Total Body Irradiation

This information explains total body irradiation and the side effects of treatment.

You will have radiation therapy before your bone marrow or stem cell transplant. This resource tells you:

  • Why you will have it.
  • How it is planned and given.
  • The possible side effects you may have.

Purpose of Radiation Therapy Before Transplant

Many patients have total body irradiation (TBI) before transplant. It is delivered to the entire body. It is given for any or all of the following reasons:

  • To destroy cancer cells in areas not easily reached by chemotherapy. These are the nervous system, bones, skin, and testes in men.
  • To decrease the response of your immune system. If you are getting bone marrow or stem cells from a donor, your body may see these as foreign. The immune system tries to destroy cells that are foreign to your body. TBI is done so that the immune system won’t destroy these cells.
  • To create space for the new marrow to grow (engraft).
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You will first meet with the radiation oncologist and nurse. They will discuss your treatment and answer any ques- tions you have. You will then begin the planning session for your treatment. It is called simulation. This generally takes two to four hours. You do not have to do anything to prepare for it.

Simulation Day

Wear comfortable clothes and make sure not to wear earrings or necklaces. The radiation therapist will greet you. He or she will take a photograph of your face. This is placed in your folder and used to identify you throughout your treatment. The procedure will be explained to you and you can ask any questions. You will need to sign a consent form if you have not done it already. Your doctor will review this part of your treatment with you before you sign the consent.

You will need to undress from the waist up and change into a gown. Keep your shoes on. The therapist(s) will help you lie on a table. Although it will have a sheet on it, the table is hard and has no cushion. The temperature in the room is usually cool. Let the therapists know if it is too cool and you are uncomfortable. Throughout simulation, you will feel the table move to different positions. The lights in the room will be turned on and off and you will see red laser lights on each wall. The therapist(s) use these laser lights as a guide when they position you on the table. Do not look directly into the red beam as this may hurt your eyes.

The therapists will walk in and out of the room during the simulation. You will hear the therapists speaking to each other as they work. They will tell you what they are doing. Please do not speak once they begin, unless you are uncomfortable or need help. Speaking may alter your position.

Music can be played throughout the simulation. If you would like, ask a radiation therapist to play a CD for you. You may bring a CD from home if you prefer.

X-ray Images

X-ray images will be taken of your chest. They are done with an x-ray machine called a simulator. You will be standing up for these x-rays. It takes about 20 minutes.

Skin Markings (Tattoos)

The therapists will draw on your skin with a felt marker that can be washed off after simulation. These marks will be used to make the permanent skin markings called tattoos. To make the tattoos, the therapists will use a sterile needle and a drop of ink. The tattoo marks are no bigger than the head of a pin. The sensation of getting one feels like a pinprick. You will receive two tattoos, one on your upper back and one on your upper chest. They are permanent so you will not need to worry that they will wash off in the shower. Some photographs will be taken of you after you get the tattoos.

CT Scan

You will then be brought to another room for a CT scan. The CT scan is used to map your treatment plan. You will hear the machine as it is turned on and off. Even if the noise seems loud, the therapists will be able to hear you if you need to speak with them. The CT scan takes about 10 minutes.

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Treatment Planning

After your simulation, a team will plan your treatment using your x- ray and CT scan.

The lungs are very sensitive to radiation. They cannot get the same dose that the rest of your body will receive. To protect them, lung blocks will be made. They will decrease the dose of radiation that your lungs receive. The chest x-rays you had are used to make the blocks. These blocks will be placed on a screen in front of your body during each treatment.

The bones in the portion of the chest wall located behind these blocks contain a great deal of bone marrow. These areas must receive a full dose of radiation. You will receive radiation to the chest wall, front and back, without the blocks, once a day for two days of your treatment. The images taken of your chest will be used to plan the treatment to your chest wall.

The details from simulation are planned and checked. This takes between five days and two weeks.

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TBI Treatment

You will be admitted to the hospital. Your TBI will be given in divided treatments. The treatment schedule depends on the type of TBI you will have. Treatment will be given:

  • Monday through Friday twice a day (at about 8 a.m. and 4 p.m.) or
  • Tuesday through Friday three times a day (at about 8 a.m., 1 p.m., and 6 p.m.).

Wear lightweight, loose-fitting clothes when you go to treatment. Clothes should not have any metal. You can keep your socks on if you wish, but you must take off your shoes or slippers. Do not wear any jewelry or metal objects (rings, hairpins). These may increase the radiation dose to that area. CD players are in the room. You may bring a CD to play during your treatment if you would like. A VCR is also available. If you would prefer to watch a videotape, you may bring one. You can also chose from the ones we have in our department. An escort will bring you to your treatments.

Your treatment is given by radiation therapists.


Figure 1.

You must be in the correct position during treatment. Infants and very small children will be wrapped in a papoose board on a table. Older children and adults are positioned standing on a platform. You will stand over a bicycle-like seat with your hands placed on bars on either side of your hips. (Figure1) The radiation therapists will help you. You will face the machine for the first half of your treat- ment and will be turned away from it for the second half. The lung blocks are placed on a board that hangs in front of your chest. They do not touch your body. The tattoos you got during simulation will be used to place the blocks. A large Plexiglass®  screen is placed in the front of your body before the treatment begins. It assures that the treatment is evenly distributed.

