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or turbo field echo (TFE) axial MRI scan with standard axial and coronal fluid attenuation
inversion recovery (FLAIR), axial T2-weighted and gadolinium contrast-enhanced T1-weighted
sequence acquisitions to allow for accurate contouring of the Hippocampus.1 The MRI scan
should use the smallest possible axial slice thickness not exceeding 1.5 mm, however the
associated coronal and sagittal acquisitions can be up to 2.5mm in slice thickness. The MRI
should be acquired within two weeks prior to treatment initiation.
CU underwent the turbo field echo (TFE) axial MRI scan with standard axial and coronal fluid
attenuation inversion recovery (FLAIR), axial T2-weighted and gadolinium contrast-enhanced
T1-weighted sequence MRI scan the week prior to the treatment planning CT simulation.
After the treatment planning simulation on the CT simulator, the images were sent to the Eclipse
treatment planning system (TPS). The images were imported into Eclipse, the CT data set was
named, the CT images were registered with the MR images, a new plan was inserted, and a
structure set was inserted from template before closing out of the patient so that the radiation
oncologist could contour the clinical target volume (CTV) and planning target volume (PTV) as
follows:
CTV: whole brain parenchyma to C1 (if no posterior fossa metastasis) or C2 (if MRI evidence
of posterior fossa metastasis).2
PTV: CTV excluding the hippocampal avoidance regions2
After the radiation oncologist contoured the CTV and PTV, the remaining organs at risk (OR)
were contoured. The OR for the treatment of the whole brain with hippocampal sparing of this
patient included the hippocampi, optic chiasm, right optic nerve, and left optic nerve. The lenses
were contoured additionally.
For this plan, optimization structures were also created. These structures include: Avoidance
(2cm ring around the PTV used to keep the dose distribution conformal), Hippocampi Avoid
(5mm margin around each hippocampus used to reduce the dose to the hippocampi), PTV near
hippocampi (PTV in 5mm ring around the hippocampi avoid used to ensure some dose coverage
while reducing dose to the hippocampi-large dose gradient), PTV in planes (PTV in the same
axial planes as the hippocampi avoid-optimized for 98% to receive 2700; dose here is allowed to
be higher so that dose might more quickly fall off at the hippocampi avoidance area), PTV (brain
that is not in the same axial plane as the hippocampi avoid-optimized to receive prescription
coverage), PTV in between (Single slice PTV between the PTV in plane and the PTV, superior
and inferior slice-optimized to receive prescription but dose here is allowed to be higher so that
dose might more quickly fall off at the hippocampi avoidance area), Dose 2500cy (area receiving
2500cGy cropped from inside the hippocampi avoid by 5mm, cropped from the area receiving
3000cGy, and cropped from outside of the brain 0mm-optimized to increase dose to areas
lacking coverage), Dose 3700cGy (area receiving 3700cGy-optimized to decrease dose to areas
receiving 3700cGy), Dose 3600cGy (area receiving 3600cGy-optimized to decrease dose to
areas receiving 3600cGy) and Lens+ (3mm margin around each eye-optimized to reduce dose to
the lens).
Figure 1. PTV contours. Contoured as seen in the whole brain irradiation with
hippocampal sparing presentation by Jin Shen, CMD.2
Beam Isocenter/Arrangement: The written directive was received from the radiation oncologist
with the intended prescription and technique. The isocenter was placed medial between the left
and right hippocampi, mid-brain anterior-posterior (approximately half the distance of the
hippocampi avoidance structure), and superiorly-inferiorly through the midline of the
hippocampi avoid. The isocenter was placed within the hippocampi region of the brain, so that
fields might be designed to treat the superior and inferior portions of the brain in separate arcs,
while blocking the hippocampus as necessary without compromising PTV coverage.
American Association of Medical Dosimetrists (AAMD) 40th annual meeting in Orlando Florida
in June of 2015.3The collimator angles and partial collimator opening used for Arcs 1 and 2
allowed the hippocampus to be blocked during treatment of the superior and inferior portions of
the brain.
evaluate the PTV coverage and ensure that the dose constraints were met and scrolling through
the images to view the dose distribution.
