Chapter 18: Total Body Irradiation

  1. When is Total Body Irradiation (TBI) used? Pg. 405
    TBI with megavoltage photon beams is most commonly used as part of the conditioning regimen for bone marrow transplantation. The role of TBI is to destroy the recipient's bone marrow and tumor cells, and to immunosuppress the patient sufficiently to avoid rejection of the donor bone marrow transplant.
  2. Numerous techniques have been used to deliver TBI. What is used in determining which, out of the many, technique will be used? Pg. 405
    The choice of a particular technique depends on the available equipment, photon beam energy, maximum possible field size, treatment distance, dose rate, patient dimensions, an the need to selectively shield certain body structures.
  3. Which technique provides the most uniform dose distribution but is inconvenient for the patient? Pg. 405
    The anteroposterior (AP) / posteroanterior (PA) technique generally provides a better dose uniformity along the longitudinal body axis but the patient positioning, other than standing upright, may pose problems.
  4. Since the AP/PA TBI technique provides significant discomfort for the patient, what is the alternative technique mostly used? Pg. 405
    The bilateral TBI (treating from left and right) can be more comfortable to the patient if seated or lying down supine on a TBI couch, but presents greater variation in body thickness along the path of the beam. Compensators are required to achieve dose uniformity along the body axis to within plus or minus 10%, although extremitites and some noncritical structures may exceed this specification.
  5. What is the photon beam energy used in TBI dictated by? Pg. 405
    The choice of photon beam energy is dictated by 

    • 1.) Patient thickness.
    • 2.) Specification of dose homogeneity. 
    • 3.) The patient diameter along the path of the beam also affects dose uniformity, depending on beam energy.
  6. What has the term "lateral tissue effect" been used to describe? Pg. 405
    The term tissue lateral effect has been used to describe the situation in which lower energy or a thicker patient treated with parallel opposed beams can give rise to an excessively higher dose to the subcutaneous tissues compared with the midpoint dose.
  7. When can a 6MV photon beam be used in TBI? Pg. 405
    If the maximum thickness of the patient parallel to the beam central axis is less than 35 cm and the source to surface dose (SSD) is at least 300 cm, a 6MV beam can be used for parallel opposed TBI fields without increasing the peripheral dose to greater than 110% of the midline dose.
  8. When should photon beam energies greater than 6MV be used when executing TBI? Pg. 406
    For patients of thickness greater than 35 cm, energies higher than 6MV should be used to minimize the tissue lateral effect.
  9. When using parallel opposed beams, what energy range of beams renders the surface or skin dose to be substantially less than the dose at the point of maximum dose? Pg. 406
    Megavoltage range. As the photon beam energy decreases, the point of maximum dose gradually moves toward the surface or skin.
  10. What are some factors that the dose buildup characteristics are dependent upon? Pg. 406
    • 1.) Energy
    • 2.) Field Size.
    • 3.) SSD.
    • 4.) Beam angle relative to the surface.
  11. Is the "skin sparing effect" wanted within the application of TBI? Pg. 406
    Most TBI protocols do not require skin sparing. Instead, a bolus or a beam spoiler is specified to bring the surface dose to at least 90% of the prescribed TBI dose.
  12. What are created to implement a specific TBI treatment technique? Pg. 406
    Patient support and positioning devices are designed to implement a given treatment technique. 

    Important criteria include...

