title: Image-guided total-marrow irradiation using helical tomotherapy in patients with multiple myeloma and acute leukemia undergoing hematopoietic cell transplantation.
abstract: OBJECTIVE
  Total-body irradiation (TBI) has an important role in patients undergoing hematopoietic cell transplantation (HCT), but is associated with significant toxicities. Targeted TBI using helical tomotherapy results in reduced doses to normal organs, which predicts for reduced toxicities compared with standard TBI.
  
  
  METHODS
  Thirteen patients with multiple myeloma were treated in an autologous tandem transplantation Phase I trial with high-dose melphalan, followed 6 weeks later by total-marrow irradiation (TMI) to skeletal bone. Dose levels were 10, 12, 14, and 16 Gy at 2 Gy daily/twice daily. In a separate allogeneic HCT trial, 8 patients (5 with acute myelogenous leukemia, 1 with acute lymphoblastic leukemia, 1 with non-Hodgkin's lymphoma, and 1 with multiple myeloma) were treated with TMI plus total lymphoid irradiation plus splenic radiotherapy to 12 Gy (1.5 Gy twice daily) combined with fludarabine/melphalan.
  
  
  RESULTS
  For the 13 patients in the tandem autologous HCT trial, median age was 54 years (range, 42-66 years). Median organ doses were 15-65% that of the gross target volume dose. Primarily Grades 1-2 acute toxicities were observed. Six patients reported no vomiting; 9 patients, no mucositis; 6 patients, no fatigue; and 8 patients, no diarrhea. For the 8 patients in the allogeneic HCT trial, median age was 52 years (range, 24-61 years). Grades 2-3 nausea, vomiting, mucositis, and diarrhea were observed. In both trials, no Grade 4 nonhematologic toxicity was observed, and all patients underwent successful engraftment.
  
  
  CONCLUSIONS
  This study shows that TMI using helical tomotherapy is clinically feasible. The reduced acute toxicities observed compare favorably with those seen with standard TBI. Initial results are encouraging and warrant further evaluation as a method to dose escalate with acceptable toxicity or to offer TBI-containing regimens to patients unable to tolerate standard approaches.
authors.affiliation: Division of Radiation Oncology and Radiation Research, City of Hope Cancer Center, Duarte, CA, USA.
authors.forename: Jeffrey Y C
authors.initials: JY
authors.lastname: Wong
authors.forename: Joseph
authors.initials: J
authors.lastname: Rosenthal
authors.forename: An
authors.initials: A
authors.lastname: Liu
authors.forename: Timothy
authors.initials: T
authors.lastname: Schultheiss
authors.forename: Stephen
authors.initials: S
authors.lastname: Forman
authors.forename: George
authors.initials: G
authors.lastname: Somlo
mesh_terms: D000328:Adult; D003131:Combined Modality Therapy; D005260:Female; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D007938:Leukemia / Q000000981:diagnostic imaging / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009101:Multiple Myeloma / Q000000981:diagnostic imaging / Q000628:therapy*; D011879:Radiotherapy Dosage; D020266:Radiotherapy, Conformal / Q000379:methods*; D013813:Therapy, Computer-Assisted / Q000379:methods; D014057:Tomography, X-Ray Computed / Q000379:methods*; D016896:Treatment Outcome; D014916:Whole-Body Irradiation / Q000379:methods*
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