Objective: Neuroblastoma is the most common extracranial solid tumor in children. In disseminated disease, total body irradiation (TBI) is used as part of myeloablative conditioning regimens prior to autologous stem cell transplantation (ASCT); however, it is associated with severe long-term sequelae including microcephaly, neurocognitive impairment, and skeletal growth arrest. Lu-177-DOTATATE is not proposed as a substitute for TBI in the conditioning setting, but rather is being evaluated as a targeted tumour therapy for relapsed or refractory SSTR2-positive high-risk neuroblastoma. This study aims to perform a dosimetric comparison of TBI and Lu-177-DOTATATE with respect to radiation doses delivered to developmentally critical organs, in order to quantify the differential organ-dose burden of each modality within its respective clinical indication.

Methods: Pediatric patients undergoing TBI as part of myeloablative conditioning and patients receiving Lu-177-DOTATATE for relapsed or refractory high-risk neuroblastoma will be enrolled following ethical approval. Dosimetric evaluation will include organ-absorbed dose calculations for the brain, growth plates, bone marrow, kidneys, and liver. TBI dosimetry will be assessed using thermoluminescent dosimeters (TLDs), and Lu-177 dosimetry will be performed using SPECT/CT-based quantification with the MIRD schema.

Expected Results: We hypothesize that Lu-177-DOTATATE delivers significantly lower absorbed doses to developmentally sensitive organs compared to TBI, while maintaining comparable anti-tumor efficacy in somatostatin receptor-positive neuroblastoma. Quantitative dosimetric data will be presented per organ and compared between the two modalities.

Conclusion: This dosimetric analysis is intended to provide radiobiological evidence supporting the integration of Lu-177-DOTATATE into standard pediatric oncology protocols as a safer alternative to TBI, particularly for patients with disseminated neuroblastoma expressing somatostatin receptor type 2.

• Lu-177-DOTATATE

• Neuroblastoma

• Total Body Irradiation

• Pediatric Dosimetry

• Radionuclide Therapy

• Somatostatin Receptor

Olmez S (2026) Comparison of Total Body Irradiation and Lu-177-DOTATATE Therapy in Pediatric Neuroblastoma: A Dosimetric Analysis of Organ-Specific Radiation Doses. JSM Clin Oncol Res 14(1): 1081.

Neuroblastoma is the most common extracranial solid malignancy in children, accounting for approximately 6–10% of all childhood cancers and nearly 15% of pediatric cancer-related mortality [1]. It arises from neural crest cells of the developing sympathetic nervous system, most frequently in the adrenal medulla, and is classified as a neuroendocrine tumor. While localized disease is often curable with surgery, disseminated high risk neuroblastoma continues to carry a poor prognosis despite multimodal treatment approaches including high dose chemotherapy, autologous stem cell transplantation (ASCT), radiation, and immunotherapy [2].

Total body irradiation (TBI) has historically been used as part of myeloablative conditioning regimens prior to ASCT in high-risk neuroblastoma. By delivering a uniform radiation dose to the entire body, TBI aims to eradicate residual tumor cells and achieve immunosuppression for engraftment [3]. However, TBI is associated with substantial long-term toxicities, which are particularly severe in the pediatric population. These include growth hormone deficiency, hypothyroidism, neurocognitive impairment, microcephaly, skeletal growth arrest, cataracts, pulmonary fibrosis, and an increased risk of secondary malignancies [4,5]. Recognizing these consequences, contemporary treatment protocols have moved toward TBI-free conditioning regimens; however, TBI continues to be used in selected patients with disseminated disease.

Lutetium-177 (Lu-177) is a beta-emitting radionuclide with a physical half-life of 6.7 days and gamma emission energies of 113 keV and 208 keV, making it suitable for both therapeutic and imaging purposes. When conjugated to somatostatin analogs such as DOTATATE, Lu-177 selectively targets somatostatin receptor type 2 (SSTR2) expressing cells, enabling targeted molecular radiotherapy with a more favorable organ dose profile than external beam radiation [6]. Lu-177-DOTATATE (Lutathera®) has been approved by the FDA and EMA for the treatment of SSTR2-positive gastroenteropancreatic neuroendocrine tumors in adults following the landmark NETTER-1 trial [7].

