCID: PMC7035790 DOI: 10.1016/j.bbmt.2019.09.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 11/26/2022]
Abstract
Our current knowledge of idiopathic pneumonia syndrome (IPS) predates improved specificity in the diagnosis of IPS and advances in hematopoietic cell transplantation (HCT) and critical care practices. In this study, we describe and update the incidence, risk factors, and outcomes of IPS. We performed a retrospective cohort study of all adults who underwent allogeneic HCT at the Fred Hutchinson Cancer Research Center between 2006 and 2013 (n = 1829). IPS was defined using the National Heart, Lung, and Blood Institute consensus definition: multilobar airspace opacities on chest imaging, absence of lower respiratory tract infection, and hypoxemia. We described IPS incidence and mortality within 120 and 365 days after HCT. We examined conditioning intensity (nonmyeloablative versus myeloablative with high-dose total body irradiation [TBI] versus myeloablative with low-dose TBI) as an IPS risk factor in a time-to-event analysis using Cox models, controlled for age at transplant, HLA matching, stem cell source, and pretransplant Lung function Score (a combined measure of impairment in Forced Expiratory Volume in the first second (FEV1) and Diffusion capacity for carbon monoxide (DLCO)). Among 1829 HCT recipients, 67 fulfilled IPS criteria within 120 days (3.7%). Individuals who developed IPS were more likely to be black/non-Hispanic versus other racial groups and have severe pulmonary impairment but were otherwise similar to participants without IPS. In adjusted models, myeloablative conditioning with high-dose TBI was associated with increased risk of IPS (hazard ratio, 2.5; 95% confidence interval, 1.2 to 5.2). Thirty-one patients (46.3%) with IPS died within the first 120 days of HCT and 47 patients (70.1%) died within 365 days of HCT. In contrast, among the 1762 patients who did not acquire IPS in the first 120 days, 204 (11.6%) died within 120 days of HCT and 510 (29.9%) died within 365 days of HCT. Our findings suggest that although the incidence of IPS may be declining, it remains associated with post-transplant mortality. Future study should focus on early detection and identifying pathologic mediators of IPS to facilitate timely, targeted therapies for those most susceptible to lung injury post-HCT.
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Affiliation(s)
- David S Wenger
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington.
| | - Matthew Triplette
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kristina Crothers
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; VA Puget Sound Healthcare System, University of Washington, Seattle, Washington
| | - Guang-Shing Cheng
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Joshua A Hill
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington; Vaccine and Infectious Disease Division & Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Hematology and Oncology, Seattle Cancer Care Alliance, Seattle, Washington
| | - Shahida Shahrir
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington
| | - Gary Schoch
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Zuro D, Vagge S, Broggi S, Agostinelli S, Takahashi Y, Brooks J, Leszcynska P, Liu A, Zucchetti C, Saldi S, Han C, Cattaneo M, Giebel S, Mahe MA, Sanchez JF, Alaei P, Anna C, Dusenbery K, Pierini A, Storme G, Aristei C, Wong JYC, Hui S. Multi-institutional evaluation of MVCT guided patient registration and dosimetric precision in total marrow irradiation: A global health initiative by the international consortium of total marrow irradiation. Radiother Oncol 2019; 141:275-282. [PMID: 31421913 DOI: 10.1016/j.radonc.2019.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/09/2019] [Accepted: 07/08/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE Total marrow irradiation (TMI) is a highly conformal treatment of the human skeleton structure requiring a high degree of precision and accuracy for treatment delivery. Although many centers worldwide initiated clinical studies using TMI, currently there is no standard for pretreatment patient setup. To this end, the accuracy of different patient setups was measured using pretreatment imaging. Their impact on dose delivery was assessed for multiple institutions. METHODS AND MATERIALS Whole body imaging (WBI) or partial body imaging (PBI) was performed using pretreatment megavoltage computed tomography (MVCT) in a helical Tomotherapy machine. Rigid registration of MVCT and planning kilovoltage computed tomography images were performed to measure setup error and its effect on dose distribution. The entire skeleton was considered the planning target volume (PTV) with five sub regions: head/neck (HN), spine, shoulder and clavicle (SC), and one avoidance structure, the lungs. Sixty-eight total patients (>300 images) across six institutions were analyzed. RESULTS Patient setup techniques differed between centers, creating variations in dose delivery. Registration accuracy varied by anatomical region and by imaging technique, with the lowest to the highest degree of pretreatment rigid shifts in the following order: spine, pelvis, HN, SC, and lungs. Mean fractional dose was affected in regions of high registration mismatch, in particular the lungs. CONCLUSIONS MVCT imaging and whole body patient immobilization was essential for assessing treatment setup, allowing for the complete analysis of 3D dose distribution in the PTV and lungs (or avoidance structures).
