The Hypothalamus

Contouring Accuracy Program

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 Outline

1. Refresher Course on the Hypothalamus

A. What is the Hypothalamus?
B. The Functions of the Hypothalamus
C. Pediatric Considerations
D. “Did You Know?”
2. Locating the Hypothalamus in Medical Images
A. Imaging Considerations
B. Superior and Inferior Limits
C. Contouring Step-by-Step Guide
3. Special Considerations for Radiation Therapy
A. Published Tolerances
B. Notable Protocols

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 1A. What is the Hypothalamus?

The hypothalamus is a area

of the brain made up of many
small nuclei.
It is located below the
thalamus and above the
midbrain.
The hypothalamus makes up
the ventral diencephalon,
which is an embryonic region
of the brain that gives rise to
the forebrain structures.
Image Credit: National
Institute Of Alcohol Abuse
Medscape and Alcoholism

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 1B. The Functions of the Hypothalamus
The hypothalamus serves as the link
between the endocrine system and
nervous system. It is responsible for
maintain the bodies internal balance
(homeostasis). This is done when the
hypothalamus stimulates or inhibits the
bodies key processes, such as:
• heart rate and blood pressure
• body temperature
• fluid and electrolyte balance
• appetite and body weight
• sleep cycles
• glandular secretions of stomach and
intestines
• influencing the pituitary gland to release Image Credit: Dr. Hareesh Krishnan
hormones
Endocrine Web

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 1C. Pediatric Considerations
• Radiation to the
hypothalamus can cause
hormone deficiencies in
growth hormone, thyroid
hormone, ACTH, and those
involved in puberty and Hypothalamus

metabolism. Pituitary

• Risk of loss at RT Dose:

o ~16 Gy = Growth Hormone
o ~30 Gy = Thyroid Hormone
o ~50-60 Gy = Complete Loss

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 1D. “Did You Know…?”

Animals that hibernate have an

internal clock which is controlled
by the hypothalamus.
The hypothalamus causes a series
of chemical reactions in the brain
that cause the hibernating animal
to wake up.

Earth Sky

Images Credit: Weird Nature

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 2A. Imaging Considerations (MRI)

• Magnetic resonance imaging is the technique

of choice for evaluating the hypothalamus.
• The very small size of this region requires the
use of specific high resolution MRI sequences.
• The hypothalamus is roughly 1-2 millimeters
across and can be difficult to identify.
• T1-weighted MRI sequences with 1-1.5 mm
slices are preferred for contouring.
• Both pre-and post contrast imaging can be
used and each provides important structural
information.

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 2B. Superior and Inferior Limits

Anatomic Boundaries

• Superior: the level of the anterior

commissure
• Anterior: the inferior anterior
border is the optic chiasm and
superiorly it is the anterior
commissure
• Posterior: the mammillary bodies
inferiorly and the thalamus and
fornix more superiorly
• Inferior (floor): the infundibular
stalk

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 2C. Contouring Step-by-Step Guide
• Contouring begins at the level of the optic chiasm, as the infundibulum terminates
into the hypothalamus
• As you move superiorly, the hypothalamus is bordered by the optic tracts anteriorly
and laterally
• The posterior border is formed by the mammillary bodies
• Note: Often the volume contoured for treatment planning is the hypothalamus *plus*
the mammillary bodies. Make sure you follow the instructions of your clinical team
and/or protocol.

Optic Chiasm
Optic Tract
Hypothalamus
Hypothalamus

Mammillary Bodies Mammillary Bodies

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 2C. Contouring Step-by-Step Guide

• As you move superiorly, the hypothalamus tracks the

lateral walls of the 3rd ventricle.

Hypothalamus
Hypothalamus
Thalamus

Anterior Commissure

Fornix
Hypothalamus

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 2C. Contouring Step-by-Step Guide

• Here it is bounded anteriorly by the anterior commissure

and posteriorly by the thalamus and fornix and laterally
by the internal capsule.
• The hypothalamic contour stops superiorly at the level
of the lateral crossing of the anterior commissure.

Anterior Commissure
Hypothalamus

Thalamus Fornix
Hypothalamus

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 3A. Published Tolerances

Volume Dose (Gy) Complication Reference Note

Growth Growth Hormone Secretion

Mean After Conformal Radiation
16Gy Hormone Therapy in Pediatric Patients Pediatric
dose
Deficiency With Localized Brain Tumors

Hypothalamic/pituitary function
following high-dose conformal
Max Endocrine radiotherapy to the base of
50Gy Dysfunction skull: demonstration of a dose– Adult
dose effect relationship using dose–
volume histogram analysis

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 3B. Other Notable Publications
• Effect of Treatment Modality on the Hypothalamic–
Pituitary Function of Patients Treated with Radiation
Therapy for Pituitary Adenomas: Hypothalamic Dose
and Endocrine Outcomes; Elson, A., Bovi, J., et al.;
Frontiers in Oncology, v.4; (2014)
• Growth Hormone Secretion After Conformal Radiation
Therapy in Pediatric Patients With Localized Brain
Tumors; Merchant, T.E., Rose, S.R., et al.; Journal of
Clinical Oncology, 29:36; (2011)
• Hypothalamic/pituitary function following high-dose
conformal radiotherapy to the base of skull:
demonstration of a dose–effect relationship using dose–
volume histogram analysis; Pai, H.H., Thornton, A., et al.;
International Journal of Radiation Oncology Biology and
Physics, 49:4; (2001)

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