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Effeney B, Pullar A, Burbery J, Hargrave C, Brady C. Dose to organs at risk for total body irradiation: Single-institution data using the modulated arc total body irradiation technique. Pediatr Blood Cancer 2024; 71:e31164. [PMID: 38953144 DOI: 10.1002/pbc.31164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/12/2024] [Accepted: 06/12/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Organs at risk (OAR) dose reporting for total body irradiation (TBI) patients is limited, and standardly reported only as mean doses to the lungs and kidneys. Consequently, dose received and effects on other OAR remain unexplored. To remedy this gap, this study reports dose data on an extensive list of OAR for patients treated at a single institution using the modulated arc total body irradiation (MATBI) technique. METHOD An audit was undertaken of all patients treated with MATBI between January 2015 and March 2021 who had completed their course of treatment. OAR were contoured on MATBI patient treatment plans, with 12 Gy in six fraction prescription. OAR dose statistics and dose volume histogram data are reported for the whole body, lungs, kidneys, bones, brain, lens, heart, liver and bowel bag. RESULTS The OAR dose data for 29 patients are reported. Mean dose results are body 11.77 Gy, lungs 9.86 Gy, kidneys 11.84 Gy, bones 12.03 Gy, brain 12.12 Gy, right lens 12.31 Gy, left lens 12.64 Gy, heart 11.07 Gy, liver 11.81 Gy and bowel bag 12.06 Gy. Dose statistics at 1-Gy intervals of V6-V13 for lungs and V10-V13 for kidneys are also included. CONCLUSION This is the first time an extensive list of OAR data has been reported for any TBI technique. Due to the paucity of reporting, this information could be used by centres implementing the MATBI technique, in addition to aiding comparison between TBI techniques, with the potential for greater understanding of the relationship between dose volume data and toxicity.
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Affiliation(s)
- Beth Effeney
- Radiation Oncology Princess Alexandra Hospital - Raymond Terrace, South Brisbane, Queensland, Australia
| | - Andrew Pullar
- Radiation Oncology Princess Alexandra Hospital - Raymond Terrace, South Brisbane, Queensland, Australia
| | - Julie Burbery
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cathy Hargrave
- Radiation Oncology Princess Alexandra Hospital - Raymond Terrace, South Brisbane, Queensland, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Carole Brady
- Radiation Oncology Princess Alexandra Hospital - Raymond Terrace, South Brisbane, Queensland, Australia
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Hering H, Effeney B, Brady C, Hargrave C. An evaluation of ankle and foot bolus in paediatric modulated arc total body irradiation (MATBI). J Med Radiat Sci 2024. [PMID: 38468597 DOI: 10.1002/jmrs.780] [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: 06/29/2023] [Accepted: 03/01/2024] [Indexed: 03/13/2024] Open
Abstract
INTRODUCTION This retrospective planning study aimed to evaluate the role of bolus in achieving dose uniformity in the ankles and feet in paediatric patients undergoing Modulated Arc Total Body Irradiation (MATBI) treatment and to identify patient factors that may negate or warrant its use. METHODS The clinically treated plans of 20 paediatric patients who received MATBI treatment utilising ankle and foot bolus (Bolus plan) were compared with two retrospectively generated plans; a plan with bolus removed and no re-optimisation (No Bolus plan), and a re-optimised plan without bolus attempting to achieve equal dosimetry to the clinical plan via monitor unit adjustment (MU plan). Descriptive statistics were used to evaluate the dose uniformity criteria of ±10% coverage of the reference dose (RD) for each subregion of the ankle and foot for the three plans. The impact of patient height, weight, and age at the time of treatment was evaluated using Spearman's correlation. RESULTS Variation in doses >10% RD was minimal across the three plans, with an average D1cc difference < 0.4Gy. For the ankle and foot regions in the Bolus plans, the volume receiving at least 90% of the RD (V90) was on average > 92%. In No Bolus and MU plans, there was an average reduction of 24.5% and 23.2% V90 coverage respectively in the toes. Spearman's correlation suggests height has the strongest relationship to D1cc. CONCLUSION This study validated the continued use of ankle and foot bolus to achieve dosimetric goals for paediatric MATBI treatments, particularly V90 coverage across all heights.