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Affiliation(s)
- Darren Zuro
- Department of Radiation Oncology, Beckman Research Institute, City of Hope, Duarte, USA; Department of Radiation Oncology, University of Minnesota, Minneapolis, USA
| | - Stefano Vagge
- Deparment of Medical Imaging and Radiation Sciences, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sara Broggi
- Department of Medical Physics, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Agostinelli
- Deparment of Medical Imaging and Radiation Sciences, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Yutaka Takahashi
- Department of Radiation Oncology, Osaka University, Suita, Japan
| | - Jamison Brooks
- Department of Radiation Oncology, Beckman Research Institute, City of Hope, Duarte, USA
| | - Paulina Leszcynska
- Department of Radiotherapy Planning, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - An Liu
- Department of Radiation Oncology, Beckman Research Institute, City of Hope, Duarte, USA
| | | | - Simonetta Saldi
- Department of Radiation Oncology, University of Nantes, France
| | - Chunhui Han
- Department of Radiation Oncology, Beckman Research Institute, City of Hope, Duarte, USA
| | - Mauro Cattaneo
- Department of Medical Physics, San Raffaele Scientific Institute, Milan, Italy
| | - Sebastian Giebel
- Department of Radiotherapy Planning, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Marc Andre Mahe
- Department of Radiation Oncology, University of Nantes, France
| | - James F Sanchez
- Department of Radiation Oncology, Beckman Research Institute, City of Hope, Duarte, USA
| | - Parham Alaei
- Department of Radiation Oncology, University of Minnesota, Minneapolis, USA
| | - Chiara Anna
- Department of Medical Physics, San Raffaele Scientific Institute, Milan, Italy
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, USA
| | - Antonio Pierini
- Division of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Italy
| | - Guy Storme
- Department of Radiotherapy UZ Brussel, Belgium
| | - Cynthia Aristei
- Department of Radiation Oncology, University of Nantes, France
| | - Jeffrey Y C Wong
- Department of Radiation Oncology, Beckman Research Institute, City of Hope, Duarte, USA
| | - Susanta Hui
- Department of Radiation Oncology, Beckman Research Institute, City of Hope, Duarte, USA.
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Esiashvili N, Lu X, Ulin K, Laurie F, Kessel S, Kalapurakal JA, Merchant TE, Followill DS, Sathiaseelan V, Schmitter MK, Devidas M, Chen Y, Wall DA, Brown PA, Hunger SP, Grupp SA, Pulsipher MA. Higher Reported Lung Dose Received During Total Body Irradiation for Allogeneic Hematopoietic Stem Cell Transplantation in Children With Acute Lymphoblastic Leukemia Is Associated With Inferior Survival: A Report from the Children's Oncology Group. Int J Radiat Oncol Biol Phys 2019; 104:513-521. [PMID: 30807822 PMCID: PMC6548591 DOI: 10.1016/j.ijrobp.2019.02.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 01/14/2019] [Accepted: 02/14/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To examine the relationship between lung radiation dose and survival outcomes in children undergoing total body irradiation (TBI)-based hematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukemia on the Children's Oncology Group trial. METHODS AND MATERIALS TBI (1200 or 1320 cGy given twice daily in 6 or 8 fractions) was used as part of 3 HSCT preparative regimens, allowing institutional flexibility regarding TBI techniques, including lung shielding. Lung doses as reported by each participating institution were calculated for different patient setups, with and without shielding, with a variety of dose calculation techniques. The association between lung dose and transplant-related mortality, relapse-free survival, and overall survival (OS) was examined using the Cox proportional hazards regression model controlling for the following variables: TBI dose rate, TBI fields, patient position during TBI, donor type, and pre-HSCT minimal residual disease level. RESULTS Of a total of 143 eligible patients, 127 had lung doses available for this analysis. The TBI techniques were heterogeneous. The mean lung dose was reported as 904.5 cGy (standard deviation, ±232.3). Patients treated