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Introduction

You have been advised to have a course of radiotherapy as part of your treatment regimen for bone marrow transplantation, BMT.

This information has been designed to give you some general information and answer some of the questions most people ask about total body irradiation (TBI). We hope that you will find it helpful. However, please let us know if you have any queries about any aspect of treatment not covered in this booklet so that we can answer your questions and relieve any anxieties.

What is total body irradiation?

TBI is radiotherapy to the whole body. Radiotherapy is the use of high energy X-rays to kill malignant cells. Contrary to some beliefs it does not make you radioactive. The machine which produces the X-rays may look intimidating but the treatment is entirely painless. TBI is very effective in killing diseased cells anywhere in the body. We use it because it also destroys your immune system and diseased bone marrow. This will be replaced by bone marrow from your donor or your own previously harvested cells.

Other normal cells will also be affected by the TBI but, unlike the diseased cells, they are able to recover.

There are long and short-term side-effects of TBI which are discussed in the following information.

Where is it given?

The treatment is given in the Oncology Centre, by radiographers. The doses are prescribed by a consultant. You will be an inpatient, but you may walk to and from your appointments alone if you feel well enough and desire to do so. Alternatively, a porter will collect you in a wheelchair.

How is TBI given?

During your treatment you will be on your own in the treatment room. You will be watched all the time by the radiographers on a television screen, and you can also be heard through an intercom facility, both of which are situated outside the treatment room. You will need to keep very still during treatment but if you need to move you can raise an arm and the machine will be turned off while you receive assistance.

Your first visit

Your first visit to the department is usually as an outpatient on a Friday afternoon. It is called a planning appointment and you will not receive any treatment.

The radiographers will take X-ray pictures of your chest. These X-rays are taken so that special lead plates can be made to shield your lungs during treatment. This is to ensure that your lungs which are very sensitive to radiotherapy, are not damaged. These X-rays are taken inside the treatment room using a small portable X-ray machine. Two films will be taken, one from the front and one from the back.

You will be required to stand during this procedure and during the treatment. There are foot positions marked on the floor to aid you to maintain the correct position. A seat is provided for you to rest against, not sit on, for additional stability.

Small metal crosses will be taped to your chest, both front and back, during the taking of the films – this is purely for reference on the films. These crosses will then be drawn on you, initially using felt tip pens but will be made more permanent with small tattooed dots. These markers ensure that the lung plates can be positioned accurately during your treatment. In addition to these X-rays, measurements are taken of your head, chest and hips. These aid calculation of the dose of radiation required for your treatment.

The lead plates take a few days to make, hence your treatment will not start until 7– 10 days later.

Commencement of treatment

Your treatment will be given over a period of four days. You are given eight treatments in total, divided into two per day.

Each visit to the department, at approximately 8.30 am and 4.00 p.m., lasts about half an hour – the treatment itself lasts 14 minutes for both front and back. During your treatment you will be standing in the same position as that in which the X-rays were taken on your first visit. The only difference being that a perspex screen will be placed close to you between you and the X-ray machine. The lung shields will be attached to this screen. A wax bag is taped to the front of your neck to compensate for the curve there. This is removed when the front treatment is complete.

The machine makes a buzzing noise whilst it is switched on. To counteract this you may wish to bring some cassette tapes of your own choice to listen to during treatment. The radiographers will supply a cassette player.

You will have to undress for your treatment and it gets quite warm in the treatment room. We recommend that you wear loose fitting underwear so that your feel comfortable, e.g. men – boxer shorts, women – camisole top and French knickers. On the ward you may wear your normal clothing.

To ensure that the correct dose is being administered, on your first and third visits small dosimeters are taped to you, front and back , in various positions. These are then measured by a physicist and any corrections to the dose are then accounted for during the subsequent treatments. X-ray films are taken during the first treatment to ensure that the lung plates are in the correct position.

Side-effects of the treatment

As stated earlier TBI affects both normal and abnormal cells and hence the resulting side-effects are seen on some of your normal tissues, e.g. the skin, hair, bone marrow, intestines and reproductive organs. Side-effects are divided into those occurring immediately, those occurring in the intermediate period and those occurring months or years following treatment.