Neuroblastoma cells frequently express SSTR2, providing a rationale for targeting them with Lu-177 DOTATATE. Early clinical experience with Lu-177 DOTATATE in pediatric neuroblastoma demonstrated the safety and feasibility of this approach [8]. Subsequent clinical trials, including the LuDO and LuDO-N studies, have built upon this foundation, exploring optimized dosing schedules in relapsed and refractory cases [9,10]. Despite these advances, a systematic dosimetric comparison between TBI and Lu-177-DOTATATE—specifically with regard to absorbed doses in developmentally critical organs in children—has not yet been reported in the literature.

This gap is clinically and radiobiologically significant. It is important to emphasise that Lu-177-DOTATATE is not proposed in this study as a substitute for TBI within the myeloablative conditioning regimen prior to ASCT. Rather, it is evaluated as a targeted tumour therapy for patients with relapsed or refractory SSTR2-positive high-risk neuroblastoma—a distinct clinical indication. The dosimetric comparison is therefore not intended to suggest that the two modalities are interchangeable, but rather to quantify the differential organ dose burden that patients in each clinical pathway are exposed to, thereby providing evidence to inform individualised treatment decisions and future clinical trial design. We hypothesize that Lu-177-DOTATATE delivers significantly lower absorbed doses to growth-sensitive organs—including the brain, growth plates, and bone marrow—compared to TBI, while maintaining relevant anti-tumour activity in SSTR2 positive disease.

Study Design and Ethical Approval

This study is designed as a prospective, comparative dosimetric analysis conducted at [Institution Name]. Ethical approval will be obtained from the institutional ethics committee prior to patient enrollment. All procedures will be performed in accordance with the Declaration of Helsinki and applicable national regulations. Written informed consent will be obtained from patients’ parents or legal guardians.

Patient Selection

Two patient cohorts will be enrolled:

Cohort A (TBI group): Pediatric patients (age 18 months–18 years) with high-risk neuroblastoma scheduled to receive TBI as part of myeloablative conditioning prior to ASCT, in accordance with institutional protocols. These patients represent the upfront consolidation setting, typically following 1–2 prior lines of induction chemotherapy.

Cohort B (Lu-177-DOTATATE group): Pediatric patients (age 18 months–18 years) with relapsed or refractory high-risk neuroblastoma who demonstrate adequate SSTR2 expression on 68Ga-DOTATATE PET/CT (uptake equal to or greater than liver background) and are scheduled to receive Lu-177-DOTATATE therapy. These patients have typically received ≥3 prior lines of therapy.

Exclusion criteria for both cohorts include: prior radiation therapy to more than two body regions, renal insufficiency (GFR < 60 mL/min/1.73 m²), active second malignancy, or inability to provide informed consent.

Acknowledgment of Cohort Heterogeneity

It is acknowledged that the two cohorts represent inherently different disease states. Cohort A (TBI) includes patients undergoing myeloablative conditioning prior to first or second ASCT in the upfront or early relapse setting, whereas Cohort B (Lu-177-DOTATATE) consists of relapsed or refractory patients who have typically received multiple prior lines of therapy and have confirmed SSTR2-positive disease. Differences in disease burden, bone marrow reserve, organ function, and tumor biology between the cohorts may therefore influence dosimetric measurements—particularly for bone marrow and kidney doses.

To capture and control for this heterogeneity, the following patient-level variables will be systematically recorded for all participants: disease stage (INRG classification), number of prior therapy lines, SSTR2 expression status (Cohort B only, scored by 68Ga-DOTATATE PET/CT), bone marrow involvement at enrollment, prior radiation history, and baseline renal function (GFR). These variables will be reported descriptively in Table 1 (Baseline Patient Characteristics) and will be considered in the interpretation of all dosimetric comparisons. While formal statistical matching is not feasible given the small expected sample size and distinct clinical indications of the two cohorts, subgroup analyses stratified by bone marrow involvement and prior treatment intensity will be performed where numbers permit.

Given these inherent differences, the dosimetric comparison between cohorts should be interpreted as hypothesis-generating rather than a formal equivalence analysis. The primary aim is to quantify and contextualize the organ dose burden of each modality within its respective clinical application, rather than to establish head-to-head equivalence between patient populations with distinct disease trajectories.

