Abstract Purpose Total marrow (and lymphoid) irradiation (TMI-TMLI) is limited by the couch travel range of modern linacs, which forces the treatment delivery to be split into two plans with opposite orientations: a head-first supine upper-body plan, and a feet-first supine lower extremities plan. A specific field junction is thus needed to obtain adequate target coverage in the overlap region of the two plans. In this study, an automatic procedure was developed for field junction creation and lower extremities plan optimization. Methods Ten patients treated with TMI-TMLI at our institution were selected retrospectively. The planning of the lower extremities was performed automatically. Target volume parameters (CTV_J‑V 98% &gt; 98%) at the junction region and several dose statistics (D 98% , D mean , and D 2% ) were compared between automatic and manual plans. The modulation complexity score (MCS) was used to assess plan complexity. Results The automatic procedure required 60–90 min, depending on the case. All automatic plans achieved clinically acceptable dosimetric results (CTV_J‑V 98% &gt; 98%), with significant differences found at the junction region, where D mean and D 2% increased on average by 2.4% ( p &lt; 0.03) and 3.0% ( p &lt; 0.02), respectively. Similar plan complexity was observed (median MCS = 0.12). Since March 2022, the automatic procedure has been introduced in our clinic, reducing the TMI-TMLI simulation-to-delivery schedule by 2 days. Conclusion The developed procedure allowed treatment planning of TMI-TMLI to be streamlined, increasing efficiency and standardization, preventing human errors, while maintaining the dosimetric plan quality and complexity of manual plans. Automated strategies can simplify the future adoption and clinical implementation of TMI-TMLI treatments in new centers. 

/pdf/automatic-planning-of-the-lower-extremities-for-total-marrow-sodp6e4j.pdf

Automatic planning of the lower extremities for total marrow irradiation using volumetric modulated arc therapy

Limited number of agents that provide protection against hematopoietic acute radiation syndrome led us to the evaluation of nitro-oleic acid (NO2OA) as a potential protector/mitigator against radiation-induced hematopoietic injury in C57/BL6 mice.NO2OA was administered before and after sub-lethal total body irradiation (TBI) and hematological parameters were evaluated 3 or 7 days after TBI.Our results show that NO2OA significantly increase bone marrow cellularity including the granulocyte-macrophage colony-forming cells and erythroid progenitors on the 3rd day after TBI. In addition, NO2OA enhanced recovery of white blood cells (lymphocytes, neutrophils, and monocytes) in peripheral blood 7 days after irradiation. These effects may be in part attributed to NO2OA-induced granulocyte colony-stimulating factor production after TBI. On the other hand, radiation-induced impairment of peripheral red blood cells, hemoglobin, and platelets were not affected with NO2OA treatment up to 7 days post TBI.In conclusion, our data show that NO2OA significantly protects hematopoiesis after irradiation, and thus showed a high potential to act as an agent for medical radiation countermeasure. 

Administration of nitro-oleic acid mitigates radiation-induced hematopoietic injury in mice.

Total marrow (lymph node) irradiation (TMI/TMLI) delivery requires more time than standard radiotherapy treatments. The patient’s extremities, through the joints, can experience large movements. The reproducibility of TMI/TMLI patients’ extremities was evaluated to find the best positioning and reduce unwanted movements. Eighty TMI/TMLI patients were selected (2013–2022). During treatment, a cone-beam computed tomography (CBCT) was performed for each isocenter to reposition the patient. CBCT-CT pairs were evaluated considering: (i) online vector shift (OVS) that matched the two series; (ii) residual vector shift (RVS) to reposition the patient’s extremities; (iii) qualitative agreement (range 1–5). Patients were subdivided into (i) arms either leaning on the frame or above the body; (ii) with or without a personal cushion for foot positioning. The Mann-Whitney test was considered (p < 0.05 significant). Six-hundred-twenty-nine CBCTs were analyzed. The median OVS was 4.0 mm, with only 1.6% of cases ranked < 3, and 24% of RVS > 10 mm. Arms leaning on the frame had significantly smaller RVS than above the body (median: 8.0 mm/6.0 mm, p < 0.05). Using a personal cushion for the feet significantly improved the RVS than without cushions (median: 8.5 mm/1.8 mm, p < 0.01). The role and experience of the radiotherapy team are fundamental to optimizing the TMI/TMLI patient setup.

/pdf/impact-of-the-extremities-positioning-on-the-set-up-k88pctse.pdf

Impact of the Extremities Positioning on the Set-Up Reproducibility for the Total Marrow Irradiation Treatment

Modern Radiation for Hematologic Stem Cell Transplantation: Total Marrow and Lymphoid Irradiation or Intensity-Modulated Radiation Therapy Total Body Irradiation.

Os cuidados paliativos e a atuação do profissional da enfermagem

Total body irradiation (TBI) is a common part of the myelo- and immuno-ablative conditioning regimen prior to an allogeneic hematopoietic stem cell transplantation (allo-HSCT). Due to concerns regarding acute and long-term complications, there is currently a decline in otherwise successfully established TBI-based conditioning regimens. Here we present an analysis of patient and treatment data with focus on survival and long-term toxicity.Patients with hematologic diseases who received TBI as part of their conditioning regimen prior to allo-HSCT at Frankfurt University Hospital between 1997 and 2015 were identified and retrospectively analyzed.In all, 285 patients with a median age of 45 years were identified. Median radiotherapy dose applied was 10.5 Gy. Overall survival at 1, 2, 5, and 10 years was 72.6, 64.6, 54.4, and 51.6%, respectively. Median follow-up of patients alive was 102 months. The cumulative incidence of secondary malignancies was 12.3% (n = 35), with hematologic malignancies and skin cancer predominating. A TBI dose ≥ 8 Gy resulted in significantly improved event-free (p = 0.030) and overall survival (p = 0.025), whereas a total dose ≤ 8 Gy and acute myeloid leukemia (AML) diagnosis were associated with significantly increased rates of secondary malignancies (p = 0.003, p = 0.048) in univariate analysis. No significant correlation was observed between impaired renal or pulmonary function and TBI dose.TBI remains an effective and well-established treatment, associated with distinct late-toxicity. However, in the present study we cannot confirm a dose-response relationship in intermediate dose ranges. Survival, occurrence of secondary malignancies, and late toxicities appear to be subject to substantial confounding in this context. 

https://link.springer.com/content/pdf/10.1007/s00066-022-01914-5.pdf

Twenty years of experience of a tertiary cancer center in total body irradiation with focus on oncological outcome and secondary malignancies

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Twenty years of experience of a tertiary cancer center in total body irradiation with focus on oncological outcome and secondary malignancies