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Milgrom SA, Dandapani SV, Wong J, Kalapurakal J, Smith KS, Han C, Simiele E, Hua CH, Fitzgerald TJ, Kry S, Wong K, Symons H, Kovalchuk N, Hiniker SM. Incorporating intensity modulated total body irradiation into a Children's Oncology Group trial: Rationale, techniques, and safeguards. Pediatr Blood Cancer 2024:e31185. [PMID: 39118225 DOI: 10.1002/pbc.31185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/21/2024] [Accepted: 06/22/2024] [Indexed: 08/10/2024]
Abstract
Historically, total body irradiation (TBI) has been delivered using static, parallel opposed photon beams (2D-TBI). Recently, centers have increasingly used intensity-modulated radiation therapy (IMRT) techniques for TBI. Relative to 2D-TBI, IMRT can reduce doses to critical organs (i.e., lungs and kidneys) while delivering myeloablative doses to the rest of the body, so it may decrease the risk of toxicity while maintaining oncologic outcomes. Despite these potential benefits, delivering TBI using IMRT introduces new challenges in treatment planning and delivery. We describe the extensive experience with IMRT-based TBI at Stanford University and City of Hope Cancer Center. These groups, and others, have reported favorable clinical outcomes and have developed methods to optimize treatment planning and delivery. A critical next step is to evaluate the broader adoption of this approach. Therefore, IMRT-based TBI will be incorporated into a prospective, multi-institutional Children's Oncology Group study with careful procedures and safeguards in place.
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Affiliation(s)
- Sarah A Milgrom
- Department of Radiation Oncology, University of Colorado, Aurora, Colorado, USA
| | | | - Jeffrey Wong
- Department of Radiation Oncology, City of Hope, Duarte, California, USA
| | - John Kalapurakal
- Department of Radiation Oncology, Northwestern Medicine, Chicago, Illinois, USA
| | - Koren S Smith
- Department of Radiation Oncology, Imaging and Radiation Oncology Core-Rhode Island, UMass Chan Medical School, Lincoln, Rhode Island, USA
| | - Chunhui Han
- Department of Radiation Oncology, City of Hope, Duarte, California, USA
| | - Eric Simiele
- Department of Radiation Oncology, Stanford University, Palo Alto, California, USA
| | - Chia-Ho Hua
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Thomas J Fitzgerald
- Department of Radiation Oncology, Imaging and Radiation Oncology Core-Rhode Island, UMass Chan Medical School, Lincoln, Rhode Island, USA
| | - Stephen Kry
- Division of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Kenneth Wong
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Heather Symons
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, Maryland, USA
| | - Nataliya Kovalchuk
- Department of Radiation Oncology, Stanford University, Palo Alto, California, USA
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Palo Alto, California, USA
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Smith J, Tan JKH, Short C, O'Neill H, Moro C. The effect of myeloablative radiation on urinary bladder mast cells. Sci Rep 2024; 14:6219. [PMID: 38485999 PMCID: PMC10940702 DOI: 10.1038/s41598-024-56655-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 03/08/2024] [Indexed: 03/18/2024] Open
Abstract
Radiation-induced cystitis is an inflammatory condition affecting the urinary bladder, which can develop as a side effect of abdominopelvic radiotherapy, specifically external-beam radiation therapy or myeloablative radiotherapy. A possible involvement of mast cells in the pathophysiology of radiation-induced cystitis has been indicated in cases of external-beam radiation therapy; however, there is no evidence that these findings apply to the myeloablative aetiology. As such, this study investigated potential changes to urinary bladder mast cell prevalence when exposed to myeloablative radiation. Lethally irradiated C57BL/6J mice that received donor rescue bone marrow cells exhibited an increased mast cell frequency amongst host leukocytes 1 week following irradiation. By 4 weeks, no significant difference in either frequency or cell density was observed. However mast cell diameter was smaller, and a significant increase in mast cell number in the adventitia was observed. This study highlights that mast cells constitute a significant portion of the remaining host leukocyte population following radiation exposure, with changes to mast cell distribution and decreased cell diameter four weeks following radiation-induced injury.
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Affiliation(s)
- Jessica Smith
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, 4226, Australia
| | - Jonathan Kah Huat Tan
- Clem Jones Centre for Regenerative Medicine, Bond University, Gold Coast, QLD, 4226, Australia
| | - Christie Short
- Clem Jones Centre for Regenerative Medicine, Bond University, Gold Coast, QLD, 4226, Australia
| | - Helen O'Neill
- Clem Jones Centre for Regenerative Medicine, Bond University, Gold Coast, QLD, 4226, Australia
| | - Christian Moro
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, 4226, Australia.