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Affiliation(s)
- Hannah Hering
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Radiation Oncology Princess Alexandra Hospital-Raymond Terrace, Metro South Health Service, South Brisbane, Queensland, Australia
| | - Beth Effeney
- Radiation Oncology Princess Alexandra Hospital-Raymond Terrace, Metro South Health Service, South Brisbane, Queensland, Australia
| | - Carole Brady
- Radiation Oncology Princess Alexandra Hospital-Raymond Terrace, Metro South Health Service, South Brisbane, Queensland, Australia
| | - Catriona Hargrave
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Radiation Oncology Princess Alexandra Hospital-Raymond Terrace, Metro South Health Service, South Brisbane, Queensland, Australia
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Strolin S, Paolani G, Santoro M, Cercenelli L, Bortolani B, Ammendolia I, Cammelli S, Cicoria G, Win PW, Morganti AG, Marcelli E, Strigari L. Improving total body irradiation with a dedicated couch and 3D-printed patient-specific lung blocks: A feasibility study. Front Oncol 2023; 12:1046168. [PMID: 36741733 PMCID: PMC9893493 DOI: 10.3389/fonc.2022.1046168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/16/2022] [Indexed: 01/20/2023] Open
Abstract
Introduction Total body irradiation (TBI) is an important component of the conditioning regimen in patients undergoing hematopoietic stem cell transplants. TBI is used in very few patients and therefore it is generally delivered with standard linear accelerators (LINACs) and not with dedicated devices. Severe pulmonary toxicity is the most common adverse effect after TBI, and patient-specific lead blocks are used to reduce mean lung dose. In this context, online treatment setup is crucial to achieve precise positioning of the lung blocks. Therefore, in this study we aim to report our experience at generating 3D-printed patient-specific lung blocks and coupling a dedicated couch (with an integrated onboard image device) with a modern LINAC for TBI treatment. Material and methods TBI was planned and delivered (2Gy/fraction given twice a day, over 3 days) to 15 patients. Online images, to be compared with planned digitally reconstructed radiographies, were acquired with the couch-dedicated Electronic Portal Imaging Device (EPID) panel and imported in the iView software using a homemade Graphical User Interface (GUI). In vivo dosimetry, using Metal-Oxide Field-Effect Transistors (MOSFETs), was used to assess the setup reproducibility in both supine and prone positions. Results 3D printing of lung blocks was feasible for all planned patients using a stereolithography 3D printer with a build volume of 14.5×14.5×17.5 cm3. The number of required pre-TBI EPID-images generally decreases after the first fraction. In patient-specific quality assurance, the difference between measured and calculated dose was generally<2%. The MOSFET measurements reproducibility along each treatment and patient was 2.7%, in average. Conclusion The TBI technique was successfully implemented, demonstrating that our approach is feasible, flexible, and cost-effective. The use of 3D-printed patient-specific lung blocks have the potential to personalize TBI treatment and to refine the shape of the blocks before delivery, making them extremely versatile.
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Affiliation(s)
- Silvia Strolin
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Paolani
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,*Correspondence: Giulia Paolani, ; Lidia Strigari,
| | - Miriam Santoro
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Laura Cercenelli
- eDIMES Lab-Laboratory of Bioengineering, Department of Experimental Diagnostic and Specialty Medicine, (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Barbara Bortolani
- eDIMES Lab-Laboratory of Bioengineering, Department of Experimental Diagnostic and Specialty Medicine, (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Ilario Ammendolia
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Gianfranco Cicoria
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Phyo Wai Win
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessio G. Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,Department of Experimental, Diagnostic and Specialty Medicine-DIMES, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Emanuela Marcelli
- eDIMES Lab-Laboratory of Bioengineering, Department of Experimental Diagnostic and Specialty Medicine, (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy,*Correspondence: Giulia Paolani, ; Lidia Strigari,
