Dosimetric Evaluation Between the Conventional Volumetrically Modulated Arc Therapy (VMAT) Total Body Irradiation (TBI) and the Novel Simultaneous Integrated Total Marrow Approach (SIMBa) VMAT TBI

Purpose The purpose of this study was to assess the treatment planning feasibility of volumetrically modulated arc therapy total body irradiation (VMAT TBI) using a simultaneous integrated marrow and body approach (SIMBa). We also aimed to compare SIMBa TBI with the more conventional VMAT TBI approach using the entire body as the target. The goal of using an integrated approach like SIMBa is to balance the known clinical benefit of TBI with the toxicity decrease of Total Marrow Irradiation (TMI) using two prescription volumes. In anticipation of a clinical trial to investigate a novel conditioning regimen that uses SIMBa, our institution retrospectively analyzed the dosimetric differences between 20 clinical VMAT TBI which were re-planned using SIMBa. Methods Twenty patients who previously received conventional VMAT TBI at our institution with a dose of 12 Gy in six fractions were re-planned using SIMBa with a planning aim of delivering a uniform dose of 12 Gy to at least 90% of the PTV_BodyEval. The planning aims of SIMBa were to deliver a uniform dose of 12 Gy to at least 90% of the PTV_Marrow and 8 Gy to at least 90% of the PTV_TotalBody while limiting the mean lung dose to less than 8 Gy. The plans were normalized so that 100% of the PTV_Marrow received at least 90% of the dose with the PTV_TotalBody optimized to stay as close to 100% at 90% as possible. Results All 20 patient plans achieved 12 Gy/8 Gy to at least 90% of the PTV_Marrow and PTV_TotalBody, respectively, with max doses of <16 Gy (130%). As compared with the delivered TBI, the following reductions in mean dose were notable: small bowel 21.3±4.2%, lung 16.3±7.9%, heart 25.3±8.6%, and kidney 16.4±6.2%. Coverage of the sanctuary sites was maintained despite a significant reduction to sensitive organs at risk (OARs). Conclusion This study supports that VMAT TBI treatment planning with SIMBa is feasible. In this sample, SIMBa provided dosimetrically similar doses to marrow and sanctuary site doses as TBI while achieving lower doses to OARs. A clinical trial is needed to investigate the clinical implications of VMAT TBI with SIMBa.