Practice Patterns of Pediatric Total Body Irradiation Techniques: A Children's Oncology Group Survey

Rassiah, Prema; Esiashvili, Natia; Olch, Arthur J.; Hua, C.; Ulin, Ken; Molineu, A.; Marcus, Karen J.; Gopalakrishnan, Mahesh; Pillai, S.; Kovalchuk, Nataliya; Liu, An; Niyazov, Greg; Peñagarícano, José; Cheung, Fanny M.; Olson, Adam C.; Wu, Cheng‐Chia; Malhotra, H; MacEwan, Iain; Faught, Jacqueline T; Breneman, John C.; Followill, David S; Fitzgerald, Thomas J.; Kalapurakal, John A.

doi:10.1016/j.ijrobp.2021.07.1715

Cited by 14 publications

(32 citation statements)

References 26 publications

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“…All of these difficulties are compounded by the fact that many institutional TBI protocols included numerous temporal adjustments to planning and delivery as well as to the dose-time-fractionation regimens used, which further hamper direct comparisons of disease control and toxicity between series. The lack of consistency in practise patterns, dosimetry and reporting of TBI doses among institutions is documented in the recent surveys of practise patterns of paediatric TBI from the European Society for Paediatric Oncology (SIOPE) and Children's Oncology Group (COG) ( 27 , 28 ). As a result of these obstacles, much of the radiobiological rationale for current TBI regimens is derived from in vitro or experimental animal studies, many dating back to the 1970s and 1980s, and only supported qualitatively by clinical data.…”

Section: Immunosuppressive and Anti-leukaemic Effects Of Tbimentioning

confidence: 99%

“…The FORUM trial delivered a conditioning of etoposide combined with TBI as a 6 times 2 Gy TBI schedule given over 3 days and lung shielding at 10 Gy ( 19 ). For the moment, fractionated TBI schedules giving doses of 12–14 Gy with lung shielding have been adopted as optimal schedules in ALL HSCT by many paediatric radiation oncology centres ( 27 , 28 ). Nonetheless, continuous reassessment of TBI optimization is needed as pre-HSCT factors improve and new combinations of chemotherapy with lower doses of TBI are researched ( 98 , 99 ).…”

Section: Clinical Data On Tbi Dose-fractionation Responsementioning

confidence: 99%

“…TBI practise worldwide remains varied, with radiotherapy centres typically developing site-specific setups and techniques ( 25 – 28 , 79 , 269 , 270 ). Conventional TBI is mostly delivered using extended SSD techniques ( 79 ), where the radiation beam covers a patient's entire body, and delivers a relatively low dose rate in the patient as a consequence of linear accelerator dose rate adjustability and the inverse square dose reduction with distance ( Figure 1 ).…”

Section: Setup and Planning For Conventional And Highly Conformal Tbi Techniquesmentioning

confidence: 99%

“…Gradually, studies showed decreased toxicities and equal or improved survival with fractionated TBI (22)(23)(24), and this has become the standard. However, institutions have developed site-specific TBI setups and techniques, making practises heterogeneous (25)(26)(27)(28). With technological advances, general radiation treatments have evolved into highly conformal intensity-modulated techniques delivering high doses to treatment volumes while increasingly sparing the surrounding tissues.…”

Section: Introductionmentioning

confidence: 99%

“…With technological advances, general radiation treatments have evolved into highly conformal intensity-modulated techniques delivering high doses to treatment volumes while increasingly sparing the surrounding tissues. For TBI, however, most centres still use two-dimensional (2D) conventional techniques with opposing beams that capture the entire body while shielding certain organs at risk (OAR) ( 27 , 28 ) ( Figure 1 ). This technique tends to deliver heterogeneous doses throughout the body while shielding also blocks bone marrow compartments.…”

Section: Introductionmentioning

confidence: 99%

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Total Body Irradiation in Haematopoietic Stem Cell Transplantation for Paediatric Acute Lymphoblastic Leukaemia: Review of the Literature and Future Directions

et al. 2021

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Total body irradiation (TBI) has been a pivotal component of the conditioning regimen for allogeneic myeloablative haematopoietic stem cell transplantation (HSCT) in very-high-risk acute lymphoblastic leukaemia (ALL) for decades, especially in children and young adults. The myeloablative conditioning regimen has two aims: (1) to eradicate leukaemic cells, and (2) to prevent rejection of the graft through suppression of the recipient's immune system. Radiotherapy has the advantage of achieving an adequate dose effect in sanctuary sites and in areas with poor blood supply. However, radiotherapy is subject to radiobiological trade-offs between ALL cell destruction, immune and haematopoietic stem cell survival, and various adverse effects in normal tissue. To diminish toxicity, a shift from single-fraction to fractionated TBI has taken place. However, HSCT and TBI are still associated with multiple late sequelae, leaving room for improvement. This review discusses the past developments of TBI and considerations for dose, fractionation and dose-rate, as well as issues regarding TBI setup performance, limitations and possibilities for improvement. TBI is typically delivered using conventional irradiation techniques and centres have locally developed heterogeneous treatment methods and ways to achieve reduced doses in several organs. There are, however, limitations in options to shield organs at risk without compromising the anti-leukaemic and immunosuppressive effects of conventional TBI. Technological improvements in radiotherapy planning and delivery with highly conformal TBI or total marrow irradiation (TMI), and total marrow and lymphoid irradiation (TMLI) have opened the way to investigate the potential reduction of radiotherapy-related toxicities without jeopardising efficacy. The demonstration of the superiority of TBI compared with chemotherapy-only conditioning regimens for event-free and overall survival in the randomised For Omitting Radiation Under Majority age (FORUM) trial in children with high-risk ALL makes exploration of the optimal use of TBI delivery mandatory. Standardisation and comprehensive reporting of conventional TBI techniques as well as cooperation between radiotherapy centres may help to increase the ratio between treatment outcomes and toxicity, and future studies must determine potential added benefit of innovative conformal techniques to ultimately improve quality of life for paediatric ALL patients receiving TBI-conditioned HSCT.