The following constraints were used for plan evaluation:
Table 1. RTOG protocol 0933 constraints.1
Treatment
Component
HA-WBRT
Parameter
Per Protocol
Variation Acceptable
Deviation
PTV
D2%>37.5Gy,<40Gy
Unacceptable
V30 < 90%
Hippocampi
Optic Nerves
16Gy
Maximum dose <
17Gy
Maximum dose <
and Chiasm
37.5Gy
37.5Gy
37.5Gy
IMRT Planning
During the first plan evaluation the plan was normalized so that the V30 of the PTV received
90% of the prescription because coverage less than this is a deviation unacceptable per the
RTOG 0933 protocol.1 The coverage achieved may be seen with the following table.
Table 2. Plan 1 evaluation.
Treatment
Component
HA-WBRT
Parameter
Variation Acceptable
Deviation
D2% <
D2%>37.5Gy,<40Gy
Unacceptable
V30 < 90%
D2% = 38.6Gy
37.5Gy
D98% = 23.8Gy
D100% = 8.5Gy
9Gy
Maximum dose
Maximum dose
Maximum
17Gy
> 17Gy
= 16.Gy
Optic
Maximum dose
Maximum dose
Chiasm
Left Optic
37.5Gy
Maximum dose <
< 37.5Gy
Maximum dose
= 39.2Gy
Maximum dose
Nerve
Right Optic
37.5Gy
Maximum dose <
< 37.5Gy
Maximum dose
= 33.1Gy
Maximum dose
Nerve
37.5Gy
< 37.5Gy
= 34.5Gy
PTV
IMRT
Planning
Hippocampi
Per Protocol
Dose Achieved
Adjustments were made to improve the plan. The structure PTV in Planes was cropped from
inside of the optic chiasm to reduce dose to the optic chiasm as PTV coverage is optimized. The
isodose level of 3700cGy was converted to a structure. The isodose level of 3000cGy was
converted to a structure. The isodose level of 2500cGy was converted to a structure and then
cropped from outside of the brain, inside the hippocampi avoid with a 5mm margin, and inside
the Dose 3000cGy. The isodose level of 2500cGy was used because this was the point at which
the coverage began to drop off at the anterior portion of the brain.
Optimization was continued from the previous plan and taken back to the second phase. Under
VMAT Optimization a lower objective was given to the Dose 2500cGy to increase dose to this
area so that the D98% might be increased. Two upper objectives were given to the Dose 3700 to
reduce dose to the area so that the D2% might be reduced. The priorities for the optic chiasm and
hippocampi were increased to further reduce dose to these structures.
After VMAT optimization the plan was normalized so that the V30 received 90% of the
prescription and then evaluated for a second time. The coverage achieved may be seen below.
Table 3. Plan 2 evaluation.
Treatment
Component
HA-WBRT
Parameter
Variation Acceptable
Deviation
D2% <
D2%>37.5Gy,<40Gy
Unacceptable
V30 < 90%
D2% = 37.7Gy
37.5Gy
D98% = 25.5Gy
D100% = 8.5Gy
9Gy
Maximum dose
Maximum dose
Maximum
17Gy
> 17Gy
= 16.6Gy
Optic
Maximum dose
Maximum dose
Chiasm
Left Optic
37.5Gy
Maximum dose <
< 37.5Gy
Maximum dose
= 36.5Gy
Maximum dose
Nerve
Right Optic
37.5Gy
Maximum dose <
< 37.5Gy
Maximum dose
= 32.3Gy
Maximum dose
Nerve
37.5Gy
< 37.5Gy
= 34.8Gy
PTV
IMRT
Planning
Hippocampi
Per Protocol
Dose Achieved
Again adjustments were made to improve the plan. The Dose 3700cGy, Dose 3000cGy, and Dose
2500cGy structures were again created. The Dose 2500cGy was cropped from outside of the
brain, inside the hippocampi avoid with a 5mm margin, and inside the Dose 3000cGy. If these
structures are to be used during optimization it is necessary to re-create them after each
optimization because the dose distribution changes with each optimization.