TBI Dosimetry

TBI will be delivered using a standard linear accelerator protocol at [Institution]. The standard fractionated regimen consists of 12 Gy total dose administered in 6 fractions (2 Gy per fraction). Dosimetric assessment will be performed using calibrated thermoluminescent dosimeters (TLDs) placed at anatomical sites corresponding to the brain, cervical/lumbar spine growth plates, sternum (bone marrow surrogate), kidneys, and liver. TLD readings will be obtained following each TBI fraction and summed to calculate total absorbed dose per organ. Dose homogeneity will be evaluated across measurement sites. All TLD measurements will be performed by a certified medical physicist.

Lu-177-DOTATATE Dosimetry

Lu-177-DOTATATE will be administered as weight based activity (200 MBq/kg) per cycle, with a planned treatment course of 4 cycles administered at 8-week intervals, in accordance with the LuDO-N protocol [9]. Dosimetric imaging will be performed following each administration. Whole-body planar scintigraphy will be acquired at 4, 24, and 96 hours post-injection. SPECT/ CT imaging of the abdomen, thorax, and skull will be performed at the 24-hour time point. Organ-absorbed doses will be calculated using the Medical Internal Radiation Dose (MIRD) schema [11], with time-integrated activity coefficients derived from multi-time-point imaging. Dosimetric software (HERMES HybridViewer with OLINDA/EXM v2.1) will be used for absorbed dose calculations, utilising age-appropriate paediatric phantoms. Cumulative organ doses across all administered cycles will be the primary dosimetric endpoint for Cohort B. If cumulative kidney dose approaches the pre-specified safety threshold of 23 Gy, subsequent cycle activity will be adjusted accordingly and this will be documented.

Organ Dose Comparison

The primary dosimetric endpoints are absorbed doses (Gy) to the following organs: brain, growth plates (proximal femur and lumbar vertebral endplates as surrogates), active bone marrow, kidneys, and liver. Doses from both cohorts will be expressed as mean ± standard deviation and compared using the Mann-Whitney U test (non-parametric), given the expected small sample sizes. A p-value of <0.05 will be considered statistically significant. All statistical analyses will be performed using SPSS v26 (IBM, Armonk, NY, USA).

Sample Size

Based on existing literature and available patient populations at our institution, we estimate enrollment of 10–15 patients per cohort over an 18-month period. Given the exploratory nature of this dosimetric study, formal power calculations were not performed; however, this sample size is consistent with similar published dosimetric feasibility studies in pediatric nuclear medicine.

Patient enrollment and data collection are currently ongoing; no participant data have been collected at the time of submission. The projected dose ranges and anticipated p-values presented in this section are not derived from preliminary patient data. They are based exclusively on: (a) published peer-reviewed dosimetric studies of Lu-177-DOTATATE in paediatric and adult neuroendocrine tumour patients [8-14], (b) institutional TBI dosimetry records consistent with the prescribed 12 Gy fractionated protocol, and (c) dosimetric modelling using age-appropriate paediatric phantoms (OLINDA/EXM v2.1). These projected values serve as a priori hypotheses to justify the study design and are explicitly labelled as expected estimates, not measured outcomes. All values will be replaced with participant-derived data upon study completion.

Patient Characteristics

We anticipate enrolling patients with a median age of [X] years (range: 18 months–18 years), with a male-to-female ratio of approximately 1.5:1, consistent with published epidemiological data on high-risk neuroblastoma. All patients in Cohort B are expected to demonstrate adequate SSTR2 expression on pre-treatment 68Ga-DOTATATE PET/ CT. Baseline patient characteristics, including disease stage, prior lines of therapy, bone marrow involvement, SSTR2 expression status, and renal function, will be presented in Table 1 upon completion of enrollment.

Table 1: Baseline Patient Characteristics and Cohort Variables (to be completed upon enrollment)

Note: Highlighted rows will be populated upon patient enrollment. SSTR2 = somatostatin receptor type 2; GFR = glomerular filtration rate; INRG = International Neuroblastoma Risk Group.

