Total marrow and total lymphoid irradiation in bone marrow transplantation for acute leukaemia

Wong, Jeffrey Y.C.; Filippi, Andrea Riccardo; Scorsetti, Marta; Song, Hui; Muren, L.P.; Mancosu, P.

doi:10.1016/s1470-2045(20)30342-9

Cited by 60 publications

(66 citation statements)

References 61 publications

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“…Another cohort analysis confirmed the reduced toxicity profile of IMRT-based TBI regarding pneumonitis [12]. Despite the presented advantages of modern techniques, benefits have to be weighted against an increased effort in contouring, planning and RT execution with the more conformal approaches [2]. A multi-institutional planning study on total marrow irradiation identified the lungs to be prone to variations in low-dose exposure between the different RT fractions [32].…”

Section: Discussionmentioning

confidence: 92%

“…With the widespread use of intensity-modulated radiation therapy (IMRT), a more selective targeting of lymphoid tissue and bone marrow is made possible. Total marrow and total lymphoid irradiation use IMRT, helical tomotherapy or volumetric arc therapy to avoid surrounding organs at risk (e.g., the lungs), thereby reducing toxicity while enabling dose escalation within the target volume [1,2]. A prospective adaptation of total marrow irradiation achieved a median lung dose of 7 Gy (with 97% of the patients receiving a total dose of 12-19 Gy), with a resulting pneumonitis rate of 0.7% [31].…”

Section: Discussionmentioning

confidence: 99%

“…Total body irradiation (TBI) is an effective conditioning modality before allogeneic stem cell transplantation (alloSCT) in the treatment of acute leukemias [1,2]. With its application not being influenced by either pharmacodynamic or -kinetics or blood supply, it may complement chemotherapy as a conditioning agent and address putative sanctuary sites such as the brain or testes [1,2]. This efficacy has to be carefully balanced with (long-term) side effects, of which pulmonary toxicity may impair both quality of life and survival.…”

Section: Introductionmentioning

confidence: 99%

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Pulmonary Toxicity after Total Body Irradiation—An Underrated Complication? Estimation of Risk via Normal Tissue Complication Probability Calculations and Correlation with Clinical Data

Oertel

Kittel

Martel

et al. 2021

Cancers

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Total body irradiation (TBI) is an essential part of various conditioning regimens prior to allogeneic stem cell transplantation, but is accompanied by relevant (long-term) toxicities. In the lungs, a complex mechanism induces initial inflammation (pneumonitis) followed by chronic fibrosis. The hereby presented analysis investigates the occurrence of pulmonary toxicity in a large patient collective and correlates it with data derived from normal tissue complication probability (NTCP) calculations. The clinical data of 335 hemato-oncological patients undergoing TBI were analyzed with a follow-up of 85 months. Overall, 24.8% of all patients displayed lung toxicities, predominantly pneumonia and pulmonary obstructions (13.4% and 6.0%, respectively). NTCP calculations estimated median risks to be 20.3%, 0.6% and 20.4% for overall pneumonitis (both radiological and clinical), symptomatic pneumonitis and lung fibrosis, respectively. These numbers are consistent with real-world data from the literature and further specify radiological and clinical apparent toxicity rates. Overall, the estimated risk for clinical apparent pneumonitis is very low, corresponding to the probability of non-infectious acute respiratory distress syndrome, although the underlying pathophysiology is not identical. Radiological pneumonitis and lung fibrosis are expected to be more common but require a more precise documentation by the transplantation team, radiologists and radiation oncologists.

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Section: Discussionmentioning

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Pulmonary Toxicity after Total Body Irradiation—An Underrated Complication? Estimation of Risk via Normal Tissue Complication Probability Calculations and Correlation with Clinical Data

Oertel

Kittel

Martel

et al. 2021

Cancers

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“…Incorporating CT scans into the planning phase has helped to deliver a more uniform dose [30,31]. Even though CT planning for TBI is still not uniformly used, recent studies conclude that dosimetric accuracy and optimization improve with conformal (3-dimensional) planning approaches [32,33] New and improved techniques of imaging the body, in an attempt to ensure a more uniform delivery of the desired dose, continues to be an area of investigation [34,35].…”

Section: Patient Factorsmentioning

confidence: 99%

“…Furthermore, interstitial pulmonary syndromes, an early and devastating complication of TBI, appear to have been reduced with the adoption of linear accelerators, although it is uncertain if this is due to the increased flexibility of radiation delivery permitted by linear accelerators compared to the limited options available with the cobalt machines [43]. Newer machines, such as those that use helical tomography, are being studied and deliver radiation throughout the body but can further concentrate the beam on the diseased tissue while greatly sparing the normal sensitive tissues, which may further minimize serious complications from TBI [35].…”

Section: Source Of Radiationmentioning

confidence: 99%

Total Body Irradiation for Hematopoietic Stem Cell Transplantation: What Can We Agree on?

