1

Evaluation of Multiple VMAT planning techniques for hippocampal sparing whole brain
radiotherapy.

Kearla Bentz, BAS, RT(R)(T); Kristen Eberhard, RT(R)(T); Allison Wright, RT(T); Nishele
Lenards, PhD, CMD, RT(R)(T), FAAMD; Ashley Hunzeker, MS, RT(T)CMD; and Matt
Tobler, CMD, RT(T), FAAMD

Medical Dosimetry Program at the University of Wisconsin-La Crosse, WI

I. Abstract
II. Introduction
A. PI: The significance of brain metastases and WBRT treatments (Reference: Liu et al,1
Lamba,2 Krayenbuehl et al3)
B. PII: Hippocampus anatomy and radiation response (Reference: Liu et al,1 Sprowls et
al,4 Kazda et al5)
C. PIII: Technology advancements and protocols with HS-WBRT constraints
(Reference: Liu et al1, Krayenbuehl et al,3 Sprowls et al,4 Shang et al,6 Sood et al7)
D. PIV: Summarize introduction points (Reference: Krayenbuehl et al,3 Pokhrel et al,8
Redmond et al9)
E. PV: State the problem and purpose of this study and summarize previous research
1. Problem: 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.
2. Purpose: The purpose of this study is to compare VMAT HS-WBRT techniques
(A, B, C) that decrease the dose to the hippocampi and hot spots in brain tissue
while maintaining PTV coverage and NRG-CC001 OAR dose constraints.
Planning technique “A” consists of 2 full arcs and 2 partial arcs with split-x
technique separating into left and right portions. Planning technique “B” consists
of 2 full arcs and 2 partial arcs using split-x separating the brain superiorly and
inferiorly and into left and right portions. Planning technique “C” consists of 4
full arcs, and a sagittal arc with contours separating the brain into superior,
middle, and lower portions that are used in the optimizer.
 2

3. Hypotheses: This research will test the hypothesis that one of the three VMAT
HS-WBRT planning techniques will decrease the dose to the hippocampus to <
1600 cGy, while maintaining PTV coverage and NRG-CC001 dose constraints
(H1A). It will also test the hypothesis that one of the three VMAT planning
techniques will reduce hot spots within the brain tissue to < 115% of the
prescribed dose, while maintaining PTV coverage and NRG-CC001 dose
constraints (H2A).
III. Material and Methods
A. Patient selection and setup
1. PI: Patient Population
a. 10 Patients
b. Inclusion criteria (Hippocampus sparing whole brain treatments planned with
VMAT; 30 Gy in 10 fx, once daily)
c. Exclusion criteria (3DCRT or IMRT techniques, retrospective >3 years prior)
d. Patient simulation set-up (supine, brain mask)
B. Contours (Reference: NRG10)
1. PI: NRG-CC001 protocol contours
a. PTV (the whole brain)
b. Hippocampi and margins
c. OAR (optic structures)
C. Treatment Planning
1. PI: Planning details
a. Treatment planning system (Eclipse)
b. Machine (Varian TrueBeam STX with HD-MLCs)
c. Algorithm (AAA 16.1.0)
d. Energies (6MV-FFF)
2. PII-PIV: Planning procedures
a. PII: Field designs, gantry angles (Figures 1A, 1B, 1C)
b. PIII: Table kicks, arc directions (Table 1A, 1B, 1C)
c. PIV: Optimization
D. Plan Comparison
 3

1. PI: Evaluated metrics (Reference: Brown et al11)

a. Hippocampus (D100%, DMax)
b. Target dose (V30, D98%, D2%)
c. OAR dose (DMax)
E. Statistical Analysis
1. PI: Representation of data
a. Data for the dose to the hippocampus (Table 2A, 2B)
b. Data for dose to the brain and the maximum dose (Table 3A, 3B, 3C)
c. Data for the dose to OAR (Table 4A, 4B, 4C)
d. Frequencies (Table 5)
e. Friedman’s test
f. P < 0.1 considered statistically significant
IV. Results
A. PI: Hippocampi (HC) dose
1. D100% HC dose > 900 cGy (Table 2A)
2. Dmax HC dose < 1600 cGy (Table 2B).
3. If Dmax HC dose P < 0.1, then research fails to reject the null hypothesis.
B. PII-III: Dose to the brain (V30Gy, D98%, D2%)
1. Target dose V30Gy > 90-95% (Table 3A)
2. Target dose D98% > 22.5-25 Gy (Table 3B)