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Hao C, Ladbury C, Wong J, Dandapani S. Modern Radiation for Hematologic Stem Cell Transplantation: Total Marrow and Lymphoid Irradiation or Intensity-Modulated Radiation Therapy Total Body Irradiation. Surg Oncol Clin N Am 2023; 32:475-495. [PMID: 37182988 DOI: 10.1016/j.soc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The development of large-field intensity-modulated radiation therapy (IMRT) has enabled the implementation of total marrow irradiation (TMI), total marrow and lymphoid irradiation (TMLI), and IMRT total body irradiation (TBI). IMRT TBI limits doses to organs at risk, primarily the lungs and in some cases the kidneys and lenses, which may mitigate complications. TMI/TMLI allows for dose escalation above TBI radiation therapy doses to malignant sites while still sparing organs at risk. Although still sparingly used, these techniques have established feasibility and demonstrated promise in reducing the adverse effects of TBI while maintaining and potentially improving survival outcomes.
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Affiliation(s)
- Claire Hao
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Jeffrey Wong
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Savita Dandapani
- Department of Radiation Oncology, City of Hope, 1500 East Duarte Road, Duarte, CA 91010, USA.
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Misson-Yates S, Cunningham R, Gonzalez R, Diez P, Clark CH. Optimised conformal total body irradiation: a heterogeneous practice, so where next? Br J Radiol 2023; 96:20220650. [PMID: 36475820 PMCID: PMC10078861 DOI: 10.1259/bjr.20220650] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The use of volumetric arc therapy and inverse planning has been in routine use in radiotherapy for two decades. However, use in total body irradiation (TBI) has been more recent and few guidelines exist as to how to plan or verify. This has led to heterogeneous approaches. The goal of this review is to provide an overview of current advanced planning and dosimetry verification protocols used in optimised conformal TBI as a basis for investigating the need for greater standardisation in TBI.
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Affiliation(s)
- Sarah Misson-Yates
- Department of Medical Physics, Guy's Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom
| | - Rissa Cunningham
- Department of Medical Physics, Guy's Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Regina Gonzalez
- Department of Medical Physics, Guy's Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Patricia Diez
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK
| | - 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
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Ladbury C, Hao C, Yang D, Hui S, Han C, Liu A, Salhotra A, Nakamura R, Rosenthal J, Stein A, Wong J, Dandapani S. Long-term follow up of patients with hematological malignancies treated with total body irradiation using intensity modulated radiation therapy. Front Oncol 2022; 12:1044539. [PMID: 36531001 PMCID: PMC9755353 DOI: 10.3389/fonc.2022.1044539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/18/2022] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND With the advent of modern radiation treatment technologies such as intensity modulated radiation therapy (IMRT), there has been increasing interest in its use for total body irradiation (TBI) conditioning regimens for hematopoietic cell transplantation (HCT) to achieve lower doses to critical organs such as the lungs and kidneys. Although this has been reported on in early studies, long-term safety and efficacy data is limited. METHODS We performed a single institution matched-pair retrospective analysis of patients treated with IMRT TBI and standard TBI between 2010 and 2020 to provide data on long-term outcomes. Patients with hematologic malignancies, who could not tolerate standing for traditional TBI or who received prior radiation received IMRT TBI. Patients were matched based on age, diagnosis, disease status, and year of transplant, and were matched 2:1 to the standard TBI and IMRT TBI cohorts. Patient and treatment characteristics, toxicity, graft-versus-host disease (GVHD), dosimetry, and outcomes were evaluated for each cohort. RESULTS A total of 13 patients met inclusion criteria for the IMRT cohort, leading to 26 patients in the standard TBI cohort. There was no significant difference in relevant clinical factors between the cohorts. Reasons for using IMRT over conventional TBI included being unable to stand (n=5), prior radiation (n=5), and pediatric patient requiring anesthesia (n=3). Among living patients, median follow-up for all patients was 5.1 years in the IMRT TBI cohort and 5.5 years in the standard TBI cohort. The 5-yr estimate of OS was 68% in the IMRT TBI cohort and 60% in the standard TBI cohort (p=0.706). The 5-yr estimate of RFS was 54% in the IMRT TBI cohort and 60% in the standard TBI cohort (p=0.529). There was no clinically significant pneumonitis, nephritis, hypothyroidism, or cataracts reported in the IMRT TBI cohort. 41.7% of patients in the IMRT TBI cohort and 79.2% of patients in the standard TBI cohort experienced Grade II-IV acute GVHD (p=0.023). CONCLUSIONS IMRT TBI appears to lead to favorable long-term outcome and dosimetry, and therefore potentially improved long-term toxicity profile compared to conventional TBI. IMRT TBI warrants further investigation as part of larger prospective trials.