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Kovalchuk N, Simiele E, Skinner L, Yang Y, Howell N, Lewis J, Hui C, Blomain ES, Hoppe RT, Hiniker SM. The Stanford VMAT TBI Technique. Pract Radiat Oncol 2022; 12:245-258. [PMID: 35182803 DOI: 10.1016/j.prro.2021.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE In this work, we describe the technical aspects of the XXX VMAT TBI technique, compare it to other VMAT TBI techniques, and share our initial experience. METHODS From September 2019 to August 2021, 35 patients were treated with VMAT TBI at our institution. Treatment planning was performed using in-house developed automated planning scripts. Organ sparing depended on the regimen: myeloablative (lungs, kidneys, and lenses); non-myeloablative with benign disease (lungs, kidneys, lenses, gonads, brain, and thyroid). Quality assurance was performed using EPID portal dosimetry and Mobius3D. Robustness was evaluated for the first ten patients by performing local and global isocenter shifts of 5 mm. Treatment was delivered using IGRT for every isocenter and every fraction. In-vivo measurements were performed on the matchline between the VMAT and AP/PA fields and on the testes for the first fraction. RESULTS The lungs, lungs-1cm, and kidneys Dmean were consistently spared to 57.6±4.4%, 40.7±5.5%, and 70.0±9.9% of the prescription dose, respectively. Gonadal sparing (Dmean=0.69±0.13 Gy) was performed for all patients with benign disease. The average PTV D1cc was 120.7±6.4% for all patients. The average Gamma passing rate for the VMAT plans was 98.1±1.6% (criteria of 3%/2mm). Minimal differences were observed between Mobius3D- and EclipseAAA-calculated PTV Dmean (0.0±0.3%) and lungs Dmean (-2.5±1.2%). Robustness evaluation showed that the PTV Dmax and lungs Dmean are insensitive to small positioning deviations between the VMAT isocenters (1.1±2.4% and 1.2±1.0%, respectively). The average matchline dose measurement indicated patient setup was reproducible (96.1±4.5% relative to prescription dose). Treatment time, including patient setup and beam-on, was 47.5±9.5 min. CONCLUSIONS The XXX VMAT TBI technique, from simulation to treatment delivery, was presented and compared to other VMAT TBI techniques. Together with publicly shared autoplanning scripts, our technique may provide the gateway for wider adaptation of this technology and the possibility of multi-institutional studies in the cooperative group setting.
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Affiliation(s)
- Nataliya Kovalchuk
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Eric Simiele
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Lawrie Skinner
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Yong Yang
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Nicole Howell
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Jonathan Lewis
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Caressa Hui
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Erik S Blomain
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Richard T Hoppe
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, California 94305, United States.
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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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6
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Aldrovandi LG, Farías RO, Mauri MF, Mairal ML. Commissioning of a three-dimensional arc-based technique for total body irradiation. J Appl Clin Med Phys 2021; 22:123-142. [PMID: 34258860 PMCID: PMC8425872 DOI: 10.1002/acm2.13355] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/25/2021] [Accepted: 06/16/2021] [Indexed: 11/24/2022] Open
Abstract
The purpose of this study is to describe the commissioning of a novel three‐dimensional arc‐based technique for total body irradiation (TBI) treatments. The development and implementation of this technique allowed our institution to transition from a bilateral two‐dimensional (2D) technique to a methodology based on volumetric dose calculation. The methodology described in this work is a derivation from the MATBI technique, with the static fields being replaced by four contiguous arc‐fields for each anterior and posterior incidence. The reduced number of fields we employed makes it possible to reach a satisfactory dose uniformity through manual optimization in a straightforward process. We use the Eclipse anisotropic analytical algorithm (AAA) algorithm, commissioned with preconfigured beam data for a 6 MV photon beam, at standard SSD (100 cm). A thorough evaluation of the accuracy of the AAA algorithm at an extended distance (approximately 200 cm) was carried out. For the evaluation, we compared measured and calculated percentage depth–dose and profiles that included open‐field, penumbra, and out‐of‐field regions. The analysis was performed for both static and arc fields, taking into consideration unshielded fields and also in the presence of lung shielding blocks. End‐to‐end tests were carried out for our institutional template plan by two means: with a 2D ion chamber array detector in solid phantom and using Gafchromic films in an anthropomorphic phantom. The results obtained in this work demonstrate that the Eclipse AAA algorithm commissioned for standard treatments can be safely used with our TBI planning technique. Moreover, this technique proved to be a highly efficient path to replace conventional treatment techniques, providing a homogeneous dose distribution, dosimetric robustness, and shorter treatment times. In addition, as inherited from the MATBI technique, our methodology can be implemented in small treatment rooms, with no need for ancillary equipment.