Immediate potential side-effects;

Nausea and vomiting

Prior to commencing TBI you will be given two specific anti-sickness tablets. These will start the evening before you undergo treatment. Some patients require additional anti-sickness therapy and therefore if you feel sick at any time you must report this to the nurse caring for you. The majority of patients complete their TBI with no nausea or vomiting.

Parotids

This is swelling and inflammation of the parotid glands in the upper neck which can cause some discomfort. It occurs within 24 hours of treatment and can be controlled with mild painkillers. The symptoms disappear after treatment is complete.

Dry mouth

This usually occurs two to three days into treatment and can last up to three months following its completion. You can help to alleviate the discomfort by taking drinks regularly and performing mouth care two hourly, as instructed by the ward nurses. If you are distressed by this side-effect report it to the doctor, who may then prescribe some artificial saliva spray.

Skin rash

Radiotherapy can make your skin dry, itchy, red and sore. This is usually only mild and temporary but to try and prevent this you should follow a strict hygiene programme.

1. Only wash in a Luke warm shower and pat your skin dry very gently with a soft towel.

2. Do not use any perfumed soaps/shower gels or shampoos.

3. Use aqueous or E45 cream to prevent dryness and itching.

4. Use unperfumed baby powder to freshen your skin.

5. Use extra sunscreen if you are going out in the sun during the following six months.

Diarrhoea

This may occur as early as 48 hrs after TBI is commenced. Inform the nurse immediately if this occurs. A specimen will be taken to look for infection and if no infection is found drugs can be prescribed to constipate you.

Unfortunately it can take up to three days to check for infection which may be distressing if you have profuse diarrhoea. During this time you must perform strict standards of hygiene and may apply aqueous/E45 cream to the anal area to prevent the development of soreness and ulceration (always use gloves).

Intermediate, potential side-effects

Alopecia (hair loss)

Bone marrow depression

Both of the above are discussed in detail in the BMT information you have been given.

Somnolence

This may occur four to six weeks following TBI. Usually it is just a feeling of tiredness but sometimes results in the constant desire to sleep! This can be distressing as it may develop after discharge from hospital in the period when you expect to feel better. Don’t worry it will pass.

Late, potential side-effects;

Pneumonitis

This is inflammation of the lung tissue. Shielding your lungs during TBI is used to prevent this side-effect. However in a small percentage of patients it does occur six weeks to six months following TBI. The symptoms are shortness of breath and cough. If this occurs it must be reported immediately to the BMT specialists.

Cataracts

This is opacity of the lens of the eye which may occur three to four years after TBI treatment. If your eyesight is affected, the lens can be replaced by a relatively simple surgical procedure, usually as a day case.

Infertility

Most patients who under go BMT will become infertile because of the doses of drugs and radiation given. Discuss this with your doctor if this information is new to you.

Women may also experience premature menopause. The doctors will take blood tests to assess hormone function and will offer hormone replacement therapy after BMT, if appropriate.

Women may also experience problems with sexual intercourse, usually due to dryness of the vagina. If this does occur please discuss it with either a doctor, nurse or the BMT Co-ordinator as it may be easily remedied or other professional help sought. The BMT information discusses fertility in greater detail.

Second malignancies

Very rarely, patients who have been successfully treated may develop a new malignancy some years later. This may be either leukaemia or cancer. It is an unusual development.

All of the above can be discussed with a doctor, the BMT Co-ordinator, radiographers or ward staff. Please ask if you have any queries before treatment commences.

Prior to commencing TBI you will be asked to sign a consent form verifying that all issues have been discussed with you.

Your doctor should inform you of any possible long-term effects from your treatment. Please ask before you consent.

Further general information Your doctors and specialist nurses are in an ideal position to give you relevant information on your disease and treatment as they know your individual circumstances. Cancerbackup has a  telephone help line ( 0808 800 1234) and a prize winning video available in English, Italian, Urdu, Bengali, Gujarati and Hindi explaining Radiotherapy & Chemotherapy. Cancernet.co.uk has over 500 pages describing cancer, common tests, its management, treatment side effects, tips to alleviate them, advice on fertility, bone health, clinical trials, and practical issues such as travelling, finance, support groups, sexuality, smoking, diet and exercise.