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Fieldwork III: Final Project

Hippocampal Sparing Whole Brain Treatment
Karol Wynn, CMD
November 22, 2015

This project will describe the IMRT treatment plan utilized to treat a patient with
metastatic brain cancer in 2013 and be compared to a VMAT plan which would be used in the
clinic currently. The use of these hippocampal sparing techniques is recommended to decrease
memory loss in patients treated with whole brain irradiation1.
Area of Disease: This 45 year old patient was diagnosed with metastatic adenocarcinoma of the
lung in June of 2010. Her treatment included chemotherapy alone until she was found to have
progression of her disease in October of 2013. An MR revealed multiple sub centimeter
metastatic lesions in the infratentorial and supratentorial regions of the brain. The radiation
oncologist recommended hippocampal sparing whole brain radiotherapy (HA-WBRT) for
treatment of her brain metastasis.
Simulation and Patient Positioning: The patient was simulated in the supine position with arms
resting on the abdomen and a knee sponge placed under the knees. The patients head was
placed on a clear B Timo headrest and immobilized with a custom thermoplastic mask. The
mask was attached to the overlay device so that the patient would be extended off the end of the
treatment table. Her chin is in a neutral position as seen in Photo 1. The head position would
have been better with a chin up position to place the hippocampal avoidance region into a
smaller axial volume2. The CT scan range was from the top of the head to C3 with 1.5mm slice
thickness.

Photo 1: This photo displays the patients immobilization device.

Contouring: The CT scan was fused to the MR scans utilizing the Velocity fusion software. The
3D spoiled gradient (SPGR) Axial T1 post contrast images were fused along with the T2
weighted axials. The physician outlined the hippocampus and the optic chiasm in the Velocity
system which was then exported to the Eclipse TPS for planning. The MR images are not shown
because the patients fusion study has been removed from the Velocity system. The dosimetrist
contoured the remaining organs at risk (OR) and the optimization volumes. The following OR
structures were outlined for this plan: Orbit_R, Orbit_L, Optic_Nerve_L, Optic Nerve_R,
Brainstem, Parotids_Bilat, Spinal_Cord, skin_5mm and the Body as seen in Image 1.

R_Orbit: Purple
L_Orbit: Teal
L_Lens: Green
Brainstem: Maroon
R_Optic Nerve: Lavender
Chiasm

Hippocampus

Image 1: These images show the OR volumes.

Treatment Planning: The plans follow the RTOG 09331 protocol definitions for contouring, OR
constraints and dose specifications. The protocol defines the hippocampal avoidance volume as
the hippocampus expanded 5mm as shown in Image 2.

Image 2: The hippocampus is drawn bilaterally in green and shown on the axial, coronal and sagittal CT
slices. The hippocampal avoidance volume is displayed in pink.

The IMRT plan utilized the recommended 9 field beam parameters from the RTOG 0933
as displayed in Image 3 and listed in Table 1. The fields were aligned to the center of the PTV.
The patient was treated with the TrueBeam linear accelerator, a product of Varian, with the
Millennium 120 MLC. The beam energy, a mixture of 6MV and 10MV, was determined by a
trial and error process evaluating the beams SSD, dose coverage and hotspot during the planning
process. The calculation was completed with Smart MLC with Jaw tracking selected and the
AAA_10028 calculation algorithm.

Image 3: This image displays the 9 field beam arrangement and isocenter for the IMRT plan.

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Table 1: The table defines the beam parameters for the IMRT plan.

The optimization volumes for the IMRT planning modality are defined in Table 2. The
planning optimization objectives are listed in image 4. The PTV was divided into two volumes to
separate the HA from the PTV. This enables the optimizer to deliver a more homogenous dose in
the non-hippocampal brain volume. The goal was avoid conflicting objectives and overlapping
structures. The prescription is 30Gy/10fx with at least 90% of PTV covered by the prescription
dose and 98% covered in the 25Gy dose volume. The NTO was given a 105 priority with limits
set to 0.5cm from target at 95% and a falloff of 50% at 0.1.

Image 4: The optimization values for the IMRT plan are shown.

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Table 2: The table describes the IMRT optimization volumes and the definition of each.
IMRT Optimization volumes

Description

CTV
PTV
PTV_HP_Volume
PTV_SUBT_PTV_HP
Lens_Bilat
Orbits_Bilat

Brain Parenchyma
CTV subtracting the HA volume
PTV in the axial volume of the HA volume only
PTV subtracting the PTV_HP_Volume (+1mm)
R&L Lens
R&L Orbits

The final plan selected for treatment met the critical structure doses and target coverage
in the acceptable deviation category. The physician selected this plan due to the volume of the
110% dose. The dose distribution (Image 5a-c) and DVH (Image 6) are displayed below. A table
detailing the comparison of the OR and PTV coverage for both planning modalities is shown in
Table 4.

