Stephanie Olson

10/16/2015
DOS 773-Final Project
Hippocampal sparing VMAT using Pinnacle Treatment Planning System
Patient Selection
Patient KM is a 34 year old female with a history of right breast cancer which was diagnosed
three years ago. At that time she underwent chemotherapy, mastectomy and radiation therapy to
the affected area. KM returned to our department over the summer presenting with brief
episodes of confusion and imbalance. She underwent a brain MRI showing a lesion in the right
occipital lobe. A CT of the chest, abdomen, and pelvis showed no disease elsewhere. The
occipital lobe lesion was resected confirming the pathology of metastatic breast cancer.
The Plan
After discussing the natural history of untreated brain metastasis and the role of radiation therapy
providing palliation, presenting KMs case at tumor board, and discussing the cases with
colleagues in attendance, it was recommended to KM and her husband to treat using a
hippocampal-sparing whole brain radiation approach. Given the breast cancer histology, duralbased location and need for surgery to establish the diagnosis, the concern was an increased risk
for more disseminated relapse, specifically leptomeningeal spread of disease. The prescription
recommended for this plan was a dose of 30 Gy at 3 Gy per fraction for 10 fractions while
keeping the maximum dose to the hippocampus to only 16 Gy. No additional boost was planned
for this patient.
Simulation
Patient KM underwent a CT simulation scan for radiation therapy treatment planning. The
patient was placed in the supine position using a Civco head Aquaplast mask with standard clear
head sponge. The patients arms were at her sides and a sponge was placed under her knees for
support. Planning CT images were acquired using 1.0 mm slices. The scanning parameters
included from the vertex of the head and extended to include the C4 vertebral body. One set of
3-point fiducials were placed on the patients head. The 3-point markings were documented on
the patients mask using tape and a Sharpie marker.

Target Delineation
After completion of the CT simulation scan, the CT data set was transferred into the Philips
Pinnacle3 treatment planning system (TPS) for contouring. Two axial MRI data sets were fused
to the treatment planning CT to assist in the contouring and target delineation process. The
radiation oncologist contoured the planning tumor volume (PTV) which included the entire brain
minus the hippocampal avoidance region. Additionally, the hippocampus and the hippocampal
avoidance structures were also contoured by the radiation oncologist. The PTV is outlined in
red, the hippocampus in purple and the hippocampal avoidance region is shown in orange in the
figure below.

The contoured organs at risk (OR) included the left and right eye in brown, left and right lens in
yellow, left and right optic nerves in maroon, chiasm in blue, brainstem in orange, and spinal
cord in green in the image below.

Once all contouring was finalized, the radiation oncologist completed a treatment planning order
which identified the prescription, dose constraints and other pertinent treatment planning
information. The instructions were based on the Radiation Therapy Oncology Group (RTOG)
09331 and are as follows:
Structure
Whole brain PTV

Ideal dose constraint

D2% 37.5 Gy

Hippocampus

D98% 25 Gy
D100% 9 Gy

Optic Nerves
Chaism

Max dose 16 Gy
Max dose 37.5 Gy
Max dose 37.5 Gy

Beam Isocenter/Arrangement

An isocenter was placed in the center of the brain at the level one CT slice superior to the most
superior aspect of the hippocampal structure.

Four beams were used to obtain optimal coverage to the PTV while sparing the hippocampus and
normal tissue constraints. Three full coplanar arcs with varying collimator angles were used with
the addition of a vertex-like arc spanning a total of 158 with the couch angle rotated 90 off of
zero. All beams were 6 megavoltage in energy. A VMAT planning technique was used.

Beams eye view and rendering for Beam_1.

Beams eye view and rendering for Beam_2.

Beams eye view and rendering for Beam_3.

Beams eye view and rendering for Beam_4.

