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i. Acute: fatigue, plugging of the ears, otitis media, sore throat, and thrush
ii. Long-term: worsening memory, slowing of cognition, and also potential
radionecrosis
VII. The Plan (prescription)
a. Pulse reduced dose rate (PRDR) IMRT
i. 15 fields at 10 different gantry angles
ii. 6 MV for all fields
iii. 3 minutes between fields to deliver radiation at 6.67 cGy/min or 100
MU/min dose rate
iv. Normalized to the 97% isodose line
b. Total dose of 54 Gy given in 27 fractions, 2 Gy per fraction
c. CBCT done prior to every treatment for accurate alignment
VIII. Patient Setup/Immobilization
a. CT simulation done on November 2, 2016 on Siemens Edge 120 kV CT scanner
b. Positioning
i. Head first, supine on 1 inch black mattress with arms down by sides
ii. Head and shoulder board indexed at top of treatment couch
iii. black head dish and custom blue head sponge
iv. Custom Aquaplast mask
v. Large triangle cushion under knees
vi. Velcro strip around patients arms
IX. Anatomical Contouring
a. Fusion of CT simulation scan and MRI completed in MIM 6.4.5 software
b. Contours done in MIM
c. CTV, GTV, PTV, brainstem, optic chiasm, cochleas, and optic nerve contoured by
radiation oncologist
d. Normal structures contoured by dosimetrist and reviewed by radiation oncologist
i. Brain, eyes, lenses, external, skin, spinal cord
e. Constraints for structures given in treatment planning order (TPO)
X. Beam Isocenter/Arrangement
a. Varian TrueBeam radiotherapy system
b. 6 MV for all beams
c. Philips Pinnacle3 used for planning
d. Isocenter autoplaced in PTV volume by dosimetrist
e. Step and shoot IMRT
f. 15 fields
g. Gantry angles
i. 50o, 50o, 90o, 90o, 150o, 180o, 210o, 250o, 250o, 310o, 310o, 315o, 315o, 250o,
210o
h. Couch angles
i. 0o for first 11 fields
ii. 90o for last 4 fields
i. Collimator at 0o for all fields
j. Beam weighting
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i. 5%, 5%, 6.4%, 6.4%, 7.4%, 9.4%, 7.1%, 5.9%, 5.9%, 6.7%, 6.7%, 6.2%,
6.2%, 8.9%, 6.8%
k. Field shape created by using 0.7 cm margin around PTV by dosimetrist
XI. Treatment Planning
a. Philips Pinnacle3 used for planning
b. Treatment planning order (TPO) includes prescription and constraints written by
radiation oncologist
c. Dose prescribed to PTV volume using ROI Mean function in Pinnacle
d. Total dose of 54 Gy given in 27 fractions, 2 Gy per fraction
e. Physicist splits beams into certain MUs to accomplish desired dose rate (6.67
cGy/MU or 100 MU/min)
f. 6 MV for all beams
g. Step and shoot IMRT optimized on the PTV volume with a minimum of 4
segments per MU
h. Dose constraints (all met except right cochlea due to close proximity to treatment
volume)
i. Brain: Dmax < 60 Gy
ii. Brainstem: Dmax < 64 Gy
iii. Optic Chiasm: Dmax < 54 Gy
iv. Cochlea: Dmean < 35 Gy, Dmax < 40 Gy
v. Lens: Dmax < 7 Gy
vi. Optic Nerve: Dmax < 54 Gy
i. Normalized to 97%
j. Plan evaluated by dosimetrist then radiation oncologist by reviewing DVH and
isodose lines
XII. Quality Assurance/Physics Check
a. MU verification check done with Mobius3D software
i. 5% tolerance
ii. Completed by dosimetrist
b. Delta4+ used for physics QA check
i. 5% tolerance
ii. Completed by physicist
c. Plan passed both QA checks
XIII. Conclusion
a. PRDR feasible treatment option for recurrent gliomas when surgery not an option
b. Biology and physics behind this treatment technique
c. Challenging aspect of plan, length of treatment, patient on table and in mask for
over an hour each treatment
XIV. References
a. Veninga T, Langendijk HA, Slotman BJ, et al. Reirradiation of primary brain
tumours: survival, clinical response and prognostic factors. Radiotherapy and
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