Implementation of Targeted Total Body Irradiation as a Bone Marrow Transplant Conditioning Regimen: A Review

Liu, A.; Han, Chunhui; Neylon, John

doi:10.1007/978-3-030-38692-4_2

Cited by 4 publications

(5 citation statements)

References 37 publications

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“…The TMI/TMLI treatment is delivered in supine position with immobilization devices (thermoplastic mask for head and shoulders combined with a customized vacuum pillow) [ 92 ] ( Figure 2 ). Two separate CT scans are required to cover the entire body of the patient.…”

Section: Total Marrow and Total Lymphoid Irradiationmentioning

confidence: 99%

Maintain Efficacy and Spare Toxicity: Traditional and New Radiation-Based Conditioning Regimens in Hematopoietic Stem Cell Transplantation

Dogliotti,

Levis,

Martin

et al. 2024

Cancers

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Novelty in total body irradiation (TBI) as part of pre-transplant conditioning regimens lacked until recently, despite the developments in the field of allogeneic stem cell transplants. Long-term toxicities have been one of the major concerns associated with TBI in this setting, although the impact of TBI is not so easy to discriminate from that of chemotherapy, especially in the adult population. More recently, lower-intensity TBI and different approaches to irradiation (namely, total marrow irradiation, TMI, and total marrow and lymphoid irradiation, TMLI) were implemented to keep the benefits of irradiation and limit potential harm. TMI/TMLI is an alternative to TBI that delivers more selective irradiation, with healthy tissues being better spared and the control of the radiation dose delivery. In this review, we discussed the potential radiation-associated long-term toxicities and their management, summarized the evidence regarding the current indications of traditional TBI, and focused on the technological advances in radiotherapy that have resulted in the development of TMLI. Finally, considering the most recent published trials, we postulate how the role of radiotherapy in the setting of allografting might change in the future.

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Section: Total Marrow and Total Lymphoid Irradiationmentioning

confidence: 99%

Maintain Efficacy and Spare Toxicity: Traditional and New Radiation-Based Conditioning Regimens in Hematopoietic Stem Cell Transplantation

Dogliotti,

Levis,

Martin

et al. 2024

Cancers

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“…Average dose-rates are 130-180 cGy/minute to the target and 70-90 cGy/minute to the lung. TMI and conventional TBI planning and delivery at this center require similar time and resources ( 19 ). Details regarding simulation, immobilization, planning, and treatment delivery have previously been published by Liu et al.…”

Section: Implementation Of Tmimentioning

confidence: 99%

“…Details regarding simulation, immobilization, planning, and treatment delivery have previously been published by Liu et al. ( 19 ), Han et al. ( 18 ) and Schultheiss et al.…”

Section: Implementation Of Tmimentioning

confidence: 99%

Total marrow irradiation (TMI): Addressing an unmet need in hematopoietic cell transplantation - a single institution experience review

Wong

Liu²,

Han³

et al. 2022

Front. Oncol.

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PurposeTMI utilizes IMRT to deliver organ sparing targeted radiotherapy in patients undergoing hematopoietic cell transplantation (HCT). TMI addresses an unmet need, specifically patients with refractory or relapsed (R/R) hematologic malignancies who have poor outcomes with standard HCT regimens and where attempts to improve outcomes by adding or dose escalating TBI are not possible due to increased toxicities. Over 500 patients have received TMI at this center. This review summarizes this experience including planning and delivery, clinical results, and future directions.MethodsPatients were treated on prospective allogeneic HCT trials using helical tomographic or VMAT IMRT delivery. Target structures included the bone/marrow only (TMI), or the addition of lymph nodes, and spleen (total marrow and lymphoid irradiation, TMLI). Total dose ranged from 12 to 20 Gy at 1.5-2.0 Gy fractions twice daily.ResultsTrials demonstrate engraftment in all patients and a low incidence of radiation related toxicities and extramedullary relapses. In R/R acute leukemia TMLI 20 Gy, etoposide, and cyclophosphamide (Cy) results in a 1-year non-relapse mortality (NRM) rate of 6% and 2-year overall survival (OS) of 48%; TMLI 12 Gy added to fludarabine (flu) and melphalan (mel) in older patients (≥ 60 years old) results in a NRM rate of 33% comparable to flu/mel alone, and 5-year OS of 42%; and TMLI 20 Gy/flu/Cy and post-transplant Cy (PTCy) in haplo-identical HCT results in a 2-year NRM rate of 13% and 1-year OS of 83%. In AML in complete remission, TMLI 20 Gy and PTCy results in 2-year NRM, OS, and GVHD free/relapse-free survival (GRFS) rates of 0%, 86·7%, and 59.3%, respectively.ConclusionTMI/TMLI shows significant promise, low NRM rates, the ability to offer myeloablative radiation containing regimens to older patients, the ability to dose escalate, and response and survival rates that compare favorably to published results. Collaboration between radiation oncology and hematology is key to successful implementation. TMI/TMLI represents a paradigm shift from TBI towards novel strategies to integrate a safer and more effective target-specific radiation therapy into HCT conditioning beyond what is possible with TBI and will help expand and redefine the role of radiotherapy in HCT.