Treatment Planning

The radiation oncologist instructed the dose prescription and objectives, which were to cover
98% of the whole brain PTV with 25 Gy and to keep the maximum dose to the hippocampus to
16 Gy or less. To aid in the treatment planning process, additional planning structures were
created. These structures included the left and right hippocampal avoidance which consisted of
the hippocampus plus a 5 mm expansion. An optimized tumor volume (OTV) which consisted
of the PTV plus a 0.125 mm expansion and OTV sub-volumes which included sOTVa, sOTVb,
and sOTVc. These structures broke the OTV into three parts consisting of the hippocampal
avoidance structure plus a 5 mm expansion, the slices of OTV which included the sOTVa
structure, and the OTV minus the sOTVa and sOTVb structures.

To begin the optimization process, the OTV and sub-OTV volumes plus the hippocampal and
hippocampal avoidance structures were added to the inverse planning window in the Pinnacle3
TPS.

After allowing the plan to optimized until the desired objectives for the PTV and hippocampal
OAR constraints were met, additional OAR structures were included in the inverse planning
window.

As the plan optimized, the weightings of the hippocampi and OAR constraints were steadily
increased while maintaining the desired PTV coverage. Additional objectives such as max
DVH points were added to meet desired goals for the varying OAR constraints.

Plan Analysis & Evaluation

All desired PTV and OAR constraints were achievable for this treatment plan. The volume of
PTV receiving 25 Gy was 98.93% and the volume receiving 37.5 Gy was 0.0%. The maximum
dose to the hippocampus was 14.34 Gy while only 58.53% of the hippocampus volume received
9 Gy. The maximum doses to the chiasm, right optic nerve, and left optic nerve were 30.98 Gy,
30.96 Gy, and 30.26 Gy respectively. The isodose lines and dose volume histogram are shown
below. The isodose lines are as follows: 35.0 Gy (red), 30.0 Gy (green), 25.0 Gy (yellow), 20.0
Gy (light blue), 15.0 Gy (dark blue), 10.0 Gy (lavender), and 5.0 Gy (khaki).

Conclusion
The purpose of choosing this particular case was to compare TomoTherapy versus VMAT
treatment planning techniques for hippocampal sparing whole brain radiation. In both planning
techniques, all constraints were met. The table below shows a comparison between the two
planning techniques:
Structure
Whole brain PTV

Ideal dose constraint

D2% 37.5 Gy

VMAT
D37.5 Gy = 0.0%

TomoTherapy
D37.5 Gy = 0.0%

D98% 25 Gy

D25 Gy = 98.93%

D25 Gy = 99.23%

Hippocampus

D100% 9 Gy

Max dose = 35.1 Gy

D 9 Gy = 58.53%

Max dose = 30.98 Gy

D 9 Gy = 76.7%

Optic Nerves

Max dose 16 Gy
Max dose 37.5 Gy

Max dose = 14.34 Gy

Max dose = 12.41 Gy
R max dose = 30.67 Gy R max dose = 30.96 Gy

L max dose = 30.64 Gy L max dose = 30.26 Gy

Chaism
Max dose 37.5 Gy
Max dose = 30.98 Gy
Max dose = 30.98 Gy
The PTV coverage was slightly better in the TomoTherapy based treatment plan as was the
hippocampal maximum dose.
The advantage to the VMAT treatment plan is the shorter amount of time it would take to
deliver the plan. The treatment time for the TomoTherapy plan was 30.5 minutes of beam-on
time. This long beam-on time when combined with the MVCT used to align the patient for

treatment means the patient is on the table for approximately 45 minutes each day. When using
the VMAT treatment plan, it would take less than 15 minutes, which is one-third the amount of
time.
Another advantage to the VMAT treatment plan is better dose conformality between the
hippocampus structures. By using a vertex-like arc, dose is better able to be deposited into this
region. The helical delivery of TomoTherapy often causes less than optimal dose coverage
between the hippocampi and is often the place where the TomoTherapy planning system places
the hot spot.
Both treatment planning techniques produce adequate plans for the delivery of
hippocampal avoidance whole brain radiation therapy. The decision as to which technique
should be used needs to be decided by the radiation oncologist. Factors as to treatment beam-on
time and maximum hippocampal doses are factors which will need to be considered when
making that decision.

References
1 Radiation Therapy Oncology Group. RTOG 0933. A phase II trial of hippocampal avoidance
during whole brain radiotherapy for brain metastases.