Description of Treatment

Figure 2.

The radiation therapists will leave the room when you are in position. Breathe normally, but do not move during the treatment. If you move, the treatment will not be evenly distributed. You may hear the machine click as it turns on and off, but you will not feel anything. Having a radiation treatment feels like having an x-ray. It is painless. The treatments take about 15 to 20 minutes. Some patients find it helpful to listen to music.

Although you are alone during your treatment, the radiation therapist will watch you on a TV screen. They can talk to you over an intercom system (Figure 2). They can hear you if you have any questions or problems during the treatment. If at any point you are not feeling well, tell them. The treat- ment can be stopped. The therapist will come into the room to help you. Your treatment will be restarted once you are feeling better.

You and your clothes do not become radioactive during or after treatment. It is safe for you to be around other people.

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Additional Treatments

Extra doses of radiation may be given to specific areas of the body. This is called a “boost.”

Some boosts may be given before you are hospitalized for TBI and transplant. These may be to the:

  • Spleen in patients with chronic leukemia who have an enlarged spleen.
  • Fluids that bathe the brain and spinal cord if your doctor thinks cancer cells may be in these areas.

Some boosts are given while you are getting TBI. These are to the:

  • Chest wall, front and back, without the blocks, once a day for two days of your treatment.
  • Testes in male patients who have acute leukemia or myelodysplastic syndrome. This is often on the last day. You will be lying down for the treatment with your penis and scrotum exposed. The treatment does not cause any pain or discomfort.
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Side Effects of Treatment

You will not feel any pain during the treatment, but TBI has side effects. Some occur right away or during the four days of treatment. Some occur days or weeks after your treatment. And some occur months after TBI.

During the treatment, the most common side effects include:

  • Headache
  • Nausea and vomiting
  • Diarrhea
  • Fatigue
  • A skin reaction

Less common is swelling of the salivary glands. This causes pain in front of the ear and in the jaw.

Medicines can decrease nausea and vomiting. These side effects are most severe during the first day of radiation. They usually begin one to two hours after the first treatment. If you vomit, it usually becomes less frequent as the treatment proceeds. It often stops by the third day. You may also have diarrhea during the first few treatment days. Tell your nurse if you have any symptoms.

During the days of your treatment, you may not use any:

  • Lotions.
  • Creams.
  • Ointment.
  • Deodorants.

Before you come to the hospital buy Aquaphor®. Apply this to your entire body each night after your last treat- ment. Some patients develop a mild reddening of the skin during the first few days of treatment. After radiation is completed, your skin may feel dry and itchy. If you received a boost to the testes, the reaction may be more severe in the scrotal area. Continue to use the Aquaphor after your TBI treatments are over until your skin returns to normal.

There are a number of side effects you may get during the days and weeks after your TBI. These also may be from the chemotherapy you have received. They include:

  • Hair loss.
  • Discomfort in the throat and mouth.
  • Change in taste.
  • Mouth sores.
  • Nausea and vomiting.
  • Diarrhea.
  • Bone marrow suppression (low blood counts).

These will go away over time.

TBI can cause long-term side effects. They can occur months or years after your transplant.

  • Sterility is an expected side effect. Sexual function and pleasure will not be affected. Please talk to your doctor or nurse about any concerns you have.
  • About half of the patients will need thyroid supplements.

Other long-term side effects are rare, but can occur. They include:

  • Inflammation of the sac that surrounds the heart.
  • Inflammation of the lungs.
  • Cataracts.
  • Second malignancies or new cancers.

Please discuss these side effects with your doctor.

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Emotional Concerns

Having cancer is likely to cause you and the people who care about you to react in many ways. You may feel:

  • Anxious
  • Afraid
  • Nervous
  • Down
  • Depressed
  • Worried
  • Alone
  • Numb
  • Ambivalent
  • Angry

All these feelings are expected if you or someone you love has a serious illness.

You may also worry about:

  • Telling your employer that you have cancer.
  • Paying your medical bills.
  • How your family relationships may change.
  • The effect of cancer or treatment on your body.
  • Whether you will continue to be sexually attractive.
  • The cancer coming back.

When people try to protect each other by hiding their feelings, they can feel very alone. It might help to talk about your feelings. Talking can help the people around you know what you are thinking. It can bring you closer at a time when support is so needed.

Each of us has our own way of responding to difficult situations. Generally we use whatever has worked for us in the past. However, sometimes this is not enough. We encourage you to speak with your doctor, nurse, and social worker about your concerns.

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After You Complete Your Treatment

When you leave the hospital, you will be closely followed. You will have regular appointments with your doctors. These visits let us see how you responded to treatment. Blood tests, x-rays, and scans may also be ordered during these visits.

Bring a list of any questions and concerns you have. Also bring a list of all your medicines. If you are running low on any medicine, let your doctor know before you run out. Call your doctor or nurse any time if you have any questions or problems.

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We hope this resource has been helpful in preparing you for TBI. If you have any questions, please speak with your radiation oncologist or nurse.

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