This information is for patients who are going to receive total body irradiation (TBI).
This leaflet will explain:
- What is total body irradiation (TBI)
- Planning your TBI
- TBI treatment
- General information about side effects of TBI treatment
- Who to contact when you need advice
You may find it helpful to read our patient information booklet called ‘Radiotherapy’, which explains how radiotherapy works.
What is total body irradiation (TBI)?
TBI is when your whole body is treated with radiotherapy as part of your treatment regimen, for an autologous, allogeneic or reduced intensity conditioning bone marrow transplant (BMT). Radiotherapy is a treatment with high energy x-rays and is entirely painless. It does not make you radioactive.
We use TBI in patients with leukaemia, lymphoma, myeloma and some rare blood disorders. The aim of the treatment is to destroy any malignant cells and your immune system. This will then allow the new healthy bone marrow cells to grow.
Prior to having your TBI treatment, you will have a period of between 2 and 5 days of chemotherapy conditioning regimen on the Haemato-Oncology Ward - your Allogeneic Stem Cell Transplant Nurse Coordinator will confirm this location.
Two to four weeks before your TBI treatment, you will need to visit the Radiotherapy Planning Department at Clatterbridge Cancer Centre - Liverpool. You will see the doctor who will discuss with you the proposed treatment plan.
The doctor and the therapeutic radiographer will explain the radiotherapy planning and treatment in more detail. Occasionally, the transplant team and therapeutic radiographer may decide to use some additional boost radiotherapy treatments before the transplant. The doctor will explain to you the reasons for any additional boost treatments and appointments are arranged accordingly.
During the appointment with the doctor, we will explain the potential side effects of TBI. If you have any questions, please write them down and bring them with you, so you don’t forget them, and you can discuss this during your appointment. You will also be asked to sign a consent form.
Afterwards another appointment will be made for you at the Radiotherapy planning department where you will have a planning CT scan. You will be required to wear just your underwear (briefs and non-wired brassiere / crop top) for this scan.
You will be asked to lie on your back with your arms across your chest hugging a support pillow. The therapeutic radiographers will position you in a comfortable, but practical, treatment position. The therapeutic radiographers and physicists will take several measurements and then perform the CT scan. With your permission, two permanent tattoo dots are placed on each side of your hips. We use them to position you for each treatment. No other special preparation is required and you don’t need any contrast injection. The whole planning process takes about 20 minutes.
From the scan and measurements, the physicists and doctor will calculate the correct shielding to give you the same dose of radiotherapy to your entire body. Afterwards, arrangements could be made to shown the treatment room and meet the therapeutic radiographers delivering your treatment. This will give you a better understanding of what to expect through your treatment. If you are worried at all, or have any further questions, please do not hesitate to ask a member of staff.
A couple of days after your planning scan, you could be asked to attend another appointment at the Radiotherapy Department for a ’Test Dose’. This is like a practice run through of the actual treatment. Only a very small amount of radiotherapy is delivered, so there are no side effects from this session. You will be positioned on the couch in the same position as you were for the scan. The therapeutic radiographers will gently move you into the correct position lining up the tattoos on your hips with the in-room lasers.
Once you are in the right position, bags of Vaseline called bolus are placed between your legs and over your knees, chest and neck. These bags are to ensure the radiation treatment is evenly distributed throughout your body. Special measuring devices will be attached to various parts of your body with tape to monitor the dose you receive throughout your treatment.
After checking you are comfortable, the staff will leave the treatment room and deliver a small amount of radiation to these measuring devices. The therapeutic radiographers will be watching you all the time on closed circuit television monitors. The therapeutic radiographers then come back into the room and reposition the couch. The Test Dose takes about an hour.
TBI treatment
The transplant team and the doctors on the Haemato-Oncology Ward, along with your oncologist at The Clatterbridge Cancer Centre, will discuss the number of treatments (fractions) you will need with you.
More recently, most treatments are in one fraction although they can be done in eight treatments. If it is more than one treatment, then the treatments will be twice a day with a minimum of six hours between each treatment.
Most chemotherapy conditioning regimes are given over a period of between 2 and 5 days before the TBI on the Haemato-Oncology Ward - however some regimes may involve post TBI chemotherapy.
The treatment is exactly the same as the Test Dose and the same duration except more radiation is delivered; hence you will be on your own in the room for longer. Treatment is delivered to each side of your body (right and left). You will not feel anything during treatment. The radiation will not hurt but you may hear a buzzing noise when the machine switches on. The radiographers are watching you all the time on closed circuit television monitors.
Single treatment (fraction) TBI has very limited side effects and you may only experience nausea vomiting and diarrhoea for the first 24 hours; all other side effects are very rare.