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Affiliation(s)
- León G Aldrovandi
- Departamento de Física Médica, Mevaterapia Oncología Radiante, Ciudad Autónoma de Buenos Aires, Argentina
| | - Rubén O Farías
- Departamento de Física Médica, Mevaterapia Oncología Radiante, Ciudad Autónoma de Buenos Aires, Argentina
| | - María F Mauri
- Departamento de Física Médica, Mevaterapia Oncología Radiante, Ciudad Autónoma de Buenos Aires, Argentina
| | - María L Mairal
- Departamento de Física Médica, Mevaterapia Oncología Radiante, Ciudad Autónoma de Buenos Aires, Argentina
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Stanley D, McConnell K, Iqbal Z, Everett A, Dodson J, Keene K, McDonald A. Dosimetric Evaluation Between the Conventional Volumetrically Modulated Arc Therapy (VMAT) Total Body Irradiation (TBI) and the Novel Simultaneous Integrated Total Marrow Approach (SIMBa) VMAT TBI. Cureus 2021; 13:e15646. [PMID: 34306856 PMCID: PMC8279336 DOI: 10.7759/cureus.15646] [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] [Accepted: 06/12/2021] [Indexed: 11/05/2022] Open
Abstract
Purpose The purpose of this study was to assess the treatment planning feasibility of volumetrically modulated arc therapy total body irradiation (VMAT TBI) using a simultaneous integrated marrow and body approach (SIMBa). We also aimed to compare SIMBa TBI with the more conventional VMAT TBI approach using the entire body as the target. The goal of using an integrated approach like SIMBa is to balance the known clinical benefit of TBI with the toxicity decrease of Total Marrow Irradiation (TMI) using two prescription volumes. In anticipation of a clinical trial to investigate a novel conditioning regimen that uses SIMBa, our institution retrospectively analyzed the dosimetric differences between 20 clinical VMAT TBI which were re-planned using SIMBa. Methods Twenty patients who previously received conventional VMAT TBI at our institution with a dose of 12 Gy in six fractions were re-planned using SIMBa with a planning aim of delivering a uniform dose of 12 Gy to at least 90% of the PTV_BodyEval. The planning aims of SIMBa were to deliver a uniform dose of 12 Gy to at least 90% of the PTV_Marrow and 8 Gy to at least 90% of the PTV_TotalBody while limiting the mean lung dose to less than 8 Gy. The plans were normalized so that 100% of the PTV_Marrow received at least 90% of the dose with the PTV_TotalBody optimized to stay as close to 100% at 90% as possible. Results All 20 patient plans achieved 12 Gy/8 Gy to at least 90% of the PTV_Marrow and PTV_TotalBody, respectively, with max doses of <16 Gy (130%). As compared with the delivered TBI, the following reductions in mean dose were notable: small bowel 21.3±4.2%, lung 16.3±7.9%, heart 25.3±8.6%, and kidney 16.4±6.2%. Coverage of the sanctuary sites was maintained despite a significant reduction to sensitive organs at risk (OARs). Conclusion This study supports that VMAT TBI treatment planning with SIMBa is feasible. In this sample, SIMBa provided dosimetrically similar doses to marrow and sanctuary site doses as TBI while achieving lower doses to OARs. A clinical trial is needed to investigate the clinical implications of VMAT TBI with SIMBa.
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Affiliation(s)
- Dennis Stanley
- Radiation Oncology, The University of Alabama at Birmingham, Birmingham, USA
| | - Kristen McConnell
- Radiation Oncology/Medical Physics, The University of Alabama at Birmingham, Birmingham, USA
| | - Zohaib Iqbal
- Radiation Oncology/Medical Physics, The University of Alabama at Birmingham, Birmingham, USA
| | - Ashlyn Everett
- Radiation Oncology, The University of Alabama at Birmingham, Birmingham, USA
| | - Jonathan Dodson
- Radiation Oncology, The University of Alabama at Birmingham, Birmingham, USA
| | - Kimberly Keene
- Radiation Oncology, The University of Alabama at Birmingham, Birmingham, USA
| | - Andrew McDonald
- Radiation Oncology, The University of Alabama at Birmingham, Birmingham, USA
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Simiele E, Skinner L, Yang Y, Blomain ES, Hoppe RT, Hiniker SM, Kovalchuk N. A Step Toward Making VMAT TBI More Prevalent: Automating the Treatment Planning Process. Pract Radiat Oncol 2021; 11:415-423. [PMID: 33711488 DOI: 10.1016/j.prro.2021.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/08/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
PURPOSE Our purpose was to automate the treatment planning process for total body irradiation (TBI) with volumetric modulated arc therapy (VMAT). METHODS AND MATERIALS Two scripts were developed to facilitate autoplanning: the binary plug-in script automating the creation of optimization structures, plan generation, beam placement, and setting of the optimization constraints and the stand-alone executable performing successive optimizations. Ten patients previously treated in our clinic with VMAT TBI were used to evaluate the efficacy of the proposed autoplanning process. Paired t tests were used to compare the dosimetric indices of the produced auto plans to the manually generated clinical plans. In addition, 3 physicians were asked to evaluate the manual and autoplans for each patient in a blinded retrospective review. RESULTS No significant differences were observed between the manual and autoplan global Dmax (P < .893), planning target volume V110% (P < .734), kidneys Dmean (P < .351), and bowel Dmax (P < .473). Significant decreases in the Dmean to the lungs and lungs-1cm (ie, lungs with 1-cm inner margin) volumes of 5.4% ± 6.4% (P < .024) and 6.8% ± 