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Section: Immunosuppressive and Anti-leukaemic Effects Of Tbimentioning

confidence: 99%

Section: Clinical Data On Tbi Dose-fractionation Responsementioning

confidence: 99%

Section: Setup and Planning For Conventional And Highly Conformal Tbi Techniquesmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Total Body Irradiation in Haematopoietic Stem Cell Transplantation for Paediatric Acute Lymphoblastic Leukaemia: Review of the Literature and Future Directions

et al. 2021

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Total body irradiation delivered using a dedicated Co‐60 TBI unit: Evaluation of dosimetric uniformity and dose verification

Burmeister,

Bossenberger,

Nalichowski

et al. 2023

J Applied Clin Med Phys

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This work presents the dosimetric characteristics of Total Body Irradiation (TBI) delivered using a dedicated Co‐60 TBI unit. We demonstrate the ability to deliver a uniform dose to the entire patient without the need for a beam spoiler or patient‐specific compensation. Full dose distributions are calculated using an in‐house Monte Carlo treatment planning system, and cumulative dose distributions are created by deforming the dose distributions within two different patient orientations. Sample dose distributions and profiles are provided to illustrate the plan characteristics, and dose and DVH statistics are provided for a heterogeneous cohort of patients. The patient cohort includes adult and pediatric patients with a range of 132–198 cm in length and 16.5–37.5 cm in anterior‐posterior thickness. With the exception of the lungs, a uniform dose of 12 Gy is delivered to the patient with nearly the entire volume receiving a dose within 10% of the prescription dose. Mean lung doses (MLDs) are maintained below the estimated threshold for radiation pneumonitis, with MLDs ranging from 7.3 to 9.3 Gy (estimated equivalent dose in 2 Gy fractions (EQD2) of 6.2‐8.5 Gy). Dose uniformity is demonstrated across five anatomical locations within the patient for which mean doses are all within 3.1% of the prescription dose. In‐vivo dosimetry demonstrates excellent agreement between measured and calculated doses, with 78% of measurements within ±5% of the calculated dose and 99% within ±10%. These results demonstrate a state‐of‐the‐art TBI planning and delivery system using a dedicated TBI unit and hybrid in‐house and commercial planning techniques which provide comprehensive dosimetric data for TBI treatment plans that are accurately verified using in‐vivo dosimetry.

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Validation of Acuros for total body irradiation at extended distance

Nelson,

Sarkar,

Szegedi

et al. 2024

J Applied Clin Med Phys

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PurposeStandardized and accurately reported doses are essential in conventional total body irradiation (TBI), especially lung doses. This study evaluates the accuracy of the Acuros algorithm in predicting doses for extended‐distance TBI.MethodsMeasurements and calculations were done with both 6 and 18 MV. Tissue Maximum Ratio (TMR), output and off axis ratios (OAR) were measured at 200 and 500 cm source to detector distance and compared to Acuros calculated values. Two end‐to‐end tests were carried out, one with an in‐house phantom (solid water and Styrofoam) with inserted ion chambers and the other was with the Imaging and Radiation Oncology Core (IROC) TBI anthropomorphic phantom equipped with TLDs. The end‐to‐end test was done for 6 and 18 MV both with and without lung blocks. The source to midplane distance for both phantoms were at 518 and 508 cm respectively. Lung blocks were placed at the phantom surface and a beam spoiler was positioned 30 cm from the surface of the phantoms as per our clinical set up.ResultsThe agreement between measured and calculated TMR, output and off axis ratios for both 6 and 18 MV were within 2%. Ion chamber measurements in both the Styrofoam and solid water for both energies carried out with and without lung blocks were within 2% of calculated values. TLD measured doses for both 6 and 18 MV in the IROC phantom were within 5% of calculated doses which is within the uncertainty of the TLD measurement.ConclusionsThe results indicate that the clinical beam model for Acuros 16.1 commissioned at standard clinical distances is capable of calculating doses accurately at extended distances up to 500 cm.

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Practice Patterns of Pediatric Total Body Irradiation Techniques: A Children's Oncology Group Survey

Cited by 14 publications

References 26 publications

Total Body Irradiation in Haematopoietic Stem Cell Transplantation for Paediatric Acute Lymphoblastic Leukaemia: Review of the Literature and Future Directions

Total Body Irradiation in Haematopoietic Stem Cell Transplantation for Paediatric Acute Lymphoblastic Leukaemia: Review of the Literature and Future Directions

Total body irradiation delivered using a dedicated Co‐60 TBI unit: Evaluation of dosimetric uniformity and dose verification

Validation of Acuros for total body irradiation at extended distance

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