with lateral fields were more likely to receive lung doses ≥800 cGy (P < .001). The influence of lung dose ≥800 cGy on transplant-related mortality was not significant (hazard ratio [HR], 1.78; P = .21). On univariate analysis, lung dose ≥800 cGy was associated with inferior relapse-free survival (HR, 1.76; P = .04) and OS (HR, 1.85; P = .03). In the multivariate analysis, OS maintained statistical significance (HR, 1.85; P = .04). CONCLUSIONS The variability in TBI techniques resulted in uncertainty with reported lung doses. Lateral fields were associated with higher lung dose, and thus they should be avoided. Patients treated with lung dose <800 cGy in this study had better outcomes. This approach is currently being investigated in the Children's Oncology Group AALL1331 study. Additionally, the Imaging and Radiation Oncology Core Group is evaluating effects of TBI techniques on lung doses using a phantom.
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Affiliation(s)
| | - Xiaomin Lu
- Children's Oncology Group Data Center, Biostatistics, University of Florida, Gainesville, Florida
| | - Ken Ulin
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - Fran Laurie
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - Sandy Kessel
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - John A Kalapurakal
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois
| | | | - David S Followill
- Imaging and Radiation Oncology Rhode Island QA Center, Houston, Texas
| | | | - Mary K Schmitter
- Imaging and Radiation Oncology Rhode Island QA Center, Lincoln, Rhode Island
| | - Meenakshi Devidas
- Children's Oncology Group Data Center, Biostatistics, University of Florida, Gainesville, Florida
| | - Yichen Chen
- Children's Oncology Group Data Center, Biostatistics, University of Florida, Gainesville, Florida
| | - Donna A Wall
- Manitoba Blood and Marrow Transplant Program, Winnipeg, Manitoba, Canada
| | - Patrick A Brown
- Johns Hopkins University Kimmel Cancer Center, Baltimore, Maryland
| | - Stephen P Hunger
- Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephan A Grupp
- Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Pulsipher
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
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38
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LeBaron TW, Kura B, Kalocayova B, Tribulova N, Slezak J. A New Approach for the Prevention and Treatment of Cardiovascular Disorders. Molecular Hydrogen Significantly Reduces the Effects of Oxidative Stress. Molecules 2019; 24:E2076. [PMID: 31159153 PMCID: PMC6600250 DOI: 10.3390/molecules24112076] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/20/2019] [Accepted: 05/24/2019] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular diseases are the most common causes of morbidity and mortality worldwide. Redox dysregulation and a dyshomeostasis of inflammation arise from, and result in, cellular aberrations and pathological conditions, which lead to cardiovascular diseases. Despite years of intensive research, there is still no safe and effective method for their prevention and treatment. Recently, molecular hydrogen has been investigated in preclinical and clinical studies on various diseases associated with oxidative and inflammatory stress such as radiation-induced heart disease, ischemia-reperfusion injury, myocardial and brain infarction, storage of the heart, heart transplantation, etc. Hydrogen is primarily administered via inhalation, drinking hydrogen-rich water, or injection of hydrogen-rich saline. It favorably modulates signal transduction and gene expression resulting in suppression of proinflammatory cytokines, excess ROS production, and in the activation of the Nrf2 antioxidant transcription factor. Although H2 appears to be an important biological molecule with anti-oxidant, anti-inflammatory, and anti-apoptotic effects, the exact mechanisms of action remain elusive. There is no reported clinical toxicity; however, some data suggests that H2 has a mild hormetic-like effect, which likely mediate some of its benefits. The mechanistic data, coupled with the pre-clinical and clinical studies, suggest that H2 may be useful for ROS/inflammation-induced cardiotoxicity and other conditions.
