Total body irradiation

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Total body irradiation (TBI) is a form of radiotherapy used primarily as part of the preparative regimen for haematopoietic stem cell (or bone marrow) transplantation. As the name implies, TBI involves irradiation of the entire body, though in modern practice the lungs are often partially shielded to lower the risk of radiation-induced lung injury.[1][2] Total body irradiation in the setting of bone marrow transplantation serves to destroy or suppress the recipient's immune system, preventing immunologic rejection of transplanted donor bone marrow or blood stem cells. Additionally, high doses of total body irradiation can eradicate residual cancer cells in the transplant recipient, increasing the likelihood that the transplant will be successful.

Dosage

Doses of total body irradiation used in bone marrow transplantation typically range from 10 to >12 Gy. For reference, a dose of 4.5 Gy is fatal in 50% of exposed individuals without aggressive medical care.[3] Such high total body doses are made possible by spreading the total dose out between several sessions, or "fractions," with an interval of time in between allowing other normal tissues some time to repair some of the damage caused. However, at these doses, total body irradiation both destroys the patient's bone marrow (allowing donor marrow to engraft) and kills residual cancer cells. Non-myeloablative bone marrow transplantation uses lower doses of total body irradiation, typically about 2 Gy, which do not destroy the host bone marrow but do suppress the host immune system sufficiently to promote donor engraftment.

In modern practice, total body irradiation is typically fractionated. Early research in bone marrow transplantation by E. Donnall Thomas and colleagues demonstrated that this process of splitting TBI into multiple smaller doses resulted in lower toxicity and better outcomes than delivering a single, large dose.[4][5]

Usage in other cancers

In addition to its use in bone marrow transplantation, total body irradiation has been explored as a treatment modality for high-risk Ewing sarcoma.[6] However, subsequent findings suggest that TBI in this setting causes toxicity without improving disease control,[7] and TBI is not currently used in the treatment of Ewing sarcoma outside of clinical trials.

Fertility

Total body irradiation results in female infertility in most cases, with recovery of gonadal function occurring in 10−14% of cases. The number of pregnancies observed after hematopoietic stem cell transplantation involving such as procedure is lower than 2%.[8] Fertility preservation measures mainly include cryopreservation of ovarian tissue, embryos or oocytes.

References

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  3. Department of Homeland Security Working Group on Radiological Dispersal Device (RDD) Preparedness, from the United States Department of Homeland Security. Accessed May 29, 2008.
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  5. Thomas ED, Clift RA, Hersman J, et al. (May 1982). "Marrow transplantation for acute nonlymphoblastic leukemic in first remission using fractionated or single-dose irradiation". Int. J. Radiat. Oncol. Biol. Phys. 8 (5): 817–21. PMID 7050046.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
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  8. André Tichelli, Alicia Rovó. Fertility Issues Following Hematopoietic Stem Cell Transplantation. Expert Rev Hematol. 2013;6(4):375-388.
    In turn citing:Salooja N, Szydlo RM, Socie G et al. Pregnancy outcomes after peripheral blood or bone marrow transplantation: a retrospective survey. Lancet 358(9278), 271–276(2001).