Image 5a-b: The axial and coronal view of the isodose distribution is shown.

Image 5c: The sagittal view of the isodose distribution is shown.

PTV
L_Optic Nerve
R&L Orbit

Chiasm

Hippocampus
R&L
Lenses

Image 6: The DVH displayed for the IMRT plan.

R_Optic Nerve

The VMAT plan utilizes the same CT data set and OR structures as the IMRT plan. The
plan has two VMAT arcs centered to the hippocampal volume. The first 358 arc was defined to
the inferior volume with the MLC shaped to the PTV Inf plus 5mm at a collimator angle of 95.
The second 358 arc was defined to the superior volume with the MLC shaped to the PTV Sup
plus 5mm at a collimator angle of 265(Images 7&8). The VMAT optimization volumes and
objectives follow the recent paper published in Medical Dosimetry by Shen, Bender, and
Yaparpalvi etal3 as shown in Table 3. These volumes are shown in Image 9. The VMAT OR
constraints and PTV optimization objectives are shown in images 10 and 11.
Table 3: The table describes the VMAT optimization volumes and the definition of each.
VMAT Optimization Volumes

Descriptions

CTV
PTV_VMAT
PTV Sup
PTV Inf
sPTV1
sPTV2
sPTV3
sPTVu

Brain Parenchyma
CTV subtracting the HA volume
PTV above the center of the hippocampus
PTV below the center of the hippocampus
5mm ring around the HA volume
PTV in the axial volume of the HA minus sPTV1
PTV subtracting sPTV2 (+1mm)
1.5 mm slice at the superior and inferior volume of
sPTV2

Images 7 & 8: The DRR on left is the Inf Arc and the right DRR is the Sup Arc.

Image 9: The optimization volumes are defined as sPTV1 in blue, sPTV2 in red, sPTV3 in orange and
sPTVu in green.

Image 10: This optimization table is for the VMAT plans critical structures.

Image 11: This optimization table is for the VMAT plans target structures.

The plan was optimized using the TrueBeam linear accelerator with the Millennium 120
MLC with 10MV beam energy. The calculation was completed with the AAA_11031 algorithm
and optimized with the Progressive Resolution Optimizer, Version 11.0.31. This plan met the
majority of the plans objectives in the variation acceptable dose criteria. The hippocampus was
slightly over the RTOG constraints. The bilateral lenses and orbits were over the departmental
dose constraints. This was most likely due to the head position. The 110% volume was located
in the HA area as expected. The isodose distribution and the DVH are displayed in images 12 a-c
& 13. I prefer the VMAT distribution and planning steps. The PTV optimization volumes are a
good fit for this treatment and the treatment time would be considerably less for the patient. In
this case, the IMRT plan was superior for volume coverage and critical structure doses. With
better head positioning and more planning experience, the VMAT technique should prove to be
superior.

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Table 4: RTOG Criteria comparison between the IMRT and VMAT plans
Structures

Variation Acceptable

IMRT

VMAT

Optic Nerves

RTOG 0933
Criteria
D2% 37.5Gy
D98% 25Gy
D100% 9Gy
Max 16Gy
Max 37.5Gy

D2% >37.5Gy 40Gy

D98%< 25Gy
D100% 10Gy
Max 17Gy
Max 37.5Gy

Chiasm

Max 37.5Gy

Max 37.5Gy

D2% =32.9Gy (Met)

D98% =25.7Gy
D100% =9.3Gy (Met)
Max=16Gy
Max_R =32.6Gy
(Met)
Max_L =31.1Gy(Met)
Max= 33Gy (Met)

D2% =34.7Gy (Met)

D98%= 24.2Gy
D100% =8.7Gy
Max=16.8Gy
Max_R= 33.9Gy
(Met)
Max_L= 34.2Gy
Max= 36.7Gy (Met)

PTV
Hippocampus

Image 12a-c: The axial and coronal views of the isodose distribution are shown for the VMAT plan.

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Chiasm

PTV
Hippocampus
R&L
Lenses

Image 13: The DVH displayed for the VMAT plan.

L_Orbit

R_Orbit

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References
1. A phase II trial of hippocampal avoidance during whole brain radiotherapy for
metastases: RTOG 0933: version date: 12/5/2011
2. Cheon G, Kang S, Kim T. et al. Optimization of patient head angle position to spare
hippocampus during the brain radiation therapy.heon G, Kang S, Kim T. et al.
Optimization of patient head angle position to spare hippocampus during the brain
radiation therapy. Med. Phys. 42, 3471 (2015); http://dx.doi.org/10.1118/1.492495.
3. Shen J, Bender E, Yaparpalvi R, Kuo H, Basavatia A, Hong L. et al. An efficient
volumetric arc therapy treatment planning approach for hippocampal-avoidance whole
brain radiation therapy. Med Dosim. 2015;40(3):205-209.