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Affiliation(s)
- Tyler W LeBaron
- Centre of Experimental Medicine, Institute for Heart Research, Slovak Academy of Sciences, Bratislava 841 04, Slovak Republic.
- Molecular Hydrogen Institute, Enoch City, UT, 847 21, USA.
| | - Branislav Kura
- Centre of Experimental Medicine, Institute for Heart Research, Slovak Academy of Sciences, Bratislava 841 04, Slovak Republic.
| | - Barbora Kalocayova
- Centre of Experimental Medicine, Institute for Heart Research, Slovak Academy of Sciences, Bratislava 841 04, Slovak Republic.
| | - Narcis Tribulova
- Centre of Experimental Medicine, Institute for Heart Research, Slovak Academy of Sciences, Bratislava 841 04, Slovak Republic.
| | - Jan Slezak
- Centre of Experimental Medicine, Institute for Heart Research, Slovak Academy of Sciences, Bratislava 841 04, Slovak Republic.
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Affiliation(s)
- Dan Pugh
- University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Tariq E. Farrah
- University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Peter J. Gallacher
- University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - David C. Kluth
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Neeraj Dhaun
- University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, Scotland
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Pierce G, Balogh A, Frederick R, Gordon D, Yarschenko A, Hudson A. Extended SSD VMAT treatment for total body irradiation. J Appl Clin Med Phys 2018; 20:200-211. [PMID: 30592152 PMCID: PMC6333187 DOI: 10.1002/acm2.12519] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 11/09/2018] [Accepted: 11/13/2018] [Indexed: 12/17/2022] Open
Abstract
In this work, we develop a total body irradiation technique that utilizes arc delivery, a buildup spoiler, and inverse optimized multileaf collimator (MLC) motion to shield organs at risk. The current treatment beam model is verified to confirm its applicability at extended source‐to‐surface distance (SSD). The delivery involves 7–8 volumetric modulated arc therapy arcs delivered to the patient in the supine and prone positions. The patient is positioned at a 90° couch angle on a custom bed with a 1 cm acrylic spoiler to increase surface dose. Single‐step optimization using a patient CT scan provides enhanced dose homogeneity and limits organ at risk dose. Dosimetric data of 109 TBI patients treated with this technique is presented along with the clinical workflow. Treatment planning system (TPS) verification measurements were performed at an extended SSD of 175 cm. Measurements included: a 4‐point absolute depth‐dose curve, profiles at 1.5, 5, and 10 cm depth, absolute point‐dose measurements of an treatment field, 2D Gafchromic® films at four locations, and measurements of surface dose at multiple locations of a Alderson phantom. The results of the patient DVH parameters were: Body‐5 mm D98 95.3 ± 1.5%, Body‐5 mm D2 114.0 ± 3.6%, MLD 102.8 ± 2.1%. Differences between measured and calculated absolute depth‐dose values were all <2%. Profiles at extended SSD had a maximum point difference of 1.3%. Gamma pass rates of 2D films were greater than 90% at 5%/1 mm. Surface dose measurements with film confirmed surface dose values of >90% of the prescription dose. In conclusion, the inverse optimized delivery method presented in the paper has been used to deliver homogenous dose to over 100 patients. The method provides superior patient comfort utilizing a commercial TPS. In addition, the ability to easily shield organs at risk is available through the use of MLCs.
