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Total body irradiation

This is a presentation on total body irradiation. This presentation explains about various techniques. positions used for TBI. Advantages and disadvantages of TBI.
It also gives an idea on Dosage and side effects.

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Total body irradiation

  1. 1. TOTAL BODY IRRADIATION BASIL PAUL SUNNY RADIOTHERAPIST
  2. 2. INTRODUCTION • TBI started using in 1956 by Dr. Donnall Thomas to treat patients with end stage leukemia • He was awarded Nobel prize for medicine in 1990 • Rationale for use of TBI not changed • Tremendous change in  Delivery of TBI  Radiation sources used – Co^60 / LINAC  Dose measure techniques- more reliable and accurate rather than erythema dose for determination of dose delivered
  3. 3. INTRODUCTION • One of main component in interdisciplinary treatment of hematological malignancies- leukemia, lymphoma, rarely solid tumors • Enables myeloablative high dose therapy (HDT) & immunoablative conditioning therapy prior to stem cell transplantation
  4. 4. TASKS OF TBI • Eradicating diseased marrow • Reducing tumor burden • Immunosuppression- lymphocyte elimination to allow grafting of donor bone marrow • Deplete the BM to allow physical space for engraftment of healthy donor marrow • Eradication of cells with genetic disorders- Fanconi’s anemia, thalassemia major, Wiskott- Aldrich syndrome
  5. 5. TBI IN CONDITIONING REGIMENS MALIGNANT 1. LUKEMIAS, ACUTE MYELOID LUKEMIA (AML) ACUTE LYMPHOBLASTIC LUKEMIA (ALL) CHRONIC MYELOID LUKEMIA (CML) HAIRY CELL LUKEMIA 2. LYMPHOMAS/ MYELOPROLIFERATIVE DISORDERS NON HODGKINS LYMPHOMAS REFRACTORY HODGKINS DISEASES MYELODYSPLASIA MULTIPLE MYELOMA
  6. 6. TBI IN CONDITIONING REGIMENS • PEDIATRIC SOLID TUMORS NEUROBLASTOMA EWINGS SARCOMA • ADULT SOLID TUMORS SMALL CELL OF LUNG TESTICULAR CARCINOMA
  7. 7. TBI IN CONDITIONING REGIMENS • NON MALIGNANT CONDITIONS IMMUNE DISORDERS APLASTIC ANEMIA GENETIC DISORDERS WISKOTT AIDRICH SYNDROME OSTEOPETEROSIS TAR SYD FANCONI ANEMIA
  8. 8. CURRENT INDICATIONS • HIGH RISK AML/CML IN FIRST REMISSION • SECOND REMISSION AML • SECOND REMISSION ALL IF THERE IS HLA COMPATIBLE SIBLING DONOR • FIRST REMISSION ALL WITH CNS INVOLVEMENT / PH CHROMOSOME POSTIVITY • LOW GRADE LYMPHOMA AFTER CHEMO FAILURE • CHILDHOOD AML/ ALL IN SECOND / SUBSEQUENT REMISSIONS
  9. 9. ADVANTAGES • No sparing of sanctuary sites (testis, brain) • Dose homogeneity regardless of blood supply • Independent of hepatic & renal functions • No problems with excretion or detoxification • Ability to tailor the dose distribution by shielding specific organs or by boosting sites
  10. 10. DISADVANTAGES • Potential late side effects Sterility Cataract Growth retardation Neurological toxicity • Patient body contour irregularities causes adding of compensators
  11. 11. PRE- REQUISITES FOR TBI • Medical history and evaluation • Interdisciplinary approach from doctors and health professionals • RT & BM transplantation facility must be in same center • Conditions with a low risk of infections is recommended
  12. 12. PHYSICAL EXAMINATION • Evaluation of oral cavity and dentition • Neurological evaluation • PS • Organ function analysis CCT> 60 ml/min AST / ALT < twice the upper level of normal PFT EF> 40% • Infectious disease evaluation • Sperm banking
  13. 13. TECHNIQUES OF TBI • Patient comfort and Reproducibility • Position of patient and stability • The common factor in the different techniques of TBI is to deliver the prescribed dose of radiation to the entire body in uniformity of +/-10% of the prescription dose. +/-5% considered as the best. IMPORTANT CRITERIAS
  14. 14. BILATERAL TBI
  15. 15. BILATERAL TBI • Designed by Khan et al • Patient sitting or lying down on a couch Good Patient comfort Less homogeneous dose distribution due to variable body thickness, needs compensating blocks.
  16. 16. AP-PA TBI
  17. 17. AP-PA TBI • Irradiated anteroposteriorly by parallel opposed fields while positioned upright several meters from the source • More homogeneous dose distribution • The principle of the technique is that the standing TBI allows shielding of certain critical organs from photons and boosting of superficial tissues in the shadow of the blocks with electrons
