REVIEW ARTICLE

American College of Radiology (ACR) and American Society

for Radiation Oncology (ASTRO) Practice Guideline for the
Performance of Total Body Irradiation (TBI)
Suzanne L. Wolden, MD,* Rachel A. Rabinovitch, MD,w Nathan H.J. Bittner, MD,z
James M. Galvin, DSc,y Huan B. Giap, MD, PhD,8 Paula J. Schomberg, MD,z and Seth A. Rosenthal, MD#

against the use of these guidelines in litigation in which the

Abstract: Total body irradiation (TBI) is a specialized radiotherapy clinical decisions of a practitioner are called into question.
technique. It is frequently used as a component of treatment plans The ultimate judgment regarding the propriety of any
involving hematopoietic stem cell transplant for a variety of disorders, specific procedure or course of action must be made by the
most commonly hematologic malignancies. A variety of treatment
delivery techniques, doses, and fractionation schemes can be utilized.
physician or medical physicist in light of all the circumstances
A collaborative effort of the American College of Radiology and presented. Thus, an approach that differs from the guidelines,
American Society for Radiation Oncology has produced a practice standing alone, does not necessarily imply that the approach
guideline for delivery of TBI. The guideline defines the qualifications was below the standard of care. To the contrary, a con-
and responsibilities of the involved personnel, including the radiation scientious practitioner may responsibly adopt a course of
oncologist, physicist, dosimetrist, and radiation therapist. Review of action different from that set forth in the guidelines when, in
the typical indications for TBI is presented, and the importance of the reasonable judgment of the practitioner, such course of
integrating TBI into the multimodality treatment plan is discussed. action is indicated by the condition of the patient, limitations
Procedures and special considerations related to the simulation, treat- of available resources, or advances in knowledge or techno-
ment planning, treatment delivery, and quality assurance for patients
logy subsequent to publication of the guidelines. However, a
treated with TBI are reviewed. This practice guideline can be part of
ensuring quality and safety in a successful TBI program. practitioner who uses an approach substantially different from
these guidelines is advised to document in the patient record
Key Words: total body irradiation, TBI, quality assurance, safety, information sufficient to explain the approach taken.
dosimetry, practice guidelines, radiation oncology The practice of medicine involves not only the science,
but also the art of dealing with the prevention, diagnosis,
(Am J Clin Oncol 2013;36:97–101)
alleviation, and treatment of disease. The variety and com-
plexity of human conditions make it impossible to always
reach the most appropriate diagnosis or to predict with cer-
PREAMBLE tainty a particular response to treatment.
These guidelines are an educational tool designed to Therefore, it should be recognized that adherence to these
assist practitioners in providing appropriate radiation oncology guidelines will not assure an accurate diagnosis or a successful
care for patients. They are not inflexible rules or requirements outcome. All that should be expected is that the practitioner will
of practice and are not intended, nor should they be used, to follow a reasonable course of action based on current knowledge,
establish a legal standard of care. For these reasons and those available resources, and the needs of the patient to deliver
set forth below, the American College of Radiology cautions effective and safe medical care. The sole purpose of these
guidelines is to assist practitioners in achieving this objective.
From the *Department of Radiation Oncology, Memorial Sloan-Kettering
Cancer Center, New York, NY; wDepartment of Radiation Oncology,
University of Colorado, Denver, Aurora, CO; zTacoma/Valley Radia- INTRODUCTION
tion Oncology Centers, Tacoma, WA; yDepartment of Radiation
Oncology, Thomas Jefferson University, Philadelphia, PA; zDepart- This guideline was revised collaboratively with the
ment of Radiation Oncology, Mayo Clinic, Rochester, MN; 8Advanced American College of Radiology (ACR) and the American
Particle Therapy, San Diego; and #Radiation Oncology Centers, Society for Radiation Oncology (ASTRO).
Radiological Associates of Sacramento, Sacramento, CA.
This guideline was revised according to the process described under the
Total body irradiation (TBI) is a radiotherapy technique
heading “The process for developing ACR practice guidelines and frequently used as a component of hematopoietic stem cell
technical standards” on the ACR Web site (http://www.acr.org/guide- transplant (HSCT). TBI in conjunction with chemotherapeutic
lines) by the Guidelines and Standards Committee of the ACR Com- agents has proven useful for eradicating residual malignant or
mission on Radiation Oncology in collaboration with the ASTRO.This
report was previously published as ACR-ASTRO Practice Guideline
genetically disordered cells and for immunosuppression before
for the Performance of Total Body Irradiation, ACR Practice Guide- HSCT. According to data summarized by the Center for
lines and Technical Standards CD, 2011. International Blood and Marrow Transplant Research, in 2005,
rAmerican Society for Radiology Oncology (ASTRO) and American the diseases most commonly treated with HSCT were (in
College of Radiology (ACR).
The authors declare no conflicts of interest.
decreasing order of frequency): multiple myeloma, non-
Reprints: Suzanne L. Wolden, MD, Department of Radiation Oncology, Hodgkin lymphoma, acute myelogenous leukemia, Hodgkin
Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, disease, acute lymphoid leukemia, myelodysplastic syndrome,
NY 10021-6007. E-mail: [email protected]. chronic myelogenous leukemia, and additional malignant and
Copyright r 2013 American College of Radiology (ACR) and American
Society for Radiology Oncology (ASTRO)
nonmalignant diseases.1 HSCT is considered autologous if
ISSN: 0277-3732/13/3601-0097 native stem cells are reinfused, and allogeneic if the hemato-
DOI: 10.1097/COC.0b013e31826e0528 poietic graft is derived from someone other than the recipient.