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Affiliation(s)
- Greg Pierce
- Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Physics & Astronomy, University of Calgary, 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
| | - Rebecca Frederick
- Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.,Department of Physics & Astronomy, University of Calgary, Calgary, AB, Canada
| | - Deborah Gordon
- Department of Radiation Therapy, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Adam Yarschenko
- Department of Medical Physics, Tom Baker Cancer Centre, 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
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Feasibility of a novel dose fractionation strategy in TMI/TMLI. Radiat Oncol 2018; 13:248. [PMID: 30558631 PMCID: PMC6296054 DOI: 10.1186/s13014-018-1201-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 12/09/2018] [Indexed: 11/17/2022] Open
Abstract
Background To report our experience in planning and delivering total marrow irradiation (TMI) and total marrow and lymphatic irradiation (TMLI) in patients with hematologic malignancies. Methods Twenty-seven patients undergoing bone marrow transplantation were treated with TMI/TMLI using Helical Tomotherapy (HT). All skeletal bones exclusion of the mandible comprised the treatment target volume and, for TMLI, lymph node chains, liver, spleen and/or brain were also included according to the clinical indication. Planned dose of 8Gy in 2 fractions was delivered over 1 day for TMI while 10Gy in 2 fractions BID was used for TMLI. Organs at risk (OAR) contoured included the brain, brainstem, lens, eyes, optic nerves, parotids, oral cavity, lungs, heart, liver, kidneys, stomach, small bowel, bladder and rectum. In particular, a simple method to avoid hot or cold doses in the overlapping region was implemented and the plan sum was adopted to evaluate dose inhomogeneity. Furthermore, setup errors from 54 treatments were summarized to gauge the effectiveness of immobilization. Results During the TMI/TMLI treatment, no acute adverse effects occurred during the radiation treatment. Two patients suffered nausea or vomiting right after radiation course. For the 9 patients treated with TMI, the median dose reduction of major organs varied 30–65% of the prescribed dose, substantially lower than the traditional total body irradiation (TBI). Meanwhile, average biological equivalent doses to OARs with 8Gy/2F TMI approach were not different from the conventional 12Gy/6F TMI approach. In the dose junction region, the 93% of PTV was covered by the prescribed dose without obvious hotspots. For the 27 patients, the overall setup corrections were lower than 3 mm except those in the SI direction for abdomen-pelvis region, demonstrating excellent immobilization. Conclusion The present study confirmed the technical feasibility of HT-based TMI/TMLI delivering 8-10Gy in 2 fractions over 1 day. For patients undergoing hematopoietic cell transplantation the proposed 8Gy/2F TMI (or 10Gy/2F TMLI) strategy may be a novel approach to improve delivery efficiency, increase effective radiation dose to target while maintaining low risk of severe organ toxicities.
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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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Ishibashi N, Soejima T, Kawaguchi H, Akiba T, Hasegawa M, Isobe K, Ito H, Imai M, Ejima Y, Hata M, Sasai K, Shimoda E, Maebayashi T, Oguchi M, Akimoto T. National survey of myeloablative total body irradiation prior to hematopoietic stem cell transplantation in Japan: survey of the Japanese Radiation Oncology Study Group (JROSG). JOURNAL OF RADIATION RESEARCH 2018; 59:477-483. [PMID: 29584887 PMCID: PMC6054214 DOI: 10.1093/jrr/rry017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 12/15/2017] [Indexed: 06/08/2023]
Abstract
A myeloablative regimen that includes total-body irradiation (TBI) before hematopoietic stem cell transplantation results in higher patient survival rates than achieved with regimens without TBI. The TBI protocol, however, varies between institutions. In October 2015, the Japanese Radiation Oncology Study Group initiated a national survey of myeloablative TBI (covering 2010-2014). Among the 186 Japanese institutions performing TBI, 90 (48%) responded. The 82 institutions that had performed myeloablative TBI during this period treated 2698 patients with malignant disease [leukemia (2082 patients, 77.2%), malignant lymphoma (378, 14%)] and 37 with non-malignant disease [severe aplastic anemia (20, 54%), inborn errors of metabolism (5, 14%)]. A linear accelerator was used at all institutions. The institutions were divided into 41 large and 41 small institutions based on the median number of patients. The long source-surface distance technique was the method of choice in the 34 institutions (82.9%) and the moving-couch technique in the 7 (17.1%) in the large institutions. The schedules most routinely used by the participating institutions consisted of 12 Gy/6 fractions/3 days (26 institutions, 63.5%) in the large institutions. The dose rate varied from 5 to 26 cGy/min. The lungs and lenses were routinely shielded in 23 large institutions (56.1%), and only the lungs in 9 large institutions (21.9%). At lung-shielding institutions, the most frequent maximum acceptable total dose for the lungs was 8 Gy (19 institutions, 27.5%). Our results reveal considerable differences in the TBI methods used by Japanese institutions and thus the challenges in designing multicenter randomized trials based on TBI.