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“…Las dosis altas en OAR pueden causar importantes efectos secundarios; en diferentes estudios se han reportado cataratas, retraso en el crecimiento debido a disfunción en la secreción de la hormona del crecimiento y, lo más frecuente, neumonitis [6,7]. Considerando que en Colombia la leucemia es el tipo de cáncer con mayor tasa de incidencia en niños, con 582 casos nuevos anualmente [8], es complejo evitar los efectos secundarios de la TBI.…”

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“…Debido a que con los métodos convencionales de TBI no se pueden administrar dosis altas de radiación sin aumentar la toxicidad de los tejidos normales, se han implementado técnicas de VMAT para TBI, que pueden entregar dosis altas con una distribución que logra cumplir con las restricciones de dosis establecidas por el equipo médico para diferentes órganos [7]. Considerando que la VMAT recurre a algoritmos para optimizar y aplicar dosis en un tratamiento de radioterapia de intensidad modulada con rotaciones continuas en arco alrededor del paciente [12,13], se han reportado diferentes resultados respecto a una disminución significativa de la dosis en OAR.…”

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Estudio preliminar de la aplicación de la técnica VMAT en irradiación corporal total: diseño de una camilla rotable

Simbaqueba

Rodrı́guez

et al. 2022

rev. investig. apl. nucl.

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La irradiación corporal total (TBI, por sus siglas en inglés) es una terapia previa al trasplante de médula ósea en la que se administra una dosis de radiación uniforme en todo el cuerpo del paciente, que busca minimizar la dosis entregada en diferentes órganos como pulmones y, en algunas ocasiones, riñones [1]. En Colombia la TBI con rayos X generados por acelerador lineal se realiza con la técnica convencional, en la cual el paciente mantiene una posición anatómica de pie, fetal o decúbito lateral durante tiempos de irradiación prolongados, lo cual implica que la posición de tratamiento para el paciente sea incómoda y poco reproducible; adicionalmente su implementación requiere distancias fuente/paciente de hasta 4 metros y la construcción de protecciones personalizadas [2]. Con el fin de superar estas dificultades, el Instituto Nacional de Cancerología (INC) tiene el objetivo de desarrollar un protocolo para administrar la TBI empleando arcoterapia volumétrica de intensidad modulada (VMAT). Con esta técnica de optimización inversa se ha reportado una entrega de dosis de radiación más uniforme en todo el cuerpo del paciente en comparación con la técnica convencional, y una reducción de la dosis recibida por los órganos en riesgo (OAR) [3]; adicionalmente su implementación no requiere grandes áreas en la sala de tratamiento, ya que se realiza a distancias estándar fuente/isocentro. En este artículo se presenta un estudio preliminar del protocolo de TBI/VMAT y su validación, mediante el empleo de un simulador anatómico CIRS: la construcción de una camilla rotable para ser superpuesta a la mesa del acelerador y tomógrafo, que facilita el cambio de orientación craneocaudal del paciente a caudocraneal durante el tratamiento, recomendaciones para la inmovilización del paciente sobre la camilla rotable, la obtención de imágenes de tomografía computarizada de cuerpo completo mediante fusión de imágenes parciales, la planeación del tratamiento con múltiples isocentros y múltiples arcos para el cálculo de la dosis absorbida y la verificación del tratamiento con superposiciones de medidas de dosis en el software SNC Patient tomadas con detectores en el dispositivo ArcCheck en diferentes orientaciones.

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Implementation of Targeted Total Body Irradiation as a Bone Marrow Transplant Conditioning Regimen: A Review

Cited by 4 publications

References 37 publications

Maintain Efficacy and Spare Toxicity: Traditional and New Radiation-Based Conditioning Regimens in Hematopoietic Stem Cell Transplantation

Maintain Efficacy and Spare Toxicity: Traditional and New Radiation-Based Conditioning Regimens in Hematopoietic Stem Cell Transplantation

Total marrow irradiation (TMI): Addressing an unmet need in hematopoietic cell transplantation - a single institution experience review

Estudio preliminar de la aplicación de la técnica VMAT en irradiación corporal total: diseño de una camilla rotable

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