Total marrow or total body?

Total marrow irradiation is cumbersome, but the procedure has several merits over its conventional, total-body counterpart

Total marrow or total body?

In India, total body irradiation is a part of the standard of treatment for leukaemia as a conditioning regimen before bone marrow transplantation. This procedure involves irradiating the whole body with the dual purpose of suppressing the immune system to make room for new bone marrow donor cells and destroying any remaining cancer cells. Unfortunately, while this technique achieves complete cancer remission, the harmful x-rays also induce collateral damage to other key organs like lungs, heart, kidneys, liver, etc. However, despite the unwanted side effects, total body irradiation has been accepted as a necessary evil before a bone marrow transplant.

For over a decade, doctors have reported the benefits of irradiating only bone marrow while sparing other key organs, in a procedure called total marrow irradiation. This is the perfect answer to avoiding the side effects of total body irradiation, while irradiating the bone marrow. The theory is well established and has been in practice for so long that one may ask why this procedure is not more commonplace. Dr Rakesh Jalali, Medical Director and Head, Radiation Oncology, Apollo Proton Cancer Centre, Chennai, lays it out, “A lot of hard work goes into the planning of treatment for marrow selectively.” This procedure has therefore not been attempted in India until recently. Now, a team of doctors at the Apollo Proton Cancer Centre has gone all out to perform total marrow irradiation as a part of the conditioning regime for two patients from Oman.

35-year-old Abida (name changed) was the first patient to receive total marrow irradiation in India. She was originally diagnosed with Philadelphia positive, chronic myeloid leukaemia in the acute blast phase in Oman. This is an immediate indication for bone marrow transplantation. Abida was lucky that her brother was a full matched donor for bone marrow. However, the local hospital was not well equipped to perform the bone marrow transplantation. She, therefore, underwent two rounds of chemotherapy in Oman and achieved complete remission before being referred for a bone marrow transplantation to Dr. Jose M Easow, Consultant Medical Oncology and Hematology, In-charge of BMT Unit, Apollo Cancer Specialty Hospital, Chennai. Instead of the traditional total body irradiation prior to stem cell transplantation, Dr Easow proposed to try total marrow irradiation. Abida, being a nurse, understood the benefits of total marrow irradiation and was excited by
this proposal with the full understanding that this would be the first such attempt in India.

Dr Easow and Dr Srinivas Chilukuri, Senior Consultant Radiation Oncology, put together a medical team along with Dr Dayananda Shamurailatpam, Head, Department of Medical Physics, Apollo Hospitals, to prepare to perform the first ever total marrow irradiation in India.

The theory behind total marrow irradiation is well known. However, the actual procedure is extremely complex and cumbersome. To accomplish this unusually intense procedure, a lot of technical inputs were taken from the published work of two other groups, one from Sweden and another from City of Hope Hospital, California, USA. Both these teams have been using total marrow irradiation for several years and in fact, the team from City of Hope hospital had pioneered the technique. Dr Chilukuri and team worked hard towards developing a standard operating procedure that involved 10 days of preparation and logistics planning. They spent several days in generating the treatment plan, which targeted the entire bone marrow while sparing the thyroid, lungs, heart, kidneys, bowels, oral cavity etc. Once the CT scans, dosimetry and target delineation were chalked out, Abida underwent 6 radiation sessions over a period of 3 days. This was planned over a long weekend so as to minimize Abida’s exposure to other patients visiting the hospital to reduce the risk of infection.

Abida did extremely well with total marrow irradiation. The benefits were instantaneous and some of the common side effects of total body irradiation were conspicuously minimal. Abida showed less bowel toxicity, no loss of appetite, no visible skin pigmentation and some nausea and vomiting — comparatively less than seen with total body irradiation. Further, once engraftment was done, she recovered rapidly, and required fewer antibiotics, and spent less time in the hospital. Abida is now completely off medication and has gone back to Oman. She will send monthly reports as follow-ups to monitor cancer recurrence.

About 20 days after Abida’s treatment, 26-year-old Jamal (name changed) came to Dr Easow for a bone marrow transplantation. Encouraged by Abida’s success, the medical team at Apollo Proton Cancer Centre proceeded with their second effort with total marrow irradiation for a second success story!

While total marrow irradiation may be cumbersome and not done routinely, it is perhaps time that hospitals and oncologists start investing their time and efforts in this procedure as both short-term and long-term benefits are well documented. As per Dr Srinivas Chilukari, “Total marrow irradiation involves a lot of effort, but it is completely worth the effort for the patient. It has not been taken up by our oncology community yet, but I think it is time we take up this challenge.”

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