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Affiliation(s)
- Naoya Ishibashi
- Department of Radiology, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, Tokyo, Japan
| | - Toshinori Soejima
- Department of Radiation Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Hiroki Kawaguchi
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Akiba
- Department of Radiation Oncology, Tokai University, School of Medicine, Isehara, Japan
| | - Masatoshi Hasegawa
- Department of Radiation Oncology, Nara Medical University, Kashihara, Japan
| | - Kouichi Isobe
- Department of Radiology, Toho University Sakura Medical Center, Chiba, Japan
| | - Hitoshi Ito
- Department of Radiation Oncology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Michiko Imai
- Department of Radiation Oncology, Iwata City General Hospital, Shizuoka, Japan
| | - Yasuo Ejima
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaharu Hata
- Division of Radiation Oncology, Department of Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Emiko Shimoda
- Department of Radiation Oncology, Nara Medical University, Kashihara, Japan
| | - Toshiya Maebayashi
- Department of Radiology, Nihon University School of Medicine, 30-1 Oyaguchi Kami-cho, Itabashi-ku, Tokyo, Japan
| | - Masahiko Oguchi
- Department of Radiation Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, Kashiwa, Japan
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Single-Dose Daily Fractionation Is Not Inferior to Twice-a-Day Fractionated Total-Body Irradiation Before Allogeneic Stem Cell Transplantation for Acute Leukemia: A Useful Practice Simplification Resulting From the SARASIN Study. Int J Radiat Oncol Biol Phys 2018; 102:515-526. [PMID: 29928948 DOI: 10.1016/j.ijrobp.2018.06.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 06/01/2018] [Accepted: 06/09/2018] [Indexed: 01/28/2023]
Abstract
PURPOSE Total-body irradiation (TBI) is a major constituent of myeloablative conditioning regimens. The standard technique consists of 12 Gy in 6 fractions over a period of 3 days. The Standard-fractionation compAred to one-daily fRaction total body irrAdiation prior to tranSplant In LEUkemia patieNts (SARASIN) study aimed to compare standard fractionation with once-daily fractionation before transplant in leukemia. METHODS AND MATERIALS We retrospectively compared TBI regimens delivered in 2993 patients from the European Society for Blood and Marrow Transplantation database, who underwent transplantation between 2000 and 2014 for acute lymphoblastic leukemia (ALL, n = 1729) or acute myeloid leukemia (AML, n = 1264). TBI was delivered as either 12 Gy in 6 fractions (group 1, considered the reference group; 1362 ALL and 857 AML patients), 9 to 12 Gy in 2 fractions (group 2, 173 ALL and 256 AML patients), or 12 Gy in 3 to 4 fractions (group 3, 194 ALL and 151 AML patients). RESULTS The median follow-up was 60 and 84 months in ALL and AML patients, respectively. At 5 years, the leukemia-free survival rate, overall survival rate, relapse incidence, and nonrelapse mortality rate were 46.6%, 50.4%, 28.8%, and 24.6%, respectively, in ALL patients and 46.6%, 48.9%, 29.7%, and 23.6%, respectively, in AML patients. In multivariate analyses, the outcomes of groups 2 and 3 were not statistically different from those in group 1. The cumulative incidence of secondary malignancies (SMs) was significantly higher in group 2 (7.2%; P < 10-6 for group 2 vs group 1). However, group 2 was not associated with an increase in SMs when we considered non-T-cell-depleted transplant patients. CONCLUSIONS We showed that the 12-Gy fractionated TBI dose delivered either in 2 fractions or in 1 fraction per day over a period of 3 to 4 days resulted in nonsignificant differences in disease control and survival. However, 1-day fractionation may be associated with a higher risk of mucositis and hemorrhagic cystitis. The absence of a significant difference in the SM incidence in the non-T-cell-depleted group should be interpreted with caution in the context of a retrospective study design. Our findings are important to consider for radiation therapy department organization. In-depth analyses of other nonlethal toxicities and late effects are required.