For the 8 fraction TBI, the side effects will gradually appear during the course of your TBI treatment. These effects can vary from patient to patient and your consultant will have discussed your potential risks with you during the consent process. Some side effects happen soon after treatment, and some can occur months or years later. Side effects for one treatment are normally much less noticeable and late effects are very rare.
The main side effects that occur during treatment are:
Skin changes
Towards the end of treatment, you may notice that your skin reddens and feels warm to the touch. Your skin may also become dry. These are normal reactions to the treatment. You may wash, bathe or shower normally. Please ask a therapeutic radiographer for any skin care advice.
Hair loss
You may experience hair loss after your treatment and this can affect all areas of the body. Hair does usually grow back but may be different in texture.
Nausea, vomiting and diarrhoea
Most patients have experienced these symptoms as a result of their intensive chemotherapy.
Medication can control these symptoms but the radiotherapy may intensify these reactions. You will be prescribed routinely a continuous infusion of anti-sickness drugs (ondansetron and dexamethasone) on the ward. However, if you are still experiencing symptoms, it is important to inform the therapeutic radiographers and your medical support team as further medication can be prescribed. Please ask for a copy of the Macmillan leaflets 'Coping with nausea' or 'Coping with constipation or diarrhoea'.
Dry or sore mouth
This usually occurs 2-3 days into treatment and can last up to three months following treatment completion. You can alleviate this by regularly taking drinks and performing regular mouth care as instructed by the nurses. It is important that you try to drink plenty of fluids (between 1 to 2 litres a day). This can include water, squash or warm drinks.
Swelling and inflammation of the parotid (salivary) glands - known as parotitis
This affects a small proportion of patients and occurs within 24 hours of treatment. The effects may last for only 24-72 hours and can be controlled with mild painkillers.
Infections
You are at increased risk of developing infections until your new bone marrow engrafts and functions. Healthcare staff (including your transplant team) will keep you under very careful observation and treat any infections, should they occur.
Diarrhoea
Usually occurs 8-10 days after starting TBI. Please let the nursing staff know, as it is important to check for any infection and prescribe the appropriate medication.
Late side effects can occur months or years after radiotherapy has finished and are the hardest to predict. Your radiotherapy doctor will have explained the potential late side effects of radiotherapy to you as part of the consent process. The effects may include:
Common effects
Somnolence syndrome
The majority of patients undergoing TBI will experience some degree of fatigue and drowsiness during their treatment. There might be a particularly sleepy spell starting six to 12 weeks after treatment ends and going on for two to six weeks or even longer. You may notice that you have a lack of energy and cannot be bothered to do anything. This is quite rare, but resolves normally without specific treatment.
Please ask for the Macmillan leaflet 'Coping with fatigue and tiredness'.
Cataracts
Due to the unavoidable radiation to the eye, the development of mistiness of the lenses of the eye may occur. This usually develops three to four years after TBI treatment and affects about 30-40% of patients. If cataracts form, they can be removed by a simple surgical procedure.
Infertility
Most patients who undergo BMT will become infertile because of the doses of chemotherapy and radiation given. Individuals may experience vaginal dryness or premature menopause and may also suffer from a decreased sex drive. The transplant team and the radiotherapy doctors will discuss these issues with you.
Hormone changes
Certain hormone producing tissues are sensitive to radiation; the normal production may be impaired years after you had TBI. You will require regular blood tests for it and some patients need supplementary hormones.
Rare side effects
Pneumonitis
This is inflammation of the lung tissue. In a very small percentage of patients, it can occur six weeks to six months following TBI. You may experience shortness of breath and a cough. If this occurs, it must be reported to any of the doctors, at either hospital, stem cell transplant (BMT) coordinators or specialist nurses immediately.
Second malignancy
Very rarely, patients who have been successfully treated may develop a secondary malignancy some years later. The radiotherapy doctors will discuss this with you.
Macmillan booklets about coping and living with cancer and treatment side effects are available free of charge. These can be ordered by telephoning 0808 808 00 00 or by visiting the Cancer Information and Support Centre (sited in the main entrances of Clatterbridge Cancer Centres - Liverpool).
Clatterbridge Cancer Centre - Liverpool
65 Pembroke Place, Liverpool, L7 8YA
Tel: 0151 556 5000
www.
Clatterbridge Cancer Centre - Wirral
Clatterbridge Road, Bebington, Wirral, CH63 4JY
Tel: 0151 556 5000
www.
Clatterbridge Cancer Centre - Aintree
Lower Lane, Fazakerley, Liverpool, L9 7AL
Tel: 0151 556 5959
www.
Macmillan Cancer Support
www.
Tel: 0808 808 0000
Cancer Information and Support Centre
Clatterbridge Cancer Centre - Liverpool
Tel: 0151 318 8805
Lead TBI radiographer
Based at The Clatterbridge Cancer Centre
Tel: 0151 556 5341
Maggie’s Centre - Wirral
Tel: 0151 334 4301