[논문]Total body irradiation: Current indications.

doi:10.1016/S1278-3218(98)80001-2

Total body irradiation: Current indications.
L'irradiation corporelle totale : Les indications actuelles

Cancer radiothérapie : journal de la Société française de radiothérapie oncologique, v.2 no.3, 1998년, pp.245 - 251

Giraud, P , Danhier, S , Dubray, B , Cosset, JM

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SummaryThe choice of dose and fractionation for total body irradiation is made difficult by the large number of considerations to be taken into account. The outcome of bone marrow transplantation after total body irradiation can be understood in terms of tumour cell killing, engraftment, and normal tissue damage, each of these endpoints being influenced by irradiation-, disease-, transplant-, and patientrelated factors. Interpretation of clinical data is further hampered by the overwhelming influence of logistic constraints, the small numbers of randomised studies, and the concomitant variations in total dose and fraction size or dose rate. So far, three cautious conclusions can be drawn in order to tentatively adapt the total body irradiation schedule to clinically-relevant situations. Firstly, the organs at risk for normal tissue damage (lung, liver, lens, kidney) are protected by delivering small doses per fraction at low dose rate. This suggests that, when toxicity is at stake (eg, in children), fractionated irradiation should be preferred, provided that interfraction intervals are long enough. Secondly, fractionated irradiation should be avoided in case of T-cell depleted transplant, given the high risk of graft rejection in this setting. An alternative would be to increase total (or fractional) dose of fractionated total body irradiation, but this approach is likely to induce more normal tissue toxicity. Thirdly, clinical data have shown higher relapse rates in chronic myeloid leukaemia after fractionated or low dose rate total body irradiation, suggesting that fractionated irradiation should not be recommended, unless total (or fractional) dose is increased. Total body irradiation-containing regimens, primarily cyclophosphamide / total body irradiation, are either equivalent to or better than the chemotherapy-only regimens, primarily busulfan /cyclophosphamide. Busulfan / cyclophosphamide certainly represents a reasonable alternative, especially in patients who may not be eligible for total body irradiation because of prior irradiation to critical organs.

Abstract

RésuméLe choix de la dose totale et du fractionnement d'une irradiation corporelle totale est rendu difficile par le nombre de paramètres à prendre en compte. Le devenir d'une greffe de moelle osseuse après irradiation corporelle totale est lié à la destruction des cellules tumorales, mais aussi à la prise du greffon et à la toxicité sur les tissus sains. Chacun de ces effets dépend de la maladie, du mode d'irradiation, du greffon, et même du patient. Les données cliniques sont difficilement interprétables étant donné le petit nombre d'études randomisées et les variations des schémas d'irradiation utilisés. Cependant, trois conclusions schématiques semblent pouvoir être dégagées afin d'adapter les modalités de l'irradiation corporelle totale à différentes situations cliniques. Tout d'abord, de faibles doses par fraction ou un bas débit de dose épargnent mieux les tissus sains (poumons, foie, cristallins, reins). Lorsque la toxicité potentielle sur les tissus sains se situe au premier plan (par exemple en pédiatrie), on favorisera une irradiation fractionnée avec un intervalle suffisant entre les fractions. Ensuite, en présence d'un greffon dépiété en cellules T, une irradiation fractionnée classique de six fois 2 Gy ne paraît pas assurer une immunodépression suffisante. Pour éviter le rejet, on peut augmenter la dose totale ou la dose par fraction, mais au détriment des tissus sains. Enfin, l'analyse des données cliniques montre un taux de rechute plus élevé dans les leucémies myéloïdes chroniques traitées par une irradiation corporelle totale fractionnée et à bas débit de dose, suggérant le recours à une dose totale fractionnée plus élevée plutôt que le retour à la dose unique. L'association irradiation corporelle totale-cyclophosphamide semble aussi efficace, voire dans certains cas supérieure à un conditionnement associant uniquement des chimiothérapies. Cependant, certains patients ne peuvent bénéficier d'une irradiation corporelle totale en raison d'une irradiation antérieure à dose élevée sur des organes critiques. L'association d'une chimiothérapie de type busulfancyclophosphamide constitue alors une bonne alternative.

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Total body irradiation: Current indications.
L'irradiation corporelle totale : Les indications actuelles

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Total body irradiation: Current indications. L'irradiation corporelle totale : Les indications actuelles

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Total body irradiation: Current indications.
L'irradiation corporelle totale : Les indications actuelles