  18. 18. OTHER TBI TECHNIQUES MODIFIED CONVENTIONAL MACHINES • Large stationary Beam , stationary patient Extended SSD technique Collimator removal method • Moving techniques Translational beam method Sweeping beam method
  19. 19. McGill UNIVERSITY SWEEPING BEAM TECHNIQUE
  20. 20. TBI: McGill TECHNIQUE
  21. 21. TBI-IRRADIATION METHODS
  22. 22. TRANSLATIONAL COUCH Computer controlled
  23. 23. POSITION • Patient lies supine Length of patient - not more than 140 cm  If length greater than 140 cm – legs folded with pillow tucked b/n both legs • Arms flexed and placed near to chestwall • Knees adjoined together, wrapped • Positioned at extended SSD of 300 cm
  24. 24. 40 x 40 cm FieldSize, Gantry 90, Collimation 45
  25. 25. Measurements Skull Neck Shoulder Chest Abdomen Thigh Knee Calf Ankle
  26. 26. TARGET VOLUME • All malignant cells including those circulating • whole cellular immune system • The Whole Body, including Skin
  27. 27. DOSE PRESCRIPTION • High Dose TBI – 13.2 Gy in 6 fractions over 3 days • Standard dose TBI – 12 Gy in 6 fractions over 3 days • Low dose TBI – 2 Gy in single fraction • Lung is the dose-limiting organ (maximum 10 Gy).
  28. 28. DOSE REFERENCE POINTS • The dose reference point is defined at mid abdomen at the height of the umbilicus according to an international consensus
  29. 29. TREATMENT DELIVERY • Delivered in the position which measurements are taken • Under sterile conditions
  30. 30. OPTIMIZATION OF DOSE • The homogeneity of dose in the target volume • The effective sparing the lungs
  31. 31. DOSE VERIFICATION • In vivo dosimetry is done with Semiconductor diodes, mosfet, LiF TLD chips • It is placed for skull, H&N , mediastinal regions
  32. 32. 1. COMPENSATORS • Influences of irregular body contours have to be compensated. • Tissue compensators are used in Head and neck region Lower extremities and Lungs (Not required usually as effective thickness at mid mediastinum is greater than at umbilicals. Arms positioned inline with lungs and increase total thickness)
  33. 33. TBI AAPM Report 17
  34. 34. 2. BEAM SPOILER Skin/ surface doses in Megavoltage beams is less than D max Beam spoiler has to be positioned close to the patient, For build-up the surface dose up to at least 90% of the prescribed dose 1-2 cm thick acrylic is sufficient to meet these requirements .
  35. 35. 3. DOSE HOMOGENIZATION in parts of the target volume with reduced dose : • Thoracic wall receives a lower dose due to lung shielding. • Additional irradiation however is not used • Electron boost can be given if necessary
  36. 36. ACUTE COMPLICATIONS • Nausea& Vomiting • Headache • Fatigue • Ocular dryness • Esophagitis • Loss of apetite • Erythema/hyperpigmentation • Mucositis • Diarrhea • Fever
  37. 37. CHRONIC COMPLICATIONS • Ocular – Cataract, dryness, keratitis • Salivary glands – Xerostomia, dental caries, tooth abnormalities • Pneumonitis or pulmonary fibrosis • Hepatotoxicity • Radiation nephropathy • Growth abnomalities in children • Sterility and endocrine abnormalities • Secondary mets
  38. 38. Targeted TBI – TMI and TMLI • Total marrow irradiation - skeletal bone. Conditioning regimen for multiple myeloma • Total marrow and lymphoid irradiation (TMLI) - bone, major lymph node chains, liver, spleen, and sanctuary sites, such as brain. Conditioning regimen for myeloid and lymphoid leukemia
  39. 39. TOMOTHERAPY • Desirable to deliver radiation only to immune organs and bone marrow spaces sparing sensitive structures like brain, lens, lungs, kidneys • IMRT planning could accomplish this, but most systems are limited by field size issues • Accurate IMRT depends on reproducible patient position, which is complicated when considering treating the entire marrow spaces
  40. 40. TOMOTHERAPY • Tomotherapy - linear accelerator mounted in head of a spiral CT unit • IMRT delivered as beams spiral down axis of patient supine on treatment couch • The beams can be planned to deliver dose to bones and bone marrow, liver and spleen as well as major nodal groups and to relatively spare the lungs and kidneys
  41. 41. TOMOTHERAPY ISODOSE DISTRIBUTION
  42. 42. THANK YOU

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This is a presentation on total body irradiation. This presentation explains about various techniques. positions used for TBI. Advantages and disadvantages of TBI. It also gives an idea on Dosage and side effects.

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