7.4% (P < .017), respectively, were obtained with the autoplans compared with the manual plans. The autoplans were selected 77% of the time by the reviewing physicians as equivalent or superior to the manual plans. The required time for treatment planning was estimated to be 2 to 3 days for the manual plans compared with approximately 3 to 5 hours for the autoplans. CONCLUSIONS Large reductions in planning time without sacrificing plan quality were obtained using the developed autoplanning process compared with manual planning, thus reducing the required effort of the treatment planning team. Superior lung sparing with the same target coverage and similar global Dmax were observed with the autoplans as compared with the manual treatment plans. The developed scripts have been made open-source to improve access to VMAT TBI at other institutions and clinics.
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Affiliation(s)
- E Simiele
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - L Skinner
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Y Yang
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - E S Blomain
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - R T Hoppe
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - S M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - N Kovalchuk
- Department of Radiation Oncology, Stanford University, Stanford, California.
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9
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Effeney B, Biggs J, Brady C, Pemberton M, Sim L, Pullar A. Considerations and adaptions to the modulated arc total body irradiation technique: dosimetry description. J Med Radiat Sci 2019; 66:284-291. [PMID: 31696648 PMCID: PMC6920691 DOI: 10.1002/jmrs.363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 09/05/2019] [Accepted: 09/29/2019] [Indexed: 12/25/2022] Open
Abstract
Total body irradiation (TBI) is a complex treatment technique, which has been slow to transition to a three-dimensional (3D) planning approach. There is limited literature available providing a detailed description on methods to plan TBI on a 3D planning system. 3D planning using the modulated arc TBI (MATBI) technique is a complex process involving a significant number of quality assurance processes and scripts, due to more than 40 treatment beams and two patient positions. This article will focus on the workflow and technical planning aspects of our institution's MATBI technique and identify reasons for modifications made to the developing institution's original MATBI approach. Included is a description of specific simulation equipment, detailed explanation of the four-stage computing process including the role of scripting to standardise and streamline what is otherwise a complex number of steps. The information provided is specific to one centre's approach but shows the fundamental planning process and demonstrates a streamlined method, which can be adapted to other planning systems. Overall, the ability to accurately represent the TBI technique in 3D on a planning system will be shown.
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Affiliation(s)
- Beth Effeney
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Jennifer Biggs
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Carole Brady
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Melanie Pemberton
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Lucy Sim
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Andrew Pullar
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
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Gieger TL, Nolan MW, Roback DM, Suter SE. Implementation of total body photon irradiation as part of an institutional bone marrow transplant program for the treatment of canine lymphoma and leukemias. Vet Radiol Ultrasound 2019; 60:586-593. [PMID: 31146304 DOI: 10.1111/vru.12776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/27/2022] Open
Abstract
A total body irradiation (TBI) protocol was developed to support a bone marrow transplant (BMT) program for the treatment of canine hematologic malignancies. The purpose of this prospective study is to describe implementation of the protocol and resultant dosimetry. Nongraphic manual treatment planning using 6 MV photons, isocentric delivery, 40 × 40 cm field size, wall-mounted lasers to verify positioning, a lucite beam spoiler (without use of bolus material), a dose rate of 8.75 cGy/min at patient isocenter, and a source-to-axis distance of 338 cm were used for TBI. A monitor unit calculation formula was derived using ion chamber measurements and a solid water phantom. Five thermoluminescent dosimeters (TLDs) were used at various anatomic locations in each of four cadaver dogs, to verify fidelity of the monitor unit formula prior to clinical implementation. In vivo dosimetric data were then collected with five TLDs at various anatomic locations in six patients treated with TBI. A total dose of 10 Gy divided into two 5 Gy fractions was delivered approximately 16 h apart, immediately followed by autologous stem cell transplant. The mean difference between prescribed and delivered doses ranged from 99% to 109% for various sites in cadavers, and from 83% to 121% in clinical patients. The mean total body dose in cadavers and clinical patients when whole body dose was estimated by averaging doses measured by variably placed TLDs ranged from 98% to 108% and 93% to 102% of the prescribed dose, respectively, which was considered acceptable. This protocol could be used for institutional implementation of TBI.