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Affiliation(s)
- Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Claire Hao
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Dongyun Yang
- Division of Biostatistics, City of Hope National Medical Center, Duarte, CA, United States
| | - Susanta Hui
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Chunhui Han
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - An Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, United States
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, United States
| | - Joseph Rosenthal
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, United States
| | - Anthony Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, United States
| | - Jeffrey Wong
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
| | - Savita Dandapani
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States
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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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Ogawa H, Konishi T, Najima Y, Kito S, Hashimoto S, Kato C, Sakai S, Kanbara Y, Atsuta Y, Konuma R, Wada A, Murakami D, Nakasima S, Uchibori Y, Onai D, Hamamura A, Nishijima A, Shingai N, Toya T, Shimizu H, Kobayashi T, Ohashi K, Doki N, Murofushi KN. Phase I trial of myeloablative conditioning with 3-day total marrow and lymphoid irradiation for leukemia. Cancer Sci 2022; 114:596-605. [PMID: 36221800 PMCID: PMC9899623 DOI: 10.1111/cas.15611] [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: 07/18/2022] [Revised: 09/10/2022] [Accepted: 09/20/2022] [Indexed: 02/07/2023] Open
Abstract
This prospective phase I trial aimed to determine the recommended dose of 3-day total marrow and lymphoid irradiation (TMLI) for a myeloablative conditioning regimen by increasing the dose per fraction. The primary end-point of this single-institution dose escalation study was the recommended TMLI dose based on the frequency of dose-limiting toxicity (DLT) ≤100 days posthematopoietic stem cell transplantation (HSCT); a 3 + 3 design was used to evaluate the safety of TMLI. Three dose levels of TMLI (14/16/18 Gy in six fractions over 3 days) were set. The treatment protocol began at 14 Gy. Dose-limiting toxicities were defined as grade 3 or 4 nonhematological toxicities. Nine patients, with a median age of 42 years (range, 35-48), eight with acute lymphoblastic leukemia and one with chronic myeloblastic leukemia, received TMLI followed by unrelated bone marrow transplant. The median follow-up period after HSCT was 575 days (range, 253-1037). Three patients were enrolled for each dose level. No patient showed DLT within 100 days of HSCT. The recommended dose of 3-day TMLI was 18 Gy in six fractions. All patients achieved neutrophil engraftment at a median of 19 days (range, 14-25). One-year overall and disease-free survival rates were 83.3% and 57.1%, respectively. Three patients experienced relapse, and no nonrelapse mortality was documented during the observation period. One patient died due to disease relapse 306 days post-HSCT. The recommended dose of 3-day TMLI was 18 Gy in six fractions. The efficacy evaluation of this regimen is currently being planned in a phase II study.
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Affiliation(s)
- Hiroaki Ogawa
- Division of Radiation Oncology, Department of RadiologyTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Tatsuya Konishi
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Yuho Najima
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Satoshi Kito
- Division of Radiation Oncology, Department of RadiologyTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Shimpei Hashimoto
- Division of Radiation Oncology, Department of RadiologyTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Chika Kato
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Satoshi Sakai
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Yasuhiro Kanbara
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Yuya Atsuta
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Ryosuke Konuma
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Atsushi Wada
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Daisuke Murakami
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Shiori Nakasima
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Yusuke Uchibori
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Daishi Onai
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Atsushi Hamamura
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Akihiko Nishijima
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Naoki Shingai
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Takashi Toya
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Hiroaki Shimizu
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Takeshi Kobayashi
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Kazuteru Ohashi
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Noriko Doki
- Hematology DivisionTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
| | - Keiko Nemoto Murofushi
- Division of Radiation Oncology, Department of RadiologyTokyo Metropolitan Cancer and Infectious Diseases Center, Komagome HospitalTokyoJapan
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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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9
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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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10
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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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11
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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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