1
|
Cailleteau A, Maingon P, Choquet S, Bourdais R, Antoni D, Lioure B, Hulin C, Batard S, Llagostera C, Guimas V, Touzeau C, Moreau P, Mahé MA, Supiot S. Phase 1 Study of the Combination of Escalated Total Marrow Irradiation Using Helical Tomotherapy and Fixed High-Dose Melphalan (140 mg/m²) Followed by Autologous Stem Cell Transplantation at First Relapse in Multiple Myeloma. Int J Radiat Oncol Biol Phys 2023; 115:677-685. [PMID: 36174802 DOI: 10.1016/j.ijrobp.2022.09.069] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/26/2022] [Accepted: 09/11/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE A second intensification is an option at first relapse in multiple myeloma (MM) after more than 36 months of initial remission. Many conditioning regimens have been tested, with or without total body irradiation (TBI). Recently, it was found that TBI could be replaced by total marrow irradiation (TMI) using helical tomotherapy, with promising results. METHODS AND MATERIALS This study was a prospective multicenter phase 1 trial that aimed to determine the maximum tolerated dose (MTD) of TMI administered in association with melphalan 140 mg/m², followed by autologous stem cell transplantation as consolidation at first relapse in MM. Four dose levels were explored: 8 Gy, 10 Gy, 12 Gy, and 14 Gy. The dose-limiting toxicity (DLT) was defined as grade 4 neutropenia >15 days, grade 4 thrombopenia >28 days, and all other grade 4 nonhematologic toxic effects except nausea, vomiting, alopecia, mucositis, and reaction to autologous stem cell infusion. RESULTS Thirteen patients were included; only 1 DLT at the third escalated dose level (12 Gy) was observed, whereas 1 patient was treated at 14 Gy with no adverse events. The MTD was not reached. The rate of acute toxicity was low: 38% of grade 3-4 diarrhea, mucositis, or unexplained fever. Regarding the lungs, the mean dose administered was systematically less than 8 Gy. After a median follow-up of 55 months, 70% of participants were alive. Of these 13 patients, 38.5% were in very good partial response and 30.8% were in complete response. Three of them were progression-free. Six patients were long survivors, still alive after 55 months of follow-up. CONCLUSIONS Total marrow irradiation provides good results with a good tolerance profile at first relapse in MM and makes it possible to increase the dose delivered to the planning target volume while sparing organs at risk. This technique could be discussed for all regimens before auto- or allo-stem cell rescue when TBI is required.
Collapse
Affiliation(s)
- Axel Cailleteau
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes, St-Herblain, France.
| | - Philippe Maingon
- Department of Radiation Oncology, Pitié-Salpêtrière, Paris, France
| | | | - Rémi Bourdais
- Department of Radiation Oncology, Pitié-Salpêtrière, Paris, France
| | | | - Bruno Lioure
- Department of Hematology, ICANS, Strasbourg, France
| | - Cyrille Hulin
- Department of Hematology, Hôpital Haut Lévêque, University Hospital Bordeaux, Bordeaux, France
| | - Stéphanie Batard
- Department of Radiation Oncology, Institut Bergonie, Bordeaux, France
| | - Camille Llagostera
- Physics Unit, Institut de Cancérologie de l'Ouest, Nantes, St-Herblain, France
| | - Valentine Guimas
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes, St-Herblain, France
| | - Cyrille Touzeau
- Department of Hematology, University Hospital Hôtel-Dieu, Nantes, France; Nantes Université, INSERM, CNRS, Université d'Angers, CRCI2NA, Nantes, France; Site de recherche intégrée sur le cancer (SIRIC), ILIAD INCA-DGOS-Inserm U12558, Nantes, France
| | - Philippe Moreau
- Department of Hematology, University Hospital Hôtel-Dieu, Nantes, France; Site de recherche intégrée sur le cancer (SIRIC), ILIAD INCA-DGOS-Inserm U12558, Nantes, France; Nantes Université, INSERM, CNRS, Université d'Angers, CRCI2NA, Nantes, France
| | - Marc-André Mahé
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
| | - Stéphane Supiot
- Department of Radiation Oncology, Institut de Cancérologie de l'Ouest, Nantes, St-Herblain, France; Centre de Recherche en Cancérologie Nantes Angers, UMR 1232 Inserm - 6299 CNRS, Nantes, France