Sabloff

Tisseverasinghe²,

Babadağli

et al. 2021

Current Oncology

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Total body irradiation (TBI), used as part of the conditioning regimen prior to allogeneic and autologous hematopoietic cell transplantation, is the delivery of a relatively homogeneous dose of radiation to the entire body. TBI has a dual role, being cytotoxic and immunosuppressive. This allows it to eliminate disease and create “space” in the marrow while also impairing the immune system from rejecting the foreign donor cells being transplanted. Advantages that TBI may have over chemotherapy alone are that it may achieve greater tumour cytotoxicity and better tissue penetration than chemotherapy as its delivery is independent of vascular supply and physiologic barriers such as renal and hepatic function. Therefore, the so-called “sanctuary” sites such as the central nervous system (CNS), testes, and orbits or other sites with limited blood supply are not off-limits to radiation. Nevertheless, TBI is hampered by challenging logistics of administration, coordination between hematology and radiation oncology departments, increased rates of acute treatment-related morbidity and mortality along with late toxicity to other tissues. Newer technologies and a better understanding of the biology and physics of TBI has allowed the field to develop novel delivery systems which may help to deliver radiation more safely while maintaining its efficacy. However, continued research and collaboration are needed to determine the best approaches for the use of TBI in the future.

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Evaluation of plan complexity and dosimetric plan quality of total marrow and lymphoid irradiation using volumetric modulated arc therapy

Lambri

Dei

Hernández

et al. 2023

J Applied Clin Med Phys

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Purpose To assess the impact of the planner's experience and optimization algorithm on the plan quality and complexity of total marrow and lymphoid irradiation (TMLI) delivered by means of volumetric modulated arc therapy (VMAT) over 2010–2022 at our institute. Methods Eighty‐two consecutive TMLI plans were considered. Three complexity indices were computed to characterize the plans in terms of leaf gap size, irregularity of beam apertures, and modulation complexity. Dosimetric points of the target volume (D2%) and organs at risk (OAR) (Dmean) were automatically extracted to combine them with plan complexity and obtain a global quality score (GQS). The analysis was stratified based on the different optimization algorithms used over the years, including a knowledge‐based (KB) model. Patient‐specific quality assurance (QA) using Portal Dosimetry was performed retrospectively, and the gamma agreement index (GAI) was investigated in conjunction with plan complexity. Results Plan complexity significantly reduced over the years (r = −0.50, p < 0.01). Significant differences in plan complexity and plan dosimetric quality among the different algorithms were observed. Moreover, the KB model allowed to achieve significantly better dosimetric results to the OARs. The plan quality remained similar or even improved during the years and when moving to a newer algorithm, with GQS increasing from 0.019 ± 0.002 to 0.025 ± 0.003 (p < 0.01). The significant correlation between GQS and time (r = 0.33, p = 0.01) indicated that the planner's experience was relevant to improve the plan quality of TMLI plans. Significant correlations between the GAI and the complexity metrics (r = −0.71, p < 0.01) were also found. Conclusion Both the planner's experience and algorithm version are crucial to achieve an optimal plan quality in TMLI plans. Thus, the impact of the optimization algorithm should be carefully evaluated when a new algorithm is introduced and in system upgrades. Knowledge‐based strategies can be useful to increase standardization and improve plan quality of TMLI treatments.

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Total marrow and total lymphoid irradiation in bone marrow transplantation for acute leukaemia

Cited by 60 publications

References 61 publications

Pulmonary Toxicity after Total Body Irradiation—An Underrated Complication? Estimation of Risk via Normal Tissue Complication Probability Calculations and Correlation with Clinical Data

Pulmonary Toxicity after Total Body Irradiation—An Underrated Complication? Estimation of Risk via Normal Tissue Complication Probability Calculations and Correlation with Clinical Data

Total Body Irradiation for Hematopoietic Stem Cell Transplantation: What Can We Agree on?

Evaluation of plan complexity and dosimetric plan quality of total marrow and lymphoid irradiation using volumetric modulated arc therapy

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