TBI Organ Doses

TBI is expected to deliver near-uniform whole-body doses of 12 Gy (fractionated, 2 Gy per fraction × 6 fractions) based on institutional protocol. TLD measurements are anticipated to confirm doses within ±10% of the prescribed dose at all measurement sites, including the brain (expected: 11.5–12.5 Gy), growth plates (expected: 11.5–12.5 Gy), and bone marrow (expected: 11.5–12.5 Gy).

Lu-177-DOTATATE Organ Doses

Based on published paediatric dosimetric data from the LuDO trial and related studies [8-12], and on dosimetric modelling using OLINDA/EXM v2.1 with age-appropriate phantoms, Lu-177-DOTATATE is projected to deliver considerably lower absorbed doses to non-target organs compared to TBI. The planned treatment protocol for Cohort B consists of 4 cycles of Lu-177-DOTATATE (200 MBq/kg per cycle), administered at 8-week intervals, in accordance with the LuDO-N protocol [9]. Estimated organ doses per cycle and cumulative doses across 4 cycles are as follows: kidneys 2.0–4.5 Gy/cycle (cumulative: 8.0–18.0 Gy, the dose-limiting organ with a cumulative constraint of 23 Gy); bone marrow 0.1–0.5 Gy/cycle (cumulative: 0.4–2.0 Gy); liver 1.0–2.5 Gy/cycle (cumulative: 4.0–10.0 Gy); brain <0.1 Gy/cycle (cumulative: <0.4 Gy); and growth plates <0.1 Gy/cycle (cumulative: <0.4 Gy). Dosimetric imaging after each cycle will allow prospective adjustment of subsequent activity if cumulative kidney dose approaches the safety threshold. These estimates are derived from published literature and modelling, as described above, and will be updated with patient-level measured data upon study completion.

Comparative Dosimetric Analysis

The primary expected finding is a statistically significant reduction in absorbed doses to the brain, growth plates, and bone marrow in Cohort B compared to Cohort A. Critically, this comparison is made between the total TBI dose (12 Gy, single course) and the projected cumulative Lu-177 DOTATATE dose across 4 planned treatment cycles. This difference is expected to be most pronounced for brain and growth plate doses, where TBI delivers approximately 12 Gy versus a projected cumulative dose of <0.4 Gy for Lu-177-DOTATATE—a difference of more than an order of magnitude. For bone marrow, cumulative Lu-177 doses (0.4–2.0 Gy) remain substantially lower than TBI (11.5-12.5 Gy), though the bone marrow is also the primary haematopoietic target of TBI in the conditioning setting, which must be considered in interpretation. The kidney cumulative dose from Lu-177-DOTATATE (8.0–18.0 Gy) merits careful monitoring, as it may approach or exceed TBI kidney doses in patients requiring the full 4-cycle course. Table 2 summarises the expected comparative dosimetric data on a cumulative basis.

Table 2: Expected organ-absorbed doses for TBI versus Lu-177-DOTATATE

This study presents the rationale and design for the first systematic dosimetric comparison of TBI and Lu-177-DOTATATE in pediatric neuroblastoma. The central hypothesis—that Lu-177-DOTATATE delivers substantially lower absorbed doses to developmentally sensitive organs—is strongly supported by the existing literature and constitutes the primary clinical motivation for this work.

The severe long-term sequelae of TBI in children are well documented. Studies have shown that children treated with TBI-containing conditioning regimens experience significantly greater growth retardation, neurocognitive deficits, and endocrine dysfunction compared to those receiving chemotherapy-only conditioning [4,5]. Specifically, TBI delivers near-uniform doses of 10–14 Gy to the entire body, including the developing brain, growth plate cartilage, and bone marrow. In a growing child, these doses are associated with permanent impairment of multiple organ systems.

In contrast, Lu-177-DOTATATE therapy is characterized by targeted delivery of beta radiation to SSTR2-expressing tumor cells, with substantially lower doses to non-target organs. The dose-limiting organ for Lu-177-DOTATATE is the kidney, which typically receives 2.0–5.0 Gy per cycle [12]. Crucially, the brain and growth plates—the organs most vulnerable to TBI-related developmental toxicity— receive negligible doses from Lu-177-DOTATATE, as they do not express significant SSTR2 and the beta particle range in tissue is limited to approximately 2 mm.