    • 1.) Patient comfort.
    • 2.) Patient stability.
    • 3.) Reproducibility of setup and treatment geometry that allows accurate calculation and delivery of dose in accordance with the TBI protocol.
  13. When using the Bilateral TBI technique, what is used to measure the distance from the source to body axis? Pg. 406
    The source to body axis distance is measured by a sagittal laser light installed in the ceiling to mark the TBI distance.
  14. Knowing that the patient thickness significantly varies when using the bilateral TBI technique, what is done to deliver a uniform dose distribution? Pg. 406
    To achieve dose uniformity within approximately plus or minus 10% along the sagittal axis of the body, compensators are designed for head and neck, lungs (if needed), and legs.
  15. When using compensators to deliver a uniform dose distribution when using the bilateral TBI technique, what is used as the reference thickness? Pg. 406
    The reference thickness for compensation is the lateral diameter of the body at the level of the umbilicus (not including the arms), assuming that the protocol specifies dose prescription to be at the midpoint at the level of the umbilicus.
  16. What is the principle of the AP/PA TBI technique? Pg. 406
    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. For example, dose to the lungs can be reduced using lung blocks of about one half-value thickness and the chest wall under the blocks can be boosted with electrons of appropriate energy.
  17. How can the AP/PA TBI technique be applied to "small" children? Pg. 408
    The AP/PA technique can also be adopted for treating small children in the reclining position. The patient is treated in the supine and posterior positions while lying down on a low-height couch, with the couch top only a few inches off the floor. The shielding blocks are placed on top of an acrylic box tray at a short distance from the patient's surface. The tray, which is about 1 cm thick, also acts as a beam spoiler to build up the skin dose to at least 90% of the prescription dose when treated with parallel opposed TBI fields.
  18. How can a direct output calibration of the machine for TBI be performed? Pg. 408
    A direct output calibration of the machine for TBI may be performed by measuring dose per monitor unit using 0.6-cm-cubed Farmer-type ionization chamber placed in a water phantom of dimensions approximately 40 x 40 x 40 cm-cubed. The position of the chamber is fixed at the TBI distance (source to body axis distance). The collimator is opened to its maximum size and the chamber depth is varied by moving the chamber and the phantom while keeping the source to chamber distance constant (equal to TBI distance).
  19. Are TMRs for large fields (> 30 x 30 cm-cubed) sensitive to field dimensions? Pg. 409
    It is assumed in this case that the patient is dosimetrically equivalent to the phantom, which is not a bad approximation considering the fact that the tissue maximal ratios (TMRs) for large fields (e.g., > 30 x 30 cm) are not very sensitive to field dimensions.
  20. What does the "equivalent field" at the point of calculation mean? Pg. 410
    The equivalent field at the point of calculation means that it is dosimetrically equivalent to the patient in terms of scatter.
  21. When trying to determine the equivalent field size, is it alright just to use 40 x 40 cm-sqr for adults and 30 x 30 cm-sqr for pediatric patients? Pg. 410
    Although patient dimensions vary, scatter factors are not too sensitive to field size variation for large fields. Therefore, it is reasonable to use a fixed equivalent field size for TBI. A 40 x 40 cm field for large patients and a 30 x 30 cm field for pediatric patients seem to be reasonable approximations (within approximately plus or minus 2% of dose accuracy.
  22. What is the percentage range in which most TBI protocols require dose homogeneity along the body axis to be within? Pg. 410
    Most TBI protocols require dose homogeneity along the body axis to be within plus or minus 10%. This requirement cannot be met without the use of compensators.
  23. Why is compensator design for TBI complicated? Pg. 410
    General principles of compensator design have been discussed in Chapter 12. Compensator design for TBI is complicated because of...

    • 1.) large variation in body thickness
    • 2.) lack of complete body immobilization
    • 3.) internal tissue heterogeneities. 

    Considering only the lung inhomogeneity and change in body thickness, compensators can be designed to deliver the dose within acceptable uniformity.
  24. What does the compensator thickness determination depend on? Pg. 410
    The thickness of compensator require along a ray line depends on...

    • 1.) tissue deficit compared to the reference depth at the prescription point
    • 2.) material of the compensator (e.g., its density)
    • 3.) distance of the compensator from the point of dose compensation
    • 4.) depth of the point of dose compensation
    • 5.) field size
    • 6.) beam energy
  25. Why is the bolus-equivalent thickness of the compensator is reduced? Pg. 410
    Because the compensator is designed to be dosimetrically equivalent to a bolus (of thickness equall to the tissue deficit) but placed at a distance from the skin surface, the bolus-equivalent thickness of the compensator is reduce to compensate for reduction in scatter reaching the point of dose compensation.
  26. What is the compensator thickness ratio mean, or how is it defined? Pg. 410
    The required thickness of a tissue-equivalent compensator that gives the same dose at the point of interest as would a bolus of thickness equal to the tissue deficit is called the thickness ratio (tau).
  27. For all beam energies and compensation conditions, what average value of tau would provide a good approximation?
    0.70. The overall dosimetric accuracy of a compensator is approximately plus or minus 5% considering all variables.
  28. How should a compensator be designed/selected to prevent the occurrence of large errors in dose? Pg. 411
    Depending on the tissue deficits encountered in a particular TBI technique, compensator material should be selected so that the compensator is not too bulky or of too high a density that small errors would amount to large errors in dose.
  29. Compensators are mainly used to make up for tissue deficit to provide a uniform dose distribution. What else can compensators be used for? Pg. 411
    Compensators can be designed to take into account not only tissue deficit, but also tissue inhomogeneities such as lungs. In the latter case, a bulk density correction is used to calculate radiologic path length through the inhomogeneity.
  30. Why are invivo patient dose measurements necessary? Pg. 411
    After a particular TBI technique has been established and commissioned for clinical use, it is recommended that an invivo dosimetry check be performed on the first 20 or so patients. Thermoluminescent dosimeter (TLD) capsules or chips, surrounded by suitable buildup bolus, may be placed on the patient's skin at strategic locations and doses measured for the actual treatments given. TLD results should be compared with expected doses, calculated by summing entrance and exit doses at the location of the TLDs and taking into account thickness variation, compensation, and off-axis ratios at the depth of TLDs. An agreement of plus or minus 5% between the calculated and measured doses is considered reasonably good. An overall dose uniformity of plus or minus 10% is considered acceptable for most protocols.
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Chapter 18: Total Body Irradiation