American Journal of Clinical Oncology  Volume 36, Number 1, February 2013 www.amjclinicaloncology.com | 97
Wolden et al American Journal of Clinical Oncology  Volume 36, Number 1, February 2013

Allogeneic grafts can be from related or unrelated individuals, challenges that must be considered/addressed to improve dose
but “matching” of donor and recipient is performed. The graft uniformity. Very young children who require anesthesia may
may be in the form of bone marrow, peripheral stem cells, and be treated lying on the floor with the gantry pointing downward
umbilical cord blood.2 and with the spoiler and blocks placed above the patient.
Unique features of TBI that make it a valuable component Successful planning and delivery of TBI requires close inter-
of transplant preparative regimens include: action and coordination among the radiation oncologist, med-
1. No sparing of “sanctuary” sites such as testes and the ical physicist, dosimetrists, nurses, and radiation therapists.
central nervous system. This guideline describes a quality assurance program for
2. Dose homogeneity to the whole body regardless of blood TBI and is supplementary to the ACR Practice Guideline for
supply. Radiation Oncology23 and the ACR Technical Standard for the
3. Less chance of cross-resistance with other antineoplastic Performance of Radiation Oncology Physics for External
agents (chemotherapy). Beam Therapy.24
4. No problems with excretion or detoxification.
5. Ability to tailor the dose distribution by shielding specific PROCESS OF TBI
organs or by “boosting” sites. The use of TBI is a complex process involving many
A wide variety of TBI dose and fractionation schedules trained personnel who carry out highly coordinated activities.
have been studied. The optimal regimen depends on a range of
clinical variables, including patient age, disease, and type of Clinical Evaluation
HSCT. With competing goals of disease eradication and The initial evaluation should include a detailed history,
avoidance of toxicity, the most commonly accepted total dose including a review of issues that may impact on treatment toler-
of TBI for myeloablative HSCT is 12 to 15 Gy delivered in 8 to ance (previous radiotherapy to sensitive organs, factors affecting
12 fractions over 4 days.3,4 Numerous investigators have pulmonary, renal, or hepatic function, and exposure to infectious
shown that efficacy is improved and a variety of important late agents); physical examination; review of all pertinent diagnostic
toxicities are significantly decreased when TBI is fractionated and laboratory tests; and communication with the referring
in 2 to 3 treatments per day.5,6 Relatively low-dose rates are physician and other physicians involved in the patient’s care in
also important for optimal outcome.7 Many protocols require a accordance with the ACR Practice Guideline for Communication:
dose rate of < 0.2 Gy per minute. Radiation Oncology.25 Careful review of the applicable treatment
Low-dose TBI, often in conjunction with chemotherapy, plan or clinical trial protocol for the particular disease being
has recently emerged as an effective form of conditioning in treated is essential as standardized institutional or cooperative
reduced intensity HSCT for patients who may not be able to group protocols are typically used for transplantation.
tolerate myeloablation because of poor performance status or As with delivery of any chemotherapy or radiotherapy,
comorbidity. Notable studies have included TBI doses of 2 to policies and procedures should be in place to determine
8 Gy in 1 to 4 fractions.8–12 whether a female patient is pregnant before initiating any
It is essential that the complicated treatment and care of component of a transplant program, including TBI. If the
the patient receiving TBI be well coordinated among the var- patient is determined to be pregnant, other therapies should be
ious subspecialties (medical oncology, radiation oncology, considered in an effort to preserve the pregnancy. Alter-
etc.) and caregivers (physicians, nurses, physicists, psycholo- natively, if the patient wishes to proceed with transplant, the
gists, dieticians, etc). TBI presents a unique challenge because pregnancy may be electively terminated.
it results in potentially lethal myeloablation without intensive
medical support and stem cell backup. Incorrectly delivered Informed Consent
TBI may result in fatal toxicity. Anticipated immediate tox- Before simulation and treatment, informed consent must be
icity includes the following signs and symptoms: nausea, obtained and documented and must be in compliance with