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Paix A, Antoni D, Waissi W, Ledoux MP, Bilger K, Fornecker L, Noel G. Total body irradiation in allogeneic bone marrow transplantation conditioning regimens: A review. Crit Rev Oncol Hematol 2018; 123:138-148. [PMID: 29482775 DOI: 10.1016/j.critrevonc.2018.01.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/28/2017] [Accepted: 01/24/2018] [Indexed: 12/30/2022] Open
Abstract
Hematologic malignancies may require, at one point during their treatment, allogeneic bone marrow transplantation. Total body irradiation combined with chemotherapy or radiomimetic used in allogeneic bone marrow transplantation is known to be very toxic. Total body irradiation (TBI) induces immunosuppression to prevent the rejection of donor marrow. TBI is also used to eradicate malignant cells and is in sanctuary organs that are not reached by chemotherapy drugs. TBI has evolved since its introduction in the late fifties, but acute and late toxicities remain. Helical tomotherapy, which is widely used for some solid tumors, is a path for the improvement of outcomes and toxicities in TBI because of its sparing capacities. In this article, we first review the practical aspects of TBI with patient positioning, radiobiological considerations and total dose and fractionation prescriptions. Second, we review the use of intensity modulated radiation therapy in bone marrow transplantation with a focus on helical tomotherapy TBI, helical tomotherapy total marrow irradiation (TMI) and total marrow and lymphoid irradiation (TMLI) and their dosimetric and clinical outcomes. Finally, we review the perspective of dose escalation and the extension to older patients and patients with comorbidity who do not benefit from a standard bone marrow transplantation conditioning regimen.
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Affiliation(s)
- Adrien Paix
- Radiation Oncology Department, Centre Paul Strauss 3 rue de la Porte de l'hôpital, 67065, Strasbourg Cedex, France
| | - Delphine Antoni
- Radiation Oncology Department, Centre Paul Strauss 3 rue de la Porte de l'hôpital, 67065, Strasbourg Cedex, France; Radiobiology Laboratory, EA3430, Strasbourg University, 3 rue de la Porte de l'hôpital, 67000, Strasbourg, France
| | - Waisse Waissi
- Radiation Oncology Department, Centre Paul Strauss 3 rue de la Porte de l'hôpital, 67065, Strasbourg Cedex, France; Radiobiology Laboratory, EA3430, Strasbourg University, 3 rue de la Porte de l'hôpital, 67000, Strasbourg, France
| | - Marie-Pierre Ledoux
- Hematology Department, CHU Hautepierre, 1, rue Molière, 67000, Strasbourg, France
| | - Karin Bilger
- Hematology Department, CHU Hautepierre, 1, rue Molière, 67000, Strasbourg, France
| | - Luc Fornecker
- Hematology Department, CHU Hautepierre, 1, rue Molière, 67000, Strasbourg, France
| | - Georges Noel
- Radiation Oncology Department, Centre Paul Strauss 3 rue de la Porte de l'hôpital, 67065, Strasbourg Cedex, France; Radiobiology Laboratory, EA3430, Strasbourg University, 3 rue de la Porte de l'hôpital, 67000, Strasbourg, France.
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Yanagisawa R, Abe S, Fujihara I, Komori K, Kondo Y, Sakashita K, Nakamura T. Transfusion-associated hypoxemia in pediatric patients with solid tumors after autologous peripheral blood stem cell transplantation. Transfus Apher Sci 2017; 56:744-747. [PMID: 28965826 DOI: 10.1016/j.transci.2017.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 09/07/2017] [Accepted: 09/11/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Although several types of transfusion-related adverse reactions (TRARs) have been reported, one of the most important involves respiratory features during and after blood transfusion. Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the most severe adverse events following blood transfusion, whereas transfusion-associated dyspnea (TAD) is a less severe respiratory distress. However, there exists little evidence of these factors in pediatric populations. CASE REPORT Here, two cases of atypical TRARs with respiratory features, in pediatric patients with solid tumors, appearing after transfusion of platelet concentrate following autologous peripheral blood stem cell transplantation are reported. Both patients developed mild hypoxemia during PC transfusion, which continued for approximately 2 weeks. Chest radiography in either patient did not reveal any abnormalities that are included in the criteria of either TRALI or TACO. Both patients recovered following oxygen administration. CONCLUSION This complication of TRARs with respiratory features may occur more frequently in pediatric populations than realized because it may be under-recognized or under-reported. Accumulation of additional cases, including non-typical cases, is necessary to fully understand the pathology of TRARs, correctly classify these reactions, and improve care of patients receiving blood transfusions.