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Affiliation(s)
- Tracy L Gieger
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina.,Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Michael W Nolan
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina.,Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina.,Duke Cancer Institute, Durham, North Carolina
| | - Donald M Roback
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina.,Rex Cancer Center - UNC Rex Healthcare, Raleigh, North Carolina
| | - Steven E Suter
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina.,Comparative Medicine Institute, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina.,Duke Cancer Institute, Durham, North Carolina.,Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
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Pemberton M, Brady C, Taylor B, Tyrrell D, Sim L, Zawlodzka‐Bednarz S, Biggs J, Peters M, Baines J, Hargrave C. Modification of a modulated arc total body irradiation technique: Implementation and first clinical experience for paediatric patients. J Med Radiat Sci 2018; 65:291-299. [PMID: 30230247 PMCID: PMC6275264 DOI: 10.1002/jmrs.305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 08/03/2018] [Accepted: 08/16/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION To implement the modulated arc total body irradiation (MATBI) technique within the existing infrastructure of a radiation oncology department. The technique needed to treat paediatric patients of all ages, some of whom would require general anaesthesia (GA). METHODS The MATBI technique required minor modifications to be incorporated within existing departmental infrastructure. Ancillary equipment essential to the technique were identified and in some cases custom designed to meet health and safety criteria. GA equipment was also considered. To evaluate the effectiveness of the implemented technique, an audit of the cases clinically treated was conducted. RESULTS A motorised treatment couch was designed to allow the patient to be positioned in stabilisation equipment at a height, then lowered to the floor to accommodate source-to-skin-distances from 180 cm to 198 cm to treat the fixed 40 cm × 40 cm field size. Treatment couch design also facilitated positioning of the bespoke two-part spoiler. While organ at risk dose is limited using a beam weight optimisation technique, the dose is further reduced using compensators placed close to the patient's skin on a 3D printed custom-made support bridge. A digital radiography system is used to verify compensator position. Fifteen patients have been treated to date for various diseases using a variety of dose fractionations ranging from 2 Gy in a single fraction to 12 Gy in 6 fractions. Five patients have required GA due to age or behavioural issues. CONCLUSION The modified MATBI technique and the equipment required for treatment delivery has been found to be well tolerated by all patients.
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Affiliation(s)
- Melanie Pemberton
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Carole Brady
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Beth Taylor
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Danielle Tyrrell
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Lucy Sim
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Sylwia Zawlodzka‐Bednarz
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Jennifer Biggs
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Mitchell Peters
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - John Baines
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
| | - Catriona Hargrave
- Radiation Oncology Princess Alexandra Hospital – Raymond TerraceMetro South Health Service DistrictSouth BrisbaneQueenslandAustralia
- School of Clinical SciencesFaculty of HealthQueensland University of TechnologyBrisbaneQueenslandAustralia
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Park SY, Kim JI, Joo YH, Lee JC, Park JM. Total body irradiation with a compensator fabricated using a 3D optical scanner and a 3D printer. Phys Med Biol 2017; 62:3735-3756. [PMID: 28327469 DOI: 10.1088/1361-6560/aa6866] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We propose bilateral total body irradiation (TBI) utilizing a 3D printer and a 3D optical scanner. We acquired surface information of an anthropomorphic phantom with the 3D scanner and fabricated the 3D compensator with the 3D printer, which could continuously compensate for the lateral missing tissue of an entire body from the beam's eye view. To test the system's performance, we measured doses with optically stimulated luminescent dosimeters (OSLDs) as well as EBT3 films with the anthropomorphic phantom during TBI without a compensator, conventional bilateral TBI, and TBI with the 3D compensator (3D TBI). The 3D TBI showed the most uniform dose delivery to the phantom. From the OSLD measurements of the 3D TBI, the deviations between the measured doses and the prescription dose ranged from -6.7% to 2.4% inside the phantom and from -2.3% to 0.6% on the phantom's surface. From the EBT3 film measurements, the prescription dose could be delivered to the entire body of the phantom within ±10% accuracy, except for the chest region, where tissue heterogeneity is extreme. The 3D TBI doses were much more uniform than those of the other irradiation techniques, especially in the anterior-to-posterior direction. The 3D TBI was advantageous, owing to its uniform dose delivery as well as its efficient treatment procedure.
