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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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Seravalli E, Bosman ME, Han C, Losert C, Pazos M, Engström PE, Engellau J, Fulcheri CPL, Zucchetti C, Saldi S, Ferrer C, Ocanto A, Hiniker SM, Clark CH, Hussein M, Misson-Yates S, Kobyzeva DA, Loginova AA, Hoeben BAW. Technical recommendations for implementation of Volumetric Modulated Arc Therapy and Helical Tomotherapy Total Body Irradiation. Radiother Oncol 2024; 197:110366. [PMID: 38830537 DOI: 10.1016/j.radonc.2024.110366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/10/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Abstract
As a component of myeloablative conditioning before allogeneic hematopoietic stem cell transplantation (HSCT), Total Body Irradiation (TBI) is employed in radiotherapy centers all over the world. In recent and coming years, many centers are changing their technical setup from a conventional TBI technique to multi-isocenter conformal arc therapy techniques such as Volumetric Modulated Arc Therapy (VMAT) or Helical Tomotherapy (HT). These techniques allow better homogeneity and control of the target prescription dose, and provide more freedom for individualized organ-at-risk sparing. The technical design of multi-isocenter/multi-plan conformal TBI is complex and should be developed carefully. A group of early adopters with conformal TBI experience using different treatment machines and treatment planning systems came together to develop technical recommendations and share experiences, in order to assist departments wishing to implement conformal TBI, and to provide ideas for standardization of practices.
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Affiliation(s)
- Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mirjam E Bosman
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Chunhui Han
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Christoph Losert
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Per E Engström
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Jacob Engellau
- Department of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Claudio Zucchetti
- Section of Medical Physics, Perugia General Hospital, Perugia, Italy
| | - Simonetta Saldi
- Section of Radiation Oncology, Perugia General Hospital, Perugia, Italy
| | - Carlos Ferrer
- Department of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Abrahams Ocanto
- Department of Radiation Oncology, San Francisco de Asís University Hospital, GenesisCare, Madrid, Spain
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Catharine H Clark
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK; Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK; Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK; Medical Physics and Bioengineering Department, University College London, London, UK
| | - Mohammad Hussein
- Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK
| | - Sarah Misson-Yates
- Medical Physics Department, Guy's and St Thomas' Hospital, London, UK; UK School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK; National Physical Laboratory, Metrology for Medical Physics Centre, London, UK
| | - Daria A Kobyzeva
- Deptartment of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Deptartment of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
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Seravalli E, Willemsen-Bosman M, Zoetelief A, Roosenboom S, Harderwijk T, Krikke L, Bol G, Kotte A, Huijboom E, van Loon K, Hoeben B. Treatment robustness of total body irradiation with volumetric modulated arc therapy. Phys Imaging Radiat Oncol 2024; 29:100537. [PMID: 38292651 PMCID: PMC10827537 DOI: 10.1016/j.phro.2024.100537] [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: 09/14/2023] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 02/01/2024] Open
Abstract
This study evaluated the robustness of multi-isocenter Volumetric Modulated Arc Therapy Total Body Irradiation dose distribution in the overlapping region between the head-first and feet-first computed tomography scans, considering the longitudinal isocenter shifts recorded during treatment delivery. For 15 out of 22 patients, the dose distribution in the overlapping region fulfilled all three the robustness criteria. The overlapping region dose distribution of the remaining 7 cases fulfilled two robustness criteria. The dose distribution was found to be robust against daily recorded longitudinal isocenter shifts, as a consequence of the patient position verification procedure, of up to 16 mm.
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Affiliation(s)
- Enrica Seravalli
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Mirjam Willemsen-Bosman
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Annelies Zoetelief
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Sanne Roosenboom
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Tessa Harderwijk
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Lean Krikke
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Gijsbert Bol
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Alexis Kotte
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Eline Huijboom
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Karel van Loon
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
| | - Bianca Hoeben
- University Medical Center Utrecht, Department of Radiation Oncology, Utrecht, The Netherlands
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Yagihashi T, Inoue T, Shiba S, Yamano A, Minagawa Y, Omura M, Inoue K, Nagata H. Impact of delivery time factor on treatment time and plan quality in tomotherapy. Sci Rep 2023; 13:12207. [PMID: 37500671 PMCID: PMC10374581 DOI: 10.1038/s41598-023-39047-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023] Open
Abstract
Delivery time factor (DTF) is a new parameter introduced by the RayStation treatment planning system for tomotherapy treatment planning. This study investigated the effects of this factor on various tomotherapy plans. Twenty-five patients with cancer (head and neck, 6; lung, 9; prostate, 10) were enrolled in this study. Helical tomotherapy plans with a field width of 2.5 cm, pitch of 0.287, and DTF of 2.0 were created. All the initial plans were recalculated by changing the DTF parameter from 1.0 to 3.0 in increments of 0.1. Then, DTF's impact on delivery efficiency and plan quality was evaluated. Treatment time and modulation factor increased monotonically with increasing DTF. Increasing the DTF by 0.1 increased the treatment time and modulation factor by almost 10%. This relationship was similar for all treatment sites. Conformity index (CI), homogeneity index, and organ at risk doses were improved compared to plans with a DTF of 1.0, except for the CI in the lung cancer case. However, the improvement in most indices ceased at a certain DTF; nevertheless, treatment time continued to increase following an increase in DTF. DTF is a critical parameter for improving the quality of tomotherapy plans.