| |
Collapse
|
2
|
Total marrow and total lymphoid irradiation in bone marrow transplantation for acute leukaemia. Lancet Oncol 2020; 21:e477-e487. [PMID: 33002443 DOI: 10.1016/s1470-2045(20)30342-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/20/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
The use of total body irradiation as part of conditioning regimens for acute leukaemia is progressively declining because of concerns of late toxic effects and the introduction of radiation-free regimens. Total marrow irradiation and total marrow and lymphoid irradiation represent more targeted forms of radiotherapy compared with total body irradiation that have the potential to decrease toxicity and escalate the dose to the bone marrow for high-risk patients. We review the technological basis and the clinical development of total marrow irradiation and total marrow and lymphoid irradiation, highlighting both the possible advantages as well as the current roadblocks for widespread implementation among transplantation units. The exact role of total marrow irradiation or total marrow and lymphoid irradiation in new conditioning regimens seems dependent on its technological implementation, aiming to make the whole procedure less time consuming, more streamlined, and easier to integrate into the clinical workflow. We also foresee a role for computer-assisted planning, as a way to improve planning and delivery and to incorporate total marrow irradiation and total marrow and lymphoid irradiation in multi-centric phase 2-3 trials.
Collapse
|
3
|
Thiyagarajan R, Sharma DS, Kaushik S, Sawant M, Ganapathy K, Nambi Raj NA, Chilukuri S, Sundar SC, Patro KC, Manikandan A, Noufal MP, Sivaraman R, Easow J, Jalali R. Leaf open time sinogram (LOTS): a novel approach for patient specific quality assurance of total marrow irradiation. Radiat Oncol 2020; 15:236. [PMID: 33054792 PMCID: PMC7557063 DOI: 10.1186/s13014-020-01669-2] [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: 04/27/2020] [Accepted: 09/17/2020] [Indexed: 11/10/2022] Open
Abstract
There is no ideal detector-phantom combination to perform patient specific quality assurance (PSQA) for Total Marrow (TMI) and Lymphoid (TMLI) Irradiation plan. In this study, 3D dose reconstruction using mega voltage computed tomography detectors measured Leaf Open Time Sinogram (LOTS) was investigated for PSQA of TMI/TMLI patients in helical tomotherapy. The feasibility of this method was first validated for ten non-TMI/TMLI patients, by comparing reconstructed dose with (a) ion-chamber (IC) and helical detector array (ArcCheck) measurement and (b) planned dose distribution using 3Dγ analysis for 3%@3mm and dose to 98% (D98%) and 2% (D2%) of PTVs. Same comparison was extended for ten treatment plans from five TMI/TMLI patients. In all non-TMI/TMLI patients, reconstructed absolute dose was within ± 1.80% of planned and IC measurement. The planned dose distribution agreed with reconstructed and ArcCheck measured dose with mean (SD) 3Dγ of 98.70% (1.57%) and 2Dγ of 99.48% (0.81%). The deviation in D98% and D2% were within 1.71% and 4.10% respectively. In all 25 measurement locations from TMI/TMLI patients, planned and IC measured absolute dose agreed within ± 1.20%. Although sectorial fluence verification using ArcCHECK measurement for PTVs chest from the five upper body TMI/TMLI plans showed mean ± SD 2Dγ of 97.82% ± 1.27%, the reconstruction method resulted poor mean (SD) 3Dγ of 92.00% (± 5.83%), 64.80% (± 28.28%), 69.20% (± 30.46%), 60.80% (± 19.37%) and 73.2% (± 20.36%) for PTVs brain, chest, torso, limb and upper body respectively. The corresponding deviation in median D98% and D2% of all PTVs were < 3.80% and 9.50%. Re-optimization of all upper body TMI/TMLI plans with new pitch and modulation factor of 0.3 and 3 leads significant improvement with 3Dγ of 100% for all PTVs and median D98% and D2% < 1.6%. LOTS based PSQA for TMI/TMLI is accurate, robust and efficient. A field width, pitch and modulation factor of 5 cm, 0.3 and 3 for upper body TMI/TMLI plan is suggested for better dosimetric outcome and PSQA results.
