Problem: The clinical feasibility, dosimetric reproducibility, and in vivo accuracy of a tomotherapy-based total-body irradiation (TBI) protocol in a large cohort of patients undergoing hematopoietic stem cell transplantation (HSCT) is evaluated.
Methods: Patients (128 patients with hematological malignancies undergoing TBI with helical tomotherapy) were simulated in dual orientations (head-first and feet-first supine) to accommodate extended anatomical lengths. Plans were generated as separate upper and lower components with structured gradient overlap zones and then composited for delivery. Quality assurance included an ArcCHECK 3D diode array for patient-specific gamma analysis (3%/3 mm criteria), point-dose verification, and in vivo dosimetry. The gamma pass rates, regional dose deviations, and Pearson correlation coefficients were analyzed. Statistical evaluation was performed using the Shapiro–Wilk test, Levene's test, and ANOVA.
Results: All treatment plans met the institutional constraints for planning target volume (PTV) coverage and organs at risk sparing. The mean D95% of the PTV consistently exceeded 95% of the prescribed dose, ensuring robust target coverage. This reflects excellent conformity with the planned dose distribution. Region-wise gamma pass rates exceeded 97% in all areas except junctions, where rates were slightly lower owing to dose gradients. The point-dose agreement showed tight clustering within the ±3% range, with the pelvis exhibiting the most significant positive shift. The in vivo optically stimulated luminescence dosimeter dose remained within the clinically acceptable range of 0.8–1.2 Gy. A strong interregional correlation (r > 0.90) was observed, confirming reproducibility. ANOVA identified statistically significant but clinically acceptable regional dose variations (p = 0.030).
Conclusion: Tomotherapy-based TBI demonstrated high dosimetric precision, reproducibility, and workflow efficiency. This protocol offers a clinically reliable approach for modern TBI delivery in transplant conditioning.
| [1] |
Ansari F, Behfar M, Jafari L, et al. A comprehensive comparison between TBI vs non-TBI-based conditioning regimen in pediatric patients with acute lymphoblastic leukemia: A systematic review and meta-analysis. Leuk Res. 2023; 135:107416.
|
| [2] |
Takami A. Hematopoietic stem cell transplantation for acute myeloid leukemia. Int J Hematol. 2018; 107(5): 513-518.
|
| [3] |
Gabriel M, Hoeben BAW, Uhlving HH, et al. A Review of Acute and Long-Term Neurological Complications Following Haematopoietic Stem Cell Transplant for Paediatric Acute Lymphoblastic Leukaemia. Front Pediatr. 2021; 9:774853.
|
| [4] |
Lambri N, Dei D, Brioso RC, et al. Automatic base-dose planning for a robust field junction in total marrow irradiation. Physica Medica. 2025; 130:104898.
|
| [5] |
Sarkar B, Pradhan A. Long term in-vivo dosimetry result for bilateral oppose extended source to surface distance (SSD) total body irradiation. Radiat Phys and Chem. 2025; 229:112541.
|
| [6] |
Strojnik A, Méndez I, Peterlin P. Reducing the dosimetric impact of positional errors in field junctions for craniospinal irradiation using VMAT. Rep Pract Oncol Radiother. 2016; 21(3): 232-239.
|
| [7] |
Tuong PN, Duy PC, Van Thanh N, et al. Application of volumetric modulated arc therapy (VMAT) for craniospinal irradiation: Dosimetric analysis and clinical implementation. Radiat Phys and Chem. 2025; 236:112965.
|
| [8] |
Myers PA, Mavroidis P, Papanikolaou N, Stathakis S. Comparing conformal, arc radiotherapy and helical tomotherapy in craniospinal irradiation planning. J Appl Clin Med Phys. 2014; 15(5): 4724.
|
| [9] |
Sun Y, Liu G, Chen W, et al. Dosimetric comparisons of craniospinal axis irradiation using helical tomotherapy, volume-modulated arc therapy and intensity-modulated radiotherapy for medulloblastoma. Transl Cancer Res. 2019; 8(1): 191-202.
|
| [10] |
Hindmarsh J, Crowe S, Johnson J, et al. A dosimetric comparison of helical tomotherapy treatment delivery with real-time adaption and no motion correction. Phys Imaging Radiat Oncol. 2025; 34:100741.
|
| [11] |
Goddard L, Jeong K, Tomé WA. Commissioning and routine quality assurance of the Radixact Synchrony system. Med Phys. 2022; 49(2): 1181-1195.
|
| [12] |
Göksel EO. Evaluation of dose delivery accuracy of the lung with the respiratory technique of the Radixact Synchrony real-time tumor tracking system. Tech Innov Patient Support Radiat Oncol. 2025; 34:100316.
|
| [13] |
Mackie TR, Holmes T, Swerdloff S, et al. Tomotherapy: a new concept for the delivery of dynamic conformal radiotherapy. Med Phys. 1993; 20(6): 1709-1719.