emesis, parotitis, xerostomia, headache, fatigue, mucositis, applicable laws, regulations, or policies, in accordance with the
diarrhea, and loss of appetite.13 Prophylactic interventions to ACR Practice Guideline on Informed Consent: Radiation Oncol-
manage these toxicities include intravenous hydration, antie- ogy.26 This should include a detailed discussion of the benefits and
metics, and antimucositis agents.14 Patients must be counseled potential tissue-specific acute and late toxicities of TBI, as well as
regarding the risks of long-term sequelae of TBI, which vary in the details of, rationale for, and alternatives to TBI.
incidence depending on the clinical scenario and TBI regimen.
These late risks may include pneumonopathy,15 veno-occlu- Treatment Planning
sive disease of the liver,16 kidney dysfunction,17 cataracts,7 Treatment planning for TBI requires detailed knowledge
hypothyroidism,18 infertility,19 and secondary malignancies.20 of the specific transplant program to be followed (either on or
Because of the significant risk associated with this treatment, off of a clinical trial). Specific treatment parameters to be
the entire team must take great care to assure the best possible determined in advance of treatment include: field size, colli-
multidisciplinary care with attention to all facets of TBI. mator rotation, treatment distance, dose per fraction, dose rate,
Although the techniques of TBI vary widely from insti- total dose, number of fractions per day, interval between
tution to institution, certain basic principles apply, such as the fractions, beam energy, geometry to achieve dose homoge-
achievement of relative-dose homogeneity throughout the neity, bolus or beam spoilers to increase skin dose, shielding
body, with the exception of intentionally shielded or boosted and dose compensation requirements (eg, lungs, kidneys), and
areas. Most centers use opposing anterior and posterior fields boost specifications (eg, testes, chest wall). Patient thickness
with the patient standing upright several meters from the measurements should be obtained at the prescription point
source and the beam pointed horizontally. A beam spoiler (often at the level of the umbilicus) and at other points of
placed upstream may be used to prevent skin sparing.21 interest for possible dose calculations and homogeneity
Alternatively, patients can be irradiated with lateral fields in a determinations, such as head, neck, mid-mediastinum, mid-
sitting or partly reclining position.22 This approach is usually lung, pelvis, knee, ankle, etc. Patient height is recorded to
better tolerated by patients but presents additional dosimetric determine the appropriate source-to-patient distance to fit

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Society for Radiology Oncology (ASTRO)
American Journal of Clinical Oncology  Volume 36, Number 1, February 2013 ACR and ASTRO Practice Guideline for TBI

the patient within the beam with sufficient margin around the QUALIFICATIONS AND RESPONSIBILITIES OF
patient (usually >5 cm). Special attention should be paid to the PERSONNEL
dramatic decrease in dose that can be seen in the field corners Application of this guideline should be in accordance
for many treatment units when the collimator is in the full open with the ACR Practice Guideline for Radiation Oncology.23
position.
Radiation Oncologist
Simulation of Treatment The radiation oncologist should have had training in TBI
For lung or other organ blocking, simulation or other procedures before embarking on any of these regimens.
treatment planning is generally done in the treatment position, The responsibilities of the radiation oncologist include:
that is, if the patient is standing for TBI, the simulation should 1. Consultation and decision-making regarding the course of
be done in the standing position if possible. As an alternative to treatment.
computed tomography simulation in the supine position, lung 2. Coordination of the patient’s care with the transplantation
blocks may be designed on megavoltage radiographs generated service and other physicians.
by a linear accelerator with the patient in an upright position. If 3. Participation in the treatment planning process (immobili-
the planning session is performed in another position, posi- zation techniques, simulation, block design, prescription,
tional differences in organ location should be considered and dosimetric and physics review, etc).
the medical physicist should be consulted. Reference points for 4. Review of treatment verification images.
block placement at the time of treatment should be marked on 5. Clinical assessment of the patient’s tolerance during the
the patient’s body for reproducibility. treatment course.

