title: Renal shielding and dosimetry for patients with severe systemic sclerosis receiving immunoablation with total body irradiation in the scleroderma: cyclophosphamide or transplantation trial.
abstract: OBJECTIVE
  To describe renal shielding techniques and dosimetry in delivering total body irradiation (TBI) to patients with severe systemic sclerosis (SSc) enrolled in a hematopoietic stem cell transplant protocol.
  
  
  METHODS
  The Scleroderma: Cyclophosphamide or Transplantation (SCOT) protocol uses a lymphoablative preparative regimen including 800 cGy TBI delivered in two 200-cGy fractions twice a day before CD34(+) selected autologous hematopoietic stem cell transplantation. Lung and kidney doses are limited to 200 cGy to protect organs damaged by SSc. Kidney block proximity to the spinal cord was investigated, and guidelines were developed for acceptable lumbar area TBI dosing. Information about kidney size and the organ shifts from supine to standing positions were recorded using diagnostic ultrasound (US). Minimum distance between the kidney blocks (dkB) and the lumbar spine region dose was recorded, and in vivo dosimetry was performed at several locations to determine the radiation doses delivered.
  
  
  RESULTS
  Eleven patients were treated at our center with an anteroposterior (AP)/posteroanterior (PA) TBI technique. A 10% to 20% dose inhomogeneity in the lumbar spine region was achieved with a minimum kidney block separation of 4 to 5 cm. The average lumbar spine dose was 179.6 ± 18.1 cGy, with an average dkB of 5.0 ± 1.0 cm. Kidney block shield design was accomplished using a combination of US and noncontrast computerized tomography (CT) or CT imaging alone. The renal US revealed a wide range of kidney displacement from upright to supine positions. Overall, the average in vivo dose for the kidney prescription point was 193.4 ± 5.1 cGy.
  
  
  CONCLUSIONS
  The dose to the kidneys can be attenuated while maintaining a 10% to 20% dose inhomogeneity in the lumbar spine area. Kidneys were localized more accurately using both US and CT imaging. With this technique, renal function has been preserved, and the study continues to enroll patients.
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA. oana.craciunescu@duke.edu
authors.forename: Oana I
authors.initials: OI
authors.lastname: Craciunescu
authors.forename: Beverly A
authors.initials: BA
authors.lastname: Steffey
authors.forename: Chris R
authors.initials: CR
authors.lastname: Kelsey
authors.forename: Nicole A
authors.initials: NA
authors.lastname: Larrier
authors.forename: Cathy J
authors.initials: CJ
authors.lastname: Paarz-Largay
authors.forename: Robert G
authors.initials: RG
authors.lastname: Prosnitz
authors.forename: Nelson
authors.initials: N
authors.lastname: Chao
authors.forename: John
authors.initials: J
authors.lastname: Chute
authors.forename: Cristina
authors.initials: C
authors.lastname: Gasparetto
authors.forename: Mitchell
authors.initials: M
authors.lastname: Horwitz
authors.forename: Gwynn
authors.initials: G
authors.lastname: Long
authors.forename: David
authors.initials: D
authors.lastname: Rizzieri
authors.forename: Keith M
authors.initials: KM
authors.lastname: Sullivan
mesh_terms: D003520:Cyclophosphamide / Q000627:therapeutic use; D004867:Equipment Design; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007668:Kidney / Q000033:anatomy & histology / Q000000981:diagnostic imaging / Q000528:radiation effects*; D008159:Lumbar Vertebrae / Q000528:radiation effects; D008168:Lung / Q000528:radiation effects; D009929:Organ Size; D056888:Patient Positioning; D011832:Radiation Injuries / Q000517:prevention & control*; D011835:Radiation Protection / Q000379:methods*; D011859:Radiography; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods; D012595:Scleroderma, Systemic / Q000532:radiotherapy*; D016683:Supine Position; D019172:Transplantation Conditioning / Q000379:methods; D014463:Ultrasonography; D014916:Whole-Body Irradiation / Q000379:methods*
chemical_list: D007166:Immunosuppressive Agents; D003520:Cyclophosphamide
references.citation: Neoplasma. 2005;52(4):325-9
references.pmid: 16059650
references.citation: Proc Natl Acad Sci U S A. 1989 Dec;86(24):10090-4
references.pmid: 2690067
references.citation: Biol Blood Marrow Transplant. 2010 Jan;16(1 Suppl):S48-56
references.pmid: 19895895
references.citation: Br J Haematol. 2002 Dec;119(3):726-39
references.pmid: 12437652
references.citation: Blood. 2007 Aug 15;110(4):1388-96
references.pmid: 17452515
references.citation: Int J Radiat Oncol Biol Phys. 1999 Sep 1;45(2):447-9
references.pmid: 10487569
references.citation: Semin Nephrol. 2003 Sep;23(5):486-99
references.pmid: 13680538
references.citation: Int J Radiat Oncol Biol Phys. 1992;23(3):681-6
references.pmid: 1612975
references.citation: Int J Radiat Oncol Biol Phys. 2008 Aug 1;71(5):1436-43
references.pmid: 18355974
references.citation: Radiology. 2006 May;239(2):392-7
references.pmid: 16543592
references.citation: Radiother Oncol. 1997 Jan;42(1):87-90
references.pmid: 9132831
references.citation: J Rheumatol. 2005 Apr;32(4):649-55
references.pmid: 15801020
references.citation: Biol Blood Marrow Transplant. 2011 May;17(5):674-81
references.pmid: 20708086
references.citation: J Exp Med. 2005 Mar 7;201(5):805-16
references.pmid: 15738052
references.citation: Ann Intern Med. 1993 Apr 15;118(8):602-9
references.pmid: 8452326
references.citation: Arthritis Rheum. 1991 Apr;34(4):403-13
references.pmid: 1901491
references.citation: Int J Radiat Oncol Biol Phys. 2004 Mar 1;58(3):809-16
references.pmid: 14967438
references.citation: J Rheumatol. 1993 Sep;20(9):1601-3
references.pmid: 8164225
references.citation: Bone Marrow Transplant. 1997 Dec;20(12):1069-74
references.pmid: 9466280
references.citation: Blood. 2002 Sep 1;100(5):1602-10
references.pmid: 12176878
references.citation: Proc Natl Acad Sci U S A. 1985 Apr;82(8):2483-7
references.pmid: 3887403
references.citation: Arthritis Rheum. 2006 Jun;54(6):1982-6
references.pmid: 16732546
references.citation: Int J Radiat Oncol Biol Phys. 1996 Sep 1;36(2):463-8
references.pmid: 8892472