|
| [14] |
Hoeben BAW, Saldi S, Aristei C, et al. Rationale, implementation considerations, delineation and planning target objective recommendations for volumetric modulated arc therapy and helical tomotherapy total body irradiation, total marrow irradiation, total marrow and lymphoid irradiation and total lymphoid irradiation. Radiother Oncol. 2025; 206:110822.
|
| [15] |
Hoeben BAW, Wong JYC, Fog LS, et al. Total Body Irradiation in Haematopoietic Stem Cell Transplantation for Paediatric Acute Lymphoblastic Leukaemia: Review of the Literature and Future Directions. Front Pediatr. 2021; 9:774348.
|
| [16] |
Mackie TR, Balog J, Ruchala K, et al. Tomotherapy. Semin Radiat Oncol. 1999; 9(1): 108-117.
|
| [17] |
Van Gestel D, Verellen D, Van De Voorde L, et al. The Potential of Helical Tomotherapy in the Treatment of Head and Neck Cancer. Oncologist. 2013; 18(6): 697-706.
|
| [18] |
Ben Abdeljelil N, Ouerghi R, Ben Yaiche I, et al. Total body irradiation-based conditioning versus chemotherapy before allogeneic stem cell transplantation for adults with acute lymphoblastic leukemia. Clin Hematol Int. 2024; 6(3): 4-8.
|
| [19] |
Ueda N, Konuma T, Aoki J, et al. Prognostic Impact of the Fractionation of Total Body Irradiation for Patients with Acute Myeloid Leukemia Undergoing Myeloablative Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther. 2021; 27(2): 185.
|
| [20] |
Advani SH, Dinshaw KA, Nair CN, Ramakrishnan G. Total body irradiation in chronic myeloid leukemia. Int J Radiat Oncol Biol Phys. 1983; 9(4): 497-500.
|
| [21] |
Maeng CH, Ko YH, Lim DH, et al. Comparison of Total Body Irradiation (TBI) Conditioning with Non-TBI for Autologous Stem Cell Transplantation in Newly Diagnosed or Relapsed Mature T- and NK-Cell Non-Hodgkin Lymphoma. Cancer Res Treat. 2017; 49(1): 92-103.
|
| [22] |
Effeney B, Pullar A, Burbery J, Hargrave C, Brady C. Dose to organs at risk for total body irradiation: Single-institution data using the modulated arc total body irradiation technique. Pediatr Blood Cancer. 2024; 71(9):e31164.
|
| [23] |
Köksal M, Baumert J, Jazmati D, et al. Whole body irradiation with intensity-modulated helical tomotherapy prior to haematopoietic stem cell transplantation: analysis of organs at risk by dose and its effect on blood kinetics. J Cancer Res Clin Oncol. 2023; 149(10): 7007-7015.
|
| [24] |
Jessen KA, Shrimpton PC, Geleijns J, Panzer W, Tosi G. Dosimetry for optimisation of patient protection in computed tomography. Appl Radiat Isot. 1999; 50(1): 165-172.
|
| [25] |
SOMATOM go.Sim - Siemens Healthineers India. Accessed 2025. https://www.siemens-healthineers.com/en-in/radiotherapy/ct-for-rt/somatom-go-sim
|
| [26] |
Target Volume Delineation and Radiation Planning Considerations for Total Body Irradiation | SpringerLink. Accessed 2025. https://link.springer.com/chapter/10.1007/978-3-031-67722-9_11
|
| [27] |
Seravalli E, Bosman ME, Han C, et al. Technical recommendations for implementation of Volumetric Modulated Arc Therapy and Helical Tomotherapy Total Body Irradiation. Radiother Oncol. 2024; 197:110366.
|
| [28] |
Al-Wassia R, Bahig H, Poon E, Parker W, Freeman C. Daily setup uncertainty analysis for craniospinal irradiation using helical tomotherapy. Pract Radiat Oncol. 2013; 3(4): 349-355.
|
| [29] |
Mir R, Kelly SM, Xiao Y, et al. Organ at risk delineation for radiation therapy clinical trials: Global Harmonization Group consensus guidelines. Radiother Oncol. 2020; 150: 30-39.
|
| [30] |
Shi F, Hu W, Wu J, et al. Deep learning empowered volume delineation of whole-body organs-at-risk for accelerated radiotherapy. Nat Commun. 2022; 13: 6566.
|
| [31] |
Shimizu H, Sasaki K, Tachibana H, et al. Analysis of modulation factor to shorten the delivery time in helical tomotherapy. J Appl Clin Med Phys. 2017; 18(3): 83-87.
|
| [32] |
Ryczkowski A, Piotrowski T. Influence of the modulation factor on the treatment plan quality and execution time in Tomotherapy in head and neck cancer: In-phantom study. J Cancer Res Ther. 2013; 9(4): 618-623.
