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Total Marrow and Lymphoid Irradiation: A New Technology Assisting in Myeloablating Before Hematopoietic Stem Cell Transplantation
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摘要: 本文报道北京协和医院放射治疗科首次应用全骨髓全淋巴链照射(total marrow and lymphoid irradiation，TMLI)技术助力骨髓增生异常综合征合并髓系肉瘤患者行造血干细胞移植前清髓1例。于治疗前对患者进行放疗定位及靶区勾画，设计应用螺旋断层治疗加速器(TOMO加速器)进行TMLI治疗的全流程，后行放射治疗，顺利实现全骨髓和淋巴针对性照射。该患者在治疗过程中体感舒适，治疗时间(45 min~1 h/次)较全身照射技术(total body irradiation，TBI)(3~4 h/次)大大缩短，照射剂量率(800 cGy/min)较TBI(5~30 cGy/min)大幅提高，治疗后口腔黏膜炎、胃肠道反应均较轻，取得了较好的治疗效果。本文就该患者的治疗过程及TMLI技术展开讨论，为后续开展更多患者的治疗提供全流程及重要参数借鉴。Abstract: This paper reports the first case of myelodysplastic syndromes combined with myeloid sarcoma for which the department of radiotherapy used total marrow and lymphoid irradiation (TMLI) to assist in myeloablating. Radiotherapy localization and target area delineation were carried out before treatment and the entire process of TMLI treatment was designed using the TOMO therapy. Radiotherapy was performed successfully for targeted irradiation of the total bone marrow and lymph nodes. The patient felt comfortable during the treatment process and good pretreatment effects were achieved. The treatment time (45 min-1 h per session) was significantly shorter than that during total body irradiation (TBI)(3-4 h per session), the irradiation dose rate (800 cGy/min) was significantly increased compared to TBI (5-30 cGy/min), and oral mucosal inflammation and gastrointestinal reactions were mild after treatment. This article discusses the treatment process of this case and TMLI technology, to provide reference for the whole process design and important parameters for further treatment of more patients.作者贡献：沈晶负责查阅文献，撰写论文；刘志凯负责指导论文修订；管慧、甄宏楠负责协助定位；孙显松、姜斐、张悦负责完成定位及治疗；于浪、张杰负责计划设计；张福泉负责指导论文修订。利益冲突：所有作者均声明不存在利益冲突
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图 1 应用TMLI治疗的全流程设计
TMLI：全骨髓全淋巴链照射；GTV：肿瘤体积；CTV：临床靶体积；OAR：危及器官；PRV：计划危及器官；PTV：计划靶体积；MVCT：兆伏级CT
表 1 危及器官受量
危及器官 计划受照射体积/剂量(cm3/cGy) 实际受照射体积/剂量(cm3/cGy) 左侧眼球 50% 1657 右侧眼球 50% 721 左侧视神经 0.1cc 2016 右侧视神经 0.1cc 1324 视交叉 0.1cc 1295 腮腺 50% 1250 喉 50% 1200 口腔 50% 676 甲状腺 50% 1238 双肺 Dmean 807 双肺 V5 68.67% 心脏 30% 1254 肾脏 33% 743 膀胱 50% 1092 直肠 50% 880 50%、30%、33%: 50%、30%、33%受照射体积所接受的照射剂量；Dmean: 平均剂量；V5:双肺受照射剂量为5 Gy; 68.67%: 双肺受照射剂量为5 Gy的体积范围为68.67% 
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