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Multimodality Image Guided Total Marrow Irradiation and Verification of the Dose Delivered to the Lung, PTV, and Thoracic Bone in a Patient: A Case Study (p. 23-28)

This work reports our initial experience using multimodality image guidance to improve total marrow irradiation (TMI) using helical tomotherapy. We also monitored the details of the treatment delivery to glean information necessary for the implementation of future adaptive processes. A patient with metastatic Ewing?s sarcoma underwent MRI, and bone scan imaging prior to TMI. A whole body kilovoltage CT (kVCT) scan was obtained for intensity modulated TMI treatment planning, including a boost treatment to areas of bony involvement. The delivered dose was estimated by using MVCT images from the helical tomotherapy treatment unit, compared to the expected dose distributions mapped onto the kVCT images. Clinical concerns regarding patient treatment and dosimetric uncertainties were also evaluated. A small fraction of thoracic bone volume received lower radiation dose than the prescribed dose. Reconstructed planned treatment volume (PTV) and the dose delivered to the lung were identical to planned dose. Bone scan imaging had a higher sensitivity for detecting skeletal metastasis compared to MR imaging. However the bone scan lacked sufficient specificity in three dimensions to be useful for planning conformal radiation boost treatments. Inclusion of appropriate imaging modalities improves detection of metastases, which allows the possibility of a radiation dose boost to metastases during TMI. Conformal intensity modulated radiation therapy via helical tomotherapy permitted radiation delivery to metastases in the skull with reduced dose to brain in conjunction with TMI. While TMI reduces irradiation to the lungs, onboard megavoltage computed tomography (MVCT) to verify accurate volumetric dose coverage to marrow-containing thoracic bones may be essential for successful conformal TMI treatment.

Key words: Total marrow irradiation; Total body irradiation; Helical Tomotherapy; Multimodality imaging.

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TCRT February 2009

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Volume 8
No. 1 (p 1-84)
February 2009
ISSN 1533-0338

Susanta K. Hui, PhD1,*
M. R. Verneris, MD2
Jerry Froelich, MD3
K. Dusenbery, MD1
James S. Welsh, MS, MD4

1Department of Therapeutic Radiology
2Department of Pediatrics
Division of Hematology
Oncology and Bone Marrow Transplantation
3Department of Radiology
University of Minnesota
420 Delaware St SE, MMC 494
Minneapolis, MN 55455, USA
4Departments of Human Oncology and Medical Physics
Madison, Wisconsin, USA