|
| [33] |
Kaliyaperumal V, Kataria T, Tamilselvan S, et al. Optimal Combination of Pitch, Modulation Factor and Dosimetric Considerations in Treatment Planning for Total Body Irradiation Using Helical Tomotherapy. Asian Pac J Cancer Prev. 2023; 24(4): 1239-1248.
|
| [34] |
Singh S, Bhushan M, Singh BK, et al. Comparative Study of Fluence Distribution and Point Dose Using Arc-check and Delta4 Phantoms. J Med Phys. 2024; 49(4): 706-709.
|
| [35] |
Vittal K, Singh S, Osman S, et al. In-Vivo Measurements for Single and Multi-Fractional TBI Using OSLDs and Ion Chamber. AAPM 59th Annual Meeting & Exhibition - Meeting Program - Abstract Information. 2017. Accessed April 4, 2025. https://www.aapm.org/meetings/2017AM/PRAbs.asp?mid=127&aid=37143
|
| [36] |
Kry SF, Alvarez P, Cygler JE, et al. AAPM TG 191: Clinical use of luminescent dosimeters: TLDs and OSLDs. Med Phys. 2020; 47(2): e19-e51.
|
| [37] |
Python Release Python 3.10.9. Python.org. Accessed April 24, 2025. https://www.python.org/downloads/release/python-3109/
|
| [38] |
Ezzell GA, Burmeister JW, Dogan N, et al. IMRT commissioning: Multiple institution planning and dosimetry comparisons, a report from AAPM Task Group 119. Med Phys. 2009; 36(11): 5359-5373.
|
| [39] |
Miften M, Olch A, Mihailidis D, et al. Tolerance limits and methodologies for IMRT measurement-based verification QA: Recommendations of AAPM Task Group No. 218. Med Phys. 2018; 45(4): e53-e83.
|
| [40] |
Ganapathy K, Kurup PGG, Murali V, Muthukumaran M, Bhuvaneshwari N, Velmurugan J. Patient dose analysis in total body irradiation through in vivo dosimetry. J Med Phys. 2012; 37(4): 214-218.
|
| [41] |
Chow JCL, Ruda HE. In Vivo Dosimetry in Radiotherapy: Techniques, Applications, and Future Directions. Encyclopedia 2025; 5(1): 40.
|
| [42] |
Teruel JR, Taneja S, Galavis PE, et al. Automatic treatment planning for VMAT-based total body irradiation using Eclipse scripting. J Appl Clin Med Phys. 2021; 22(3): 119-130.
|
| [43] |
Chaswal V, Weldon M, Gupta N, Chakravarti A, Rong Y. Commissioning and comprehensive evaluation of the ArcCHECK cylindrical diode array for VMAT pretreatment delivery QA. J Appl Clin Med Phys. 2014; 15(4): 212-225.
|
| [44] |
Ahmed S, Nelms B, Kozelka J, Zhang G, Moros E, Feygelman V. Validation of an improved helical diode array and dose reconstruction software using TG-244 datasets and stringent dose comparison criteria. J Appl Clin Med Phys. 2016; 17(6): 163-178.
|
| [45] |
Low DA, Moran JM, Dempsey JF, Dong L, Oldham M. Dosimetry tools and techniques for IMRT. Med Phys. 2011; 38(3): 1313-1338.
|
| [46] |
Loginova AA, Tovmasian DA, Lisovskaya AO, et al. Optimized Conformal Total Body Irradiation methods with Helical TomoTherapy and Elekta VMAT: Implementation, Imaging, Planning and Dose Delivery for Pediatric Patients. Front Oncol. 2022; 12:785917.
|
| [47] |
Konishi T, Ogawa H, Najima Y, et al. Safety of total body irradiation using intensity-modulated radiation therapy by helical tomotherapy in allogeneic hematopoietic stem cell transplantation: a prospective pilot study. J Radiat Res. 2020; 61(6): 969-976.
|
| [48] |
Köksal M, Baumert J, Schoroth F, et al. Helical versus static approaches to delivering tomotherapy to the junctional target for patients taller than 135 cm undergoing total body irradiation. Eur J Med Res. 2022; 27(1): 265.
|
| [49] |
Çatlı Dinç S, Küçük N, Şenkesen Ö, Baş Ayata H. A Multicentric study on a dosimetric comparison of extended SSD technique, VMAT-Based and helical tomotherapy (HT) for total body irradiation (TBI). J Radiat Res Appl Sci. 2024; 17(3):101050.
|
RIGHTS & PERMISSIONS
2026 The Author(s). Precision Radiation Oncology published by John Wiley & Sons Australia, Ltd on behalf of Shandong Cancer Hospital & Institute.
PDF
(4333KB)
