Group 3 Research Proposal

Working Title

To determine which VMAT planning technique for HCS-WBRT minimizes the dose to the
hippocampi and hot spots within the plan while maintaining PTV coverage and OAR dose
constraints.

Problem Statement

The problem is that high dose to the hippocampi can affect neurocognitive function in patients
and increased dose within the treatment volume causes radiation-induced side effects.

Purpose Statement

The purpose of this study is to compare VMAT HCS-WBRT techniques that decrease the dose to
the hippocampi and hot spot regions while maintaining PTV coverage and NRG-CC001 OAR
dose constraints.

Hypotheses Statements or Research Questions

H1A: The first research hypothesis (H1) is a VMAT technique will result in a HCS-WBRT plan
with dose to the hippocampi <1600 cGy while maintaining PTV coverage and NRG-CC001
OAR dose constraints.
H10: The first null hypothesis (H10) is no VMAT technique will result in a HCS-WBRT plan
with dose to the hippocampi <1600 cGy while maintaining PTV coverage and NRG-CC001
OAR dose constraints.
H2A: The second research hypothesis (H2) is a VMAT technique will result in a HCS-WBRT
plan with the maximum hot spot <110% while maintaining PTV coverage and NRG-CC001
OAR dose constraints.
H20: The second null hypothesis (H20) is no VMAT technique will result in a HCS-WBRT plan
with the maximum hot spot <110% while maintaining PTV coverage and NRG-CC001 OAR
dose constraints.

Summary
Treatment of brain metastasis with whole brain radiation therapy (WBRT) has been the
standard palliative radiation therapy technique.1 Typically, WBRT treatments have been planned
using 3D conformal beams consisting of two opposed lateral fields that avoid optic structures.
These plans provide sufficient coverage of the whole brain, but they are not useful in reducing
dose to the hippocampus. The hippocampus is located in the medial temporal lobe of the brain,
and is of significance while treatment planning because it is involved with learning, memory,
emotion, motor control, and endocrine regulation.2 With advancements in technology and options
for IMRT or VMAT planning techniques, there are now many ways to approach a WBRT
treatment with focus on hippocampus sparing (HCS). Previous studies have shown that
Volumetric Modulated Arc Therapy (VMAT) planning techniques, in comparison to 3D
techniques, result in comparable target coverage but can lower dose to OAR, including the
hippocampus.3

Many radiation therapy facilities follow specific protocols such as RTOG 0933 or NRG-
CC001 when planning HCS-WBRT VMAT plans. These protocols set specific guidelines for
PTV coverage as well as OAR dose constraints to the optic chiasm, optic nerves, both lenses,
and the hippocampus. Unfortunately, often while trying to meet these protocols’ dose
constraints, and provide sufficient PTV coverage, the hippocampus receives dose levels greater
than 1600 cGy and hot spots of 110% or greater appear within the brain. It is important to
decrease dose to the hippocampi because there is a proven strong relationship between the
maximum dose to the hippocampi and short-term memory deterioration, even amongst patients
who met the hippocampal constraints of the protocol, suggesting lower constraints may be
beneficial.4 Additionally, increased dose to any area can cause the patient unwanted radiation-
induced side effects. Furthermore, when attempting to plan the HCS-WBRT treatment using
VMAT planning techniques, the options are vast and there are no templates to follow to
efficiently and effectively produce a treatment plan that meets coverage and dose constraint
requests. Trial-and-error in beam arrangements, collimator angles, couch angles, optimization
techniques, and other VMAT planning techniques can take a lot of time and still not provide an
optimal treatment plan.

Therefore, three unique VMAT planning techniques for HCS-WBRT have been created
by three different radiation treatment facilities. VMAT planning technique “A” uses 2 full arcs
with the couch at 0, fields covering the entire brain, and collimator rotations of 30 (CW)and 330
(CCW). Plan A also uses 2 sagittal arcs with the couch at 270, collimator rotations at 90, and
split-x technique separating the brain into left and right portions. All beams in this plan use 6
MV with standard MLCs. VMAT planning technique “B” uses 2 full arcs with the couch at 0,
fields covering the entire brain using split-x technique that separates the brain superiorly and
inferiorly, and collimator rotations of 85 (CW) and 95 (CCW). Plan B also uses 2 partial sagittal
arcs with the couch at 270 (CW) and 274 (CCW), split-x technique separating the brain into left
and right portions, and collimator rotations of 100 (CW) and 80 (CCW). All beams in this plan
use 6 MV Flattening Filter Free (FFF) and HDMLCs. VMAT planning technique “C” uses 4 full
arcs with the couch at 355 for the first two and 5 for the second set of arcs, fields covering the
entire brain, and collimators at 30 (CW) and 330 (CCW). Plan C also uses a sagittal arc with
couch at 90, the field covering the entire brain, and collimator at 330. All breams in this plan are
6MV FFF with HDMLCs, also contours are used to separate the brain into upper, middle and
lower sections to help with optimization and hippocampus sparing.

The goal of this research is to compare and determine which, if any, of the three VMAT
planning techniques will result in dose less than 1600 cGy to the hippocampi as well as hot spots
under 110% while maintaining PTV coverage and meeting NRG-CC001 dose constraints.
Creating WBRT plans with lower dose to the hippocampus can help prevent cognitive
dysfunction, improve patients’ quality of life and prognosis, and avoid shrinkage of the
hippocampal volume.2
 References
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2 – how far can we reduce dose? Medical Dosimetry. 2022; 47:258-263.

https://doi.org/10.1016/j.meddos.2022.04.003

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hippocampal volume changes. Biomed Res Int. 2022; 2022:1-10.

https://doi.org/10.1155/2022/4267673

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https://doi.org/10.1016/j.meddos.2021.02.007