Collapse
Affiliation(s)
- Rajesh Thiyagarajan
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India.,School of Advanced Sciences, VIT University, Vellore, 632014, India
| | | | - Suryakant Kaushik
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| | - Mayur Sawant
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| | - K Ganapathy
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| | - N Arunai Nambi Raj
- Centre for Biomaterials, Cellular and Molecular Theranostics (CBCMT), VIT University, Vellore, 632014, India
| | - Srinivas Chilukuri
- Department of Radiation Oncology, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| | - Sham C Sundar
- Department of Radiation Oncology, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| | - Kartikeswar Ch Patro
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| | - Arjunan Manikandan
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| | - M P Noufal
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| | - Rangasamy Sivaraman
- Department of Medical Physics, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| | - Jose Easow
- Department of Haematology, Blood and Marrow Transplantation, Apollo Speciality Hospital, Teynampet, Chennai, India
| | - Rakesh Jalali
- Department of Radiation Oncology, Apollo Proton Cancer Centre, 100 Feet Road Tharamani, Chennai, 600096, Tamil Nadu, India
| |
Collapse
|
4
|
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.
Collapse
|
5
|
Deshpande S, Xing A, Metcalfe P, Holloway L, Vial P, Geurts M. Clinical implementation of an exit detector-based dose reconstruction tool for helical tomotherapy delivery quality assurance. Med Phys 2017; 44:5457-5466. [PMID: 28737014 DOI: 10.1002/mp.12484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/04/2017] [Accepted: 07/11/2017] [Indexed: 11/08/2022] Open
Abstract
PURPOSE The aim of this study was to validate the accuracy of an exit detector-based dose reconstruction tool for helical tomotherapy (HT) delivery quality assurance (DQA). METHODS AND MATERIAL Exit detector-based DQA tool was developed for patient-specific HT treatment verification. The tool performs a dose reconstruction on the planning image using the sinogram measured by the HT exit detector with no objects in the beam (i.e., static couch), and compares the reconstructed dose to the planned dose. Vendor supplied (three "TomoPhant") plans with a cylindrical solid water ("cheese") phantom were used for validation. Each "TomoPhant" plan was modified with intentional multileaf collimator leaf open time (MLC LOT) errors to assess the sensitivity and robustness of this tool. Four scenarios were tested; leaf 32 was "stuck open," leaf 42 was "stuck open," random leaf LOT was closed first by mean values of 2% and then 4%. A static couch DQA procedure was then run five times (once with the unmodified sinogram and four times with modified sinograms) for each of the three "TomoPhant" treatment plans. First, the original optimized delivery plan was compared with the original machine agnostic delivery plan, then the original optimized plans with a known modification applied (intentional MLC LOT error) were compared to the corresponding error plan exit detector measurements. An absolute dose comparison between calculated and ion chamber (A1SL, Standard Imaging, Inc., WI, USA) measured dose was performed for the unmodified "TomoPhant" plans. A 3D gamma evaluation (2%/2 mm global) was performed by comparing the planned dose ("original planned dose" for unmodified plans and "adjusted planned dose" for each intentional error) to exit detector-reconstructed dose for all three "Tomophant" plans. Finally, DQA for 119 clinical (treatment length <25 cm) and three cranio-spinal irradiation (CSI) plans were measured with both the ArcCHECK phantom (Sun Nuclear Corp., Melbourne, FL, USA) and the exit detector DQA tool to assess the time required for DQA and similarity between two methods. RESULTS The measured ion chamber dose agreed to within 1.5% of the reconstructed dose computed by the exit detector DQA tool on a cheese phantom for all unmodified "Tomophant" plans. Excellent agreement in gamma pass rate (>95%) was observed between the planned and reconstructed dose for all "Tomophant" plans considered using the tool. The gamma pass rate from 119 clinical plan DQA measurements was 94.9% ± 1.5% and 91.9% ± 4.37% for the exit detector DQA tool and ArcCHECK phantom measurements (P = 0.81), respectively. For the clinical plans (treatment length <25 cm), the average time required to perform DQA was 24.7 ± 3.5 and 39.5 ± 4.5 min using the exit detector QA tool and ArcCHECK phantom, respectively, whereas the average time required for the 3 CSI treatments was 35 ± 3.5 and 90 ± 5.2 min, respectively. CONCLUSION The exit detector tool has been demonstrated to be faster for performing the DQA with equivalent sensitivity for detecting MLC LOT errors relative to a conventional phantom-based QA method. In addition, comprehensive MLC performance evaluation and features of reconstructed dose provide additional insight into understanding DQA failures and the clinical relevance of DQA results.