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Affiliation(s)
- So-Yeon Park
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea. Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul 03080, Republic of Korea. Biomedical Research Institute, Seoul National University Hospital, Seoul 03080, Republic of Korea. Center for Convergence Research on Robotics, Advanced Institutes of Convergence Technology, Suwon 16229, Republic of Korea
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Polednik M, Lohr F, Ehmann M, Wenz F. Accelerating total body irradiation with large field modulated arc therapy in standard treatment rooms without additional equipment. Strahlenther Onkol 2015; 191:869-74. [PMID: 26276407 DOI: 10.1007/s00066-015-0883-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 07/25/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to develop a generic and ultra-efficient modulated arc technique for treatment with total body irradiation (TBI) without additional equipment in standard treatment rooms. METHODS A continuous gantry arc between 300° and 70° composed of 26 subarcs (5° per subarc) using a field size of 40 × 40 cm(2) was used to perform the initial beam data measurements. The profile was measured parallel to the direction of gantry rotation at a constant depth of 9 cm (phantom thickness 18 cm). Beam data were measured for single 5° subarcs, dissecting the individual contribution of each subarc to a certain measurement point. The phantom was moved to 20 measurement positions along the profile. Then profile optimization was performed manually by varying the weighting factors of all segments until calculated doses at all points were within ± 1 %. Finally, the dose distribution of the modulated arc was verified in phantom thicknesses of 18 and 28 cm. RESULTS The measured profile showed a relative mean dose of 99.7 % [standard deviation (SD) 0.7 %)] over the length of 200 cm at a depth of 9 cm. The measured mean effective surface dose (at a depth of 2 cm) was 102.7 % (SD 2.1 %). The measurements in the 28 cm slab phantom revealed a mean dose of 95.9 % (SD 2.9 %) at a depth of 14 cm. The mean dose at a depth of 2 cm was 111.9 % (SD 4.1 %). Net beam-on-time for a 2 Gy fraction is approximately 8 min. CONCLUSION This highly efficient modulated arc technique for TBI can replace conventional treatment techniques, providing a homogeneous dose distribution, dosimetric robustness, extremely fast delivery, and applicability in small treatment rooms, with no need for additional equipment.
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Affiliation(s)
- Martin Polednik
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
| | - Frank Lohr
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Michael Ehmann
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
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Total body irradiation with step translation and dynamic field matching. BIOMED RESEARCH INTERNATIONAL 2013; 2013:216034. [PMID: 23956971 PMCID: PMC3713376 DOI: 10.1155/2013/216034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 05/31/2013] [Indexed: 11/18/2022]
Abstract
The purpose of this study is to develop a total body irradiation technique that does not require additional devices or sophisticated processes to overcome the space limitation of a small treatment room. The technique aims to deliver a uniform dose to the entire body while keeping the lung dose within the tolerance level. The technique treats the patient lying on the floor anteriorly and posteriorly. For each AP/PA treatment, two complementary fields with dynamic field edges are matched over an overlapped region defined by the marks on the body surface. A compensator, a spoiler, and lung shielding blocks were used during the treatment. Moreover, electron beams were used to further boost the chest wall around the lungs. The technique was validated in a RANDO phantom using GAFCHROMIC films. Dose ratios at different body sites along the midline ranged from 0.945 to 1.076. The dose variation in the AP direction ranged from 96.0% to 104.6%. The dose distribution in the overlapped region ranged from 98.5% to 102.8%. Lateral dose profiles at abdomen and head revealed 109.8% and 111.7% high doses, respectively, at the body edges. The results confirmed that the technique is capable of delivering a uniform dose distribution to the midline of the body in a small treatment room while keeping the lung dose within the tolerance level.
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