Optimization was continued from the previous plan and taken back to the second phase. During
VMAT Optimization the same lower objectives were entered for the new Dose 2500cGy so that
coverage might be increased in this area and increase the PTV D98%. The same upper objectives
were entered for the Dose 3700cGy so that the dose might be reduced in this area thereby
reducing the PTV D2%. Priority for the hippocampi upper objectives was increased to reduce the
maximum dose to the hippocampi.
The plan was re-evaluated after completion of the VMAT optimization. Dose achieved may be
viewed below.
Table 4. Plan 3 evaluation.
Treatment
Component
HA-WBRT
Parameter
Variation Acceptable
Deviation
D2% <
D2%>37.5Gy,<40Gy
Unacceptable
V30 < 90%
D2% = 38Gy
37.5Gy
D98% = 25.6Gy
D100% = 8.6Gy
9Gy
Maximum dose
Maximum dose
Maximum
17Gy
> 17Gy
= 15.6Gy
Optic
Maximum dose
Maximum dose
Chiasm
Left Optic
37.5Gy
Maximum dose <
< 37.5Gy
Maximum dose
= 36.5Gy
Maximum dose
Nerve
Right Optic
37.5Gy
Maximum dose <
< 37.5Gy
Maximum dose
= 32.1Gy
Maximum dose
Nerve
37.5Gy
< 37.5Gy
= 35Gy
PTV
IMRT
Planning
Hippocampi
Per Protocol
Dose Achieved
Optimization was continued from the previous plan and taken back to the second phase. In order
to reduce the D2%, the 3600cGy isodose level was converted to a structure. Under VMAT
Optimization, three upper objectives were used to reduce the dose in this area. Optimization was
continued from the previous course and taken back to the second phase. The priority was
increased slightly from that which was used for the Dose 3700cGy. No improvement was seen;
therefore the priority was increased significantly. No other objectives were changed.
The plan was re-evaluated and all constraints were met per protocol. The maximum dose was in
a satisfactory location, inside the PTV and outside of the hippocampus.
Figure 5. Axial view of the isodose distribution of the final plan. The CTV is the
entire brain shown in light pink. The PTV is the CTV excluding the hippocampi
avoidance regions, shown in brown. The 3000cGy isodose line, shown in red nearly
covers the entire PTV. The area between the hippocampi is receiving 90% of the
prescription dose at 2700cGy.
Figure 6. Coronal view of the isodose distribution of the final plan. The CTV is the
entire brain shown in light pink. The PTV is the CTV excluding the hippocampi
avoidance regions, shown in brown.
Figure 7. Coronal view of the isodose distribution of the final plan. The CTV
is the entire brain shown in light pink. The PTV is the CTV excluding the
hippocampi avoidance regions, shown in brown.
the arc rotations. During treatment planning the anterior portion of the brain was significantly
lacking coverage. So, I increased the Y field size to fully encompass the brain during the arc
rotations and completely started over. My coverage was greatly improved. I used this plan as the
first plan in this treatment planning series. With my Y field size so small, it took numerous plans
to get an acceptable plan. By opening the field size I was able to make all constraints per
protocol in only 4 plans.
References
1. Mehta, MP. A phase II trial of hippocampal avoidance during whole brain radiotherapy for
brain metastases-RTOG CCOP study.
https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0933. 2
Published 2011. Accessed October 23, 2015.
2. Shen Jin. An efficient VMAT Panning Approach for Hippocampal-Avoidance Whole-Brain
Radiation Therapy (HA-WBRT). [PowerPoint]. Bronx, NY: Department of Radiation
Oncology Montefiore Medical Center; 2015.
3. Sloman B, Richards J, Preston D, et al. Plan challenge webinars.
http://planchallenge.sunnuclear.com/webinars. Accessed September 15, 2015.