The LuDO trial, conducted at University College London Hospitals, demonstrated that Lu-177-DOTATATE is safe and feasible in children with relapsed or refractory high-risk neuroblastoma [8]. The subsequent LuDO-N multicenter trial, coordinated by Karolinska University Hospital, builds upon this experience with an intensified dosing schedule designed to maximize anti-tumor efficacy while maintaining cumulative dose constraints [9]. Our study complements these clinical efforts by providing dosimetric context: while those trials assess clinical response and toxicity, we quantify the comparative radiation burden to specific organs in the context of a direct head-to-head comparison with TBI.

An important consideration is that Lu-177-DOTATATE is only effective in tumors expressing adequate SSTR2. Patient selection via 68Ga-DOTATATE PET/CT is therefore a prerequisite for therapy. Previous studies suggest that a significant proportion of neuroblastomas express SSTR2, although expression may be heterogeneous within and between tumors [13-20]. This heterogeneity could limit the universal applicability of Lu-177-DOTATATE as a TBI substitute and will need to be addressed in future clinical guidelines.

The current study has several limitations that should be acknowledged.

First, and most importantly, the two cohorts are inherently non-comparable with respect to disease status, treatment history, and tumor biology. Cohort A (TBI) represents patients in the upfront consolidation setting with relatively uniform prior treatment exposure, whereas Cohort B (Lu-177-DOTATATE) comprises relapsed or refractory patients who have typically received multiple prior chemotherapy regimens, and who are selected on the basis of SSTR2 expression—a prerequisite not applicable to the TBI group. Differences in bone marrow reserve, organ function, degree of marrow involvement, and tumor differentiation status between cohorts may influence dosimetric measurements, particularly for bone marrow and kidney doses. Furthermore, SSTR2 expression heterogeneity within and between tumors in Cohort B introduces an additional layer of variability not present in Cohort A. These confounding variables will be systematically captured (Table 1) and considered in interpretation, but cannot be fully controlled in a study of this size. The dosimetric comparison should therefore be interpreted as hypothesis-generating and exploratory, rather than as definitive evidence of therapeutic equivalence.

Second, as a dosimetric study, it does not directly assess clinical outcomes such as tumor response, progression free survival, or overall survival. Dosimetric findings must therefore be interpreted alongside clinical efficacy data from parallel trials. Third, the relatively small expected sample size limits statistical power for subgroup analyses, including stratification by bone marrow involvement or prior treatment intensity. Fourth, the use of TLDs for TBI dosimetry, while validated and widely used, introduces measurement uncertainty of approximately ±5%. These limitations notwithstanding, the dosimetric comparison provides essential quantitative data to support evidence based treatment decisions.

From a broader perspective, the findings of this study have implications beyond neuroblastoma. The growing field of targeted radionuclide therapy is increasingly exploring the use of Lu-177 and other beta emitters as alternatives or complements to external beam radiotherapy in pediatric oncology. Demonstrating a substantially reduced dose burden to developing organs would strengthen the radiobiological case for this paradigm shift and could inform future clinical trial design, dosimetric guidelines, and regulatory submissions for pediatric use of Lu-177 labeled compounds.

This study is the first to systematically compare organ-specific absorbed doses between TBI and Lu 177-DOTATATE in pediatric neuroblastoma patients. We anticipate demonstrating that Lu-177-DOTATATE delivers substantially lower radiation doses to developmentally critical organs—including the brain, growth plates, and bone marrow—compared to TBI, while maintaining targeted anti-tumor activity in SSTR2-positive disease. It is important to note that the two cohorts differ inherently in disease status and treatment history, and dosimetric findings should be interpreted accordingly. These findings are intended to provide a radiobiological evidence base for integrating Lu-177-DOTATATE into standard treatment protocols for pediatric neuroblastoma, with the goal of reducing long-term developmental toxicity without compromising therapeutic efficacy. Prospective clinical studies incorporating both dosimetric and outcomes data, with careful attention to patient selection and cohort comparability, will be necessary to fully validate this approach.

The author wishes to thank the medical physics and nuclear medicine teams at Ankara University Institute of Nuclear Science and Hacettepe University Radiation oncology department and Nuclear medicine department for their technical support.

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