Feasibility study for linac-based intensity modulated total marrow irradiation

Total body irradiation (TBI) is used as a preconditioning regimen prior to bone marrow transplant for treatment of hematologic malignancies. During TBI, large volumes of normal tissue are irradiated, and this can lead to toxicities, most significantly in the lungs. Intensity modulated total marrow irradiation (IMTMI) may be able to reduce these toxicities by directly targeting the bone marrow while minimizing the dose to critical structures. The goal of this study was to assess the feasibility of IMTMI by following the planning and delivery process for a Rando phantom. A three isocenter technique was used to provide a full body plan for treatment on a linear accelerator. Thermoluminescent detectors (TLDs) were placed at 22 positions throughout the phantom to compare the delivered doses to the planned doses. Individual intensity modulated radiation therapy verification plans were delivered to a solid water phantom for the three isocenters, and doses measured from an ion chamber and film were compared to the planned doses. The treatment plan indicated that target coverage was achieved with this IMTMI technique, and that the doses to critical structures were reduced by 29%-65% compared to conventional TBI. TLD readings demonstrated accurate dose delivery, with an average difference of 3.5% from the calculated dose. Ion chamber readings for the verification plans were all within 3% of the expected dose, and film measurements showed accurate dose distributions. Results from this study suggest that IMTMI using the three isocenter technique can be accurately delivered and may result in substantial dose reductions to critical structures.