Collapse
Affiliation(s)
- Shrikant Deshpande
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW 2170, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Aitang Xing
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW 2170, Australia
| | - Peter Metcalfe
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW 2170, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Lois Holloway
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW 2170, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW 2522, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW 2006, Australia.,South West Sydney Clinical School, School of Medicine, University of NSW, Sydney, Australia
| | - Philip Vial
- Department of Medical Physics, Liverpool and Macarthur Cancer Therapy Centres and Ingham Institute, Sydney, NSW 2170, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, NSW 2006, Australia
| | - Mark Geurts
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
6
|
Hui S, Brunstein C, Takahashi Y, DeFor T, Holtan SG, Bachanova V, Wilke C, Zuro D, Ustun C, Weisdorf D, Dusenbery K, Verneris MR. Dose Escalation of Total Marrow Irradiation in High-Risk Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:1110-1116. [PMID: 28396164 PMCID: PMC5531195 DOI: 10.1016/j.bbmt.2017.04.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/04/2017] [Indexed: 11/30/2022]
Abstract
Patients with refractory leukemia or minimal residual disease (MRD) at transplantation are at increased risk of relapse. Augmentation of irradiation, especially to sites of disease (ie, bone marrow) is one potential strategy for overcoming this risk. We studied the feasibility of radiation dose escalation in high-risk patients using total marrow irradiation (TMI) in a phase I dose-escalation trial. Four pediatric and 8 adult patients received conditioning with cyclophosphamide and fludarabine in conjunction with image-guided radiation to the bone marrow at 15 Gy and 18 Gy (in 3-Gy fractions), while maintaining the total body irradiation (TBI) dose to the vital organs (lungs, hearts, eyes, liver, and kidneys) at <13.2 Gy. The biologically effective dose of TMI delivered to the bone marrow was increased by 62% at 15 Gy and by 96% at 18 Gy compared with standard TBI. Although excessive dose-limiting toxicity, defined by graft failure or excessive specific organ toxicity, was not encountered, 3 of 6 patients experienced treatment-related mortality at 18 Gy. Thus, we halted enrollment at this dose level and treated an additional 4 patients at 15 Gy. The 1- year overall survival was 42% (95% confidence interval [CI], 15%-67%) and disease-free survival was 22% (95% CI, 4%-49%). The rate of relapse was 36% (95% CI, 10%-62%), and nonrelapse mortality was 42% (95% CI, 14%-70%). This study shows that TMI dose escalation to 15 Gy is feasible with acceptable toxicity in pediatric and adult patients with high-risk leukemia undergoing umbilical cord blood and sibling donor transplantation.
Collapse
Affiliation(s)
- Susanta Hui
- Department of Therapeutic Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Claudio Brunstein
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Yutaka Takahashi
- Department of Therapeutic Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Todd DeFor
- Blood and Marrow Transplant Program, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Christopher Wilke
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Darren Zuro
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Celalettin Ustun
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kathryn Dusenbery
- Department of Therapeutic Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Michael R Verneris
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota.
| |
Collapse
|