Calculations Qualified Medical Physicist

Calculations are performed by the medical physicist or The responsibilities of the qualified medical physicist
his or her designee to determine the beam-on time necessary to include (see Van Dyk and colleagues21,22 for helpful details
achieve the prescribed dose, dose homogeneity, and any other relating to this section):
relevant dose points. Consideration should always be given to 1. Establish and manage the system of dosimetric measure-
differences in the patient’s separation in different body ments, calculating and shielding.
regions, with the resulting dose heterogeneities. For example 2. Establish the system for beam-spoiling designed to adjust
adjustments should be considered for overweight patients who the dose at the beam entry surface.
can experience severe head and neck mucositis when only 3. Initiate and maintain a quality assurance program for TBI
umbilical separation is used for prescribing dose. A medical performance.
physicist or a dosimetrist who did not perform the initial 4. Act as a technical resource for planning of immobilization
computation should independently check the calculation before devices, dosimetry techniques, shielding, dose compensa-
the first fraction is delivered. It is recommended here that tion devices, and bolus methods.
in vivo dosimetry be used to assess dose homogeneity. Every 5. Calibrate the external beam delivery system and the in vivo
effort should be made to maintain dose inhomogeneity to measurement system.
within ± 10%. 6. Direct supervision of dosimetry measurements and calcu-
lations for TBI delivery.
Treatment Aids 7. Verify the calculations performed by the dosimetrist.
Special TBI stands, treatment couches, or treatment tables
are often used to aid in immobilization, placement of organ Dosimetrist
shields, and patient support and comfort. The responsibilities of the dosimetrist include:
1. Generation of the dose calculations for treatment.
2. Dosimetry measurements.
Treatment Delivery
TBI containing myeloablative transplant programs typi- Radiation Therapist
cally use fractionated or hyperfractionated regimens (twice a The responsibilities of the radiation therapist include:
day or 3 times a day) over several days in order to minimize 1. Setting up the patient in the treatment position, including
both acute and chronic toxicities and to minimize overall using appropriate treatment devices.
treatment time. Before treatment, any shielding of normal 2. Verifying that the prescribed and calculated treatment
organs should be checked with portal images. In the setting of distances match the utilized treatment distances.
low-dose TBI, where total doses are typically only 2 to 4 Gy, 3. Performing and reviewing of imaging procedures to verify
organ shielding is usually not used. Dosimetry should be the setup and blocking, if any.
checked against department protocols to verify dose delivery at 4. Treating the patient according to the prescription and plan
the extended distances that are used for treatment. A medical provided.
physicist should be available during all treatments in case of 5. Monitoring and evaluating the patient during the treatments.
questions regarding dosimetric details, equipment function,
patient setup, etc. Treatments are carried out by the radiation Nurse
therapist as per the ACR Practice Guideline for Radiation The responsibilities of the nurse may include:
Oncology.23 1. Educating the patient and family about the procedures,
A physician should be in close proximity to manage any acute/late side effects, and procedures taken to promote
problems related to treatment. Avoidance of medications that safe/comfortable treatment.
may cause orthostatic hypotension and the administration of 2. Monitoring the patient’s tolerance of the procedure to
intravenous fluids for hydration or transfusions for anemia may promote adequate supportive care.
help to prevent syncope or near-syncopal episodes if the 3. Communicating any special precautions to the rest of the
patient is treated in the standing position. team regarding the care of immunosuppressed patients.

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Wolden et al American Journal of Clinical Oncology  Volume 36, Number 1, February 2013

EQUIPMENT allogeneic bone marrow transplantation. Biol Blood Marrow

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Guideline for Communication: Radiation Oncology.25
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