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Affiliation(s)
- Takayuki Yagihashi
- Department of Medical Physics, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
- Graduate School of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashiogu, Arakawa-ku, Tokyo, 116-8551, Japan
| | - Tatsuya Inoue
- Department of Medical Physics, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Shintaro Shiba
- Department of Radiation Oncology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Akihiro Yamano
- Department of Medical Physics, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Yumiko Minagawa
- Department of Radiation Oncology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Motoko Omura
- Department of Radiation Oncology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Kazumasa Inoue
- Graduate School of Human Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashiogu, Arakawa-ku, Tokyo, 116-8551, Japan
| | - Hironori Nagata
- Department of Medical Physics, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
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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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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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Ladbury C, Han C, Liu A, Wong JYC. Volumetric modulated arc therapy based total marrow and lymphoid irradiation: Workflow and clinical experience. Front Oncol 2023; 12:1042652. [PMID: 36686805 PMCID: PMC9849797 DOI: 10.3389/fonc.2022.1042652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/15/2022] [Indexed: 01/07/2023] Open
Abstract
Background The aim of this study is to report historical treatment planning experience at our institution for patients receiving total marrow and lymphatic irradiation (TMLI) using volumetric modulated arc therapy (VMAT) as part of the conditioning regimen prior to hematopoietic stem cell transplant. Methods We identified a total of fifteen patients with VMAT TMLI, ten with a prescription dose of 20 Gy (targeting the skeletal bones, lymph nodes, spleen, and spinal canal, with 12 Gy to the brain and liver) and five with a prescription dose of 12-16 Gy (targeting the skeletal bones, lymph nodes, spleen, and spinal canal). Representative dosimetric parameters including total treatment time, mean and median dose, D80, and D10 (dose covering 80% and 10% of the structure volume, respectively) for targets and normal organs were extracted and compared to historical patients treated with helical tomotherapy. Results The median treatment time for the first and subsequent fractions was 1.5 and 1.1 hours, respectively. All the target volumes had a mean dose greater than the prescribed dose except the ribs, which had an average mean dose of 19.5 Gy. The skeletal bones had an average mean dose of 21.1 Gy. The brain and liver have average mean doses of 14.8 and 14.1 Gy, respectively. The mean lung dose had an average of 7.6 ± 0.6 Gy for the 20-Gy cohort. Relative to the prescription dose of 20 Gy, the average mean dose for the normal organ volumes ranged from 16.5% to 72.0%, and the average median dose for the normal organs ranged from 16.5% to 71.0%. Dosimetry for patients treated to 12-16 Gy fell within expected ranges based on historical helical tomotherapy plans. Conclusions Dosimetric data in the VMAT TMLI plans at our institution are summarized for 20 Gy and 12-16 Gy cohorts. Dose distributions and treatment times are overall similar to plans generated with helical tomotherapy. TMLI may be delivered effectively using a VMAT technique, even at escalated doses.
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Full Body Surface Coverage with Water-Equivalent Bolus as Novel Technique for Total Body Irradiation before Hematopoietic Stem Cell Transplantation in Pediatric Acute Lymphoid Leukemia. CHILDREN 2022; 9:children9111740. [DOI: 10.3390/children9111740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
Background: Total body irradiation (TBI) 2 × 2 Gy for 3 consecutive days followed by chemotherapy for conditioning pediatric patients with acute lymphoid leukemia (ALL) before bone marrow transplantation is superior to chemo-conditioning alone. The globally used anterior-posterior/posterior-anterior (AP/PA) technique is the most referable method, but volumetric modulated arc therapy (VMAT) with modern linear accelerators is more precise in terms of ensuring better dose distribution, especially for skin, and higher protection of organs at risk, resulting in less side effects. Method: For TBI, a modern VMAT technique was used. Whole-body immobilization in the supine position was performed using a vacuum mattress with a full body coverage, with a water-equivalent bolus of 1 cm thickness. The design goal was to achieve dose inhomogeneity of less than ±10%. Results: From 2020 to 2022, we performed TBI for five pediatric patients with ALL, with full body bolus and VMAT, who later received hematopoietic stem cell transplantation. No acute complications related to TBI were observed during the treatment period with a median follow-up of 1.27 (0.43–2.11) years. Conclusion: Using full body water-equivalent bolus with VMAT for TBI provides a safe method for children with a better organ sparing in the short term follow-up.
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