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Affiliation(s)
- Ryu Yanagisawa
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan; Division of Blood Transfusion, Shinshu University Hospital, Matsumoto, Japan; Center for Advanced Cell Therapy, Shinshu University Hospital, Matsumoto, Japan.
| | - Seiki Abe
- Department of Anesthesia, Nagano Children's Hospital, Azumino, Japan
| | - Ikuko Fujihara
- Department of Hematology/Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Kazutoshi Komori
- Department of Hematology/Oncology, Nagano Children's Hospital, Azumino, Japan; Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yoshiaki Kondo
- Department of Radiology, Nagano Children's Hospital, Azumino, Japan
| | - Kazuo Sakashita
- Department of Hematology/Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Tomohiko Nakamura
- Life Science Research Center, Nagano Children's Hospital, Azumino, Japan; Division of Neonatology, Nagano Children's Hospital, Azumino, Japan
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Zhao J, Day RM, Jin JY, Quint L, Williams H, Ferguson C, Yan L, King M, Albsheer A, Matuszak M, Kong FMS. Thoracic radiation-induced pleural effusion and risk factors in patients with lung cancer. Oncotarget 2017; 8:97623-97632. [PMID: 29228638 PMCID: PMC5722590 DOI: 10.18632/oncotarget.18824] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 06/08/2017] [Indexed: 12/25/2022] Open
Abstract
The risk factors and potential practice implications of radiation-induced pleural effusion (RIPE) are undefined. This study examined lung cancer patients treated with thoracic radiation therapy (TRT) having follow-up computed tomography (CT) or 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT. Increased volumes of pleural effusion after TRT without evidence of tumor progression was considered RIPE. Parameters of lung dose-volume histogram including percent volumes irradiated with 5-55 Gy (V5-V55) and mean lung dose (MLD) were analyzed by receiver operating characteristic analysis. Clinical and treatment-related risk factors were detected by univariate and multivariate analyses. 175 out of 806 patients receiving TRT with post-treatment imaging were included. 51 patients (24.9%) developed RIPE; 40 had symptomatic RIPE including chest pain (47.1%), cough (23.5%) and dyspnea (35.3%). Female (OR = 0.380, 95% CI: 0.156-0.926, p = 0.033) and Caucasian race (OR = 3.519, 95% CI: 1.327-9.336, p = 0.011) were significantly associated with lower risk of RIPE. Stage and concurrent chemotherapy had borderline significance (OR = 1.665, p = 0.069 and OR = 2.580, p = 0.080, respectively) for RIPE. Patients with RIPE had significantly higher whole lung V5-V40, V50 and MLD. V5 remained as a significant predictive factor for RIPE and symptomatic RIPE (p = 0.007 and 0.022) after adjusting for race, gender and histology. To include, the incidence of RIPE is notable. Whole lung V5 appeared to be the most significant independent risk factor for symptomatic RIPE.
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Affiliation(s)
- Jing Zhao
- Department of Oncology, Tongji Hospital, Tongji Medial College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,Department of Radiation Oncology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Regina M Day
- Department of Pharmacology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jian-Yue Jin
- Department of Radiation Oncology, Medical College of Georgia, Augusta University, Augusta, GA, USA.,Department of Radiation Oncology, Radiation Physics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Leslie Quint
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Hadyn Williams
- Department of Radiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Catherine Ferguson
- Department of Radiation Oncology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Li Yan
- Department of Radiation Oncology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Maurice King
- Department of Radiation Oncology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Ahmad Albsheer
- Department of Radiation Oncology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Martha Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Feng-Ming Spring Kong
- Department of Radiation Oncology, Medical College of Georgia, Augusta University, Augusta, GA, USA.,Department of Radiation Oncology, IU Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
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