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Total Body Irradiation (TBI) in Pediatric Patients

A Single-center Experience after 30 Years of Low-dose Rate Irradiation

Ganzkörperbestrahlung (TBI) in der Pädiatrie – 30 Jahre Erfahrungen mit Niedrig-Dosisraten-Bestrahlung

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Abstract

Purpose:

To retrospectively analyze patient characteristics, treatment, and treatment outcome of pediatric patients with hematologic diseases treated with total body irradiation (TBI) between 1978 and 2006.

Patients and Methods:

32 pediatric patients were referred to the Department of Radiation-Oncology at the University of Zurich for TBI. Records of regular follow-up of 28 patients were available for review. Patient characteristics as well as treatment outcome regarding local control and overall survival were assessed. A total of 18 patients suffered from acute lymphoblastic leukemia (ALL), 5 from acute and 2 from chronic myelogenous leukemia, 1 from non-Hodgkin lymphoma, and 2 from anaplastic anemia. The cohort consisted of 15 patients referred after first remission and 13 patients with relapsed leukemia. Mean follow-up was 34 months (2–196 months) with 15 patients alive at the time of last follow-up. Eight patients died of recurrent disease, 1 of graft vs. host reaction, 2 of sepsis, and 2 patients died of a secondary malignancy.

Results:

The 5-year overall survival rate (OS) was 60%. Overall survival was significantly inferior in patients treated after relapse compared to those treated for newly diagnosed leukemia (24% versus 74%; p=0.004). At the time of last follow-up, 11 patients survived for more than 36 months following TBI. Late effects (RTOG ≥3) were pneumonitis in 1 patient, chronic bronchitis in 1 patient, cardiomyopathy in 2 patients, severe cataractogenesis in 1 patient (48 months after TBI with 10 Gy in a single dose) and secondary malignancies in 2 patients (36 and 190 months after TBI). Growth disturbances were observed in all patients treated prepubertally. In 2 patients with identical twins treated at ages 2 and 7, a loss of 8% in final height of the treated twin was observed.

Conclusion:

As severe late sequelae after TBI, we observed 2 secondary malignancies in 11 patients who survived in excess of 36 months. However, long-term morbidity is moderate following treatment with the fractionated TBI at the low-dose rate that was generally used here. Conditioning for bone marrow transplantation without radiation is an attractive option, but is not sufficiently effective to completely replace TBI for the most common pediatric indications.

Zusammenfassung

Ziel:

Retrospektive Analyse von Patientencharakteristika, Behandlung und Ergebnis bei Kindern mit hämatologischen Erkrankungen, die zwischen 1978 und 2006 mit Ganzkörperbestrahlung behandelt wurden.

Patienten und Methodik:

32 Kinder wurden unserer Klinik zur TBI zugewiesen, 28 Krankengeschichten waren zugänglich (n=28). 18 Patienten litten unter akuter lymphoblastischer Leukämie (ALL), 5 unter akuter (AML) und 2 unter chronisch myeloischer Leukämie (CML), einer unter Non-Hodgkin-Lymphom und zwei unter aplastischer Anämie. 15 Patienten wurden nach erster Remission zugewiesen, 13 mit Rezidiv. Bei der letzten Kontrolle lebten noch 15 Patienten (mean 34 Monate (2–196 Monate). Acht Patienten sind an einem Rezidiv verstorben, einer an einer Graft-versus-host Erkrankung, zwei an Sepsis und zwei an Sekundärtumoren.

Resultate:

Das 5-Jahres Gesamtüberleben lag bei 60%. Das Gesamtüberleben war signifikant (p=0.004) niedriger bei Patienten, die nach einem Rezidiv behandelt wurden (24%), als bei solchen die bei Erstdiagnose behandelt wurden (74%). Spättoxizität RTOG ≥3 waren eine Pneumonitis bei 1 Patienten, eine chronische Bronchitis bei einem Patienten, Kardiomyopathie bei 2 Patienten, eine Katarakt bei einem Patienten (48 Monate nach TBI mit 10Gy Einzeldosis) und Sekundärtumore bei 2 Patienten. Wachstumsstörungen mit einer Körpergrösse kleiner als die 25. Perzentile zeigten sich bei allen vor der Pubertät behandelten Kindern. Bei zwei eineiigen Zwillingen zeigt sich ein Verlust von 8% an Körpergrösse im Vergleich zum Zwilling.

Schlussfolgerung:

Wie erwartet zeigen sich schwere Spättoxizitäten nach Ganzkörperbestrahlung mit zwei Sekundärtumoren bei 11 Patienten, die länger als 36 Monate überlebt haben. Aber die Morbidität ist mässig nach fraktionierter Ganzkörperbestrahlung und der hier in fast allen Fällen verwendeten niedrigen Dosisrate. Konditionierung ohne TBI ist eine attraktive Möglichkeit, aber noch nicht effektiv genug um die TBI im Kindesalter ganz zu ersetzen.

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Authors and Affiliations

  1. Department of Radiation-Oncology – University Hospital, Zurich, Switzerland

    Claudia Linsenmeier, Daniel Thoennessen, Laura Negretti, Tino Streller, Urs Martin Lütolf & Susanne Oertel

  2. University Children’s Hospital Zurich, Department of Hemato-Oncology, Zurich, Switzerland

    Jean-Pierre Bourquin

  3. Department of Radiation Oncology – University of Heidelberg, Heidelberg, Germany

    Susanne Oertel

  4. Department of Radiation Oncology, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland

    Claudia Linsenmeier

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  1. Claudia Linsenmeier
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  2. Daniel Thoennessen
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  3. Laura Negretti
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  4. Jean-Pierre Bourquin
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  6. Urs Martin Lütolf
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Correspondence to Claudia Linsenmeier.

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Linsenmeier, C., Thoennessen, D., Negretti, L. et al. Total Body Irradiation (TBI) in Pediatric Patients. Strahlenther Onkol 186, 614–620 (2010). https://doi.org/10.1007/s00066-010-2089-2

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  • DOI: https://doi.org/10.1007/s00066-010-2089-2

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