3. Target dose D2% < 115% or 3450 cGy (Table 3C)

4. If D2% P < 0.1, then research fails to reject the null hypothesis.
C. PIV: OAR Dmax Dose
1. Optic chiasm Dmax dose < 30-37.5 Gy (Table 4A)
2. Right optic nerve Dmax dose < 30-37.5 Gy (Table 4B)
3. Left optic nerve Dmax dose < 30-37.5 Gy (Table 4C)
D. PV: Frequency of results for each VMAT planning technique (Table 5)
V. Discussion
VI. Conclusion
4
 5

References

1. Liu H, Clark R, Magliari A, et al. Rapid plan hippocampal sparing whole brain model
version 2 – how far can we reduce dose? Med Dosim. 2022;47:258-263.
https://doi.org/10.1016/j.meddos.2022.04.003
2. Lamba N., Wen P.Y., Aizer A.A. Epidemiology of brain metastases and leptomeningeal
disease. Neurol-Oncol. 2021;23(9):1447-1456. https://doi.org/10.1093/neuonc/noab101
3. Krayenbuehl J, Di Martino M, Guckenberger M, et al. Improved plan quality with
automated radiotherapy planning for whole brain with hippocampus sparing: a
comparison to the RTOG 0933 trial. Radiat Oncol. 2017;12:161.
https://doi.org/10.1186/s13014-017-0896-7
4. Crockett C, Belderbos J, Levy A, McDonald F, Le Péchoux C, Faivre-Finn C.
Prophylactic cranial irradiation (PCI), hippocampal avoidance (HA) whole brain
radiotherapy (WBRT) and stereotactic radiosurgery (SRS) in small cell lung cancer
(SCLC): where do we stand? Lung Cancer. 2021;162:96-105.
https://doi.org/10.1016/j.lungcan.2021.10.016
5. Sprowls CJ, Shah AP, Kelly P, et al. Whole brain radiotherapy with hippocampal sparing
using Varian HyperArc. Med Dosim. 2021;46:264-268.
https://doi.org/10.1016/j.meddos.2021.02.007
6. Kazda T, Vrzal M, Prochazka T, et al. Left hippocampus sparing whole brain
radiotherapy (WBRT): a planning study. Biomed Pap Med Fac Univ Palacky Olomouc
Czech Repub. 2017;161(4):397-402. https://doi.org/10.5507/bp.2017.031
7. Redmond KJ, Grim J, Robinson CG, et al. Steep dose-response relationship between
maximum hippocampal dose and memory deficits following hippocampal avoidance
whole brain radiation therapy (HA-WBRT) for brain metastases: a secondary analysis of
NRG/RTOG 0933. Int J Radiat Oncol. 2020;18(3)S176.
https://doi.org/10.1016/j.ijrobp.2020.07.956.
8. Shang W, Yao H, Sun Y, et al. Preventive effect of hippocampal sparing on cognitive
dysfunction of patients undergoing whole-brain radiotherapy and imaging assessment of
hippocampal volume changes. Biomed Res Int. April 5,2022;2022:1-10.
https://doi.org/10.1155/2022/4267673
 6

9. Sood S, Pokhrel D, McClinton C, et al. Volumetric-modulated arc therapy (VMAT) for

whole brain radiotherapy: not only for hippocampal sparing, but also for reduction of
dose to organs at risk. Med Dosim. 2017;42:375-383.
https://doi.org/10.1016/j.meddos.2017.07.005
10. Pokhrel D, Sood S, McClinton C, et al. Treatment planning strategy for whole-brain
radiotherapy with hippocampal sparing and simultaneous integrated boost for multiple
brain metastases using intensity-modulated arc therapy. Med Dosim. 2016;41(4)315-322.
https://doi.org/10.1016/j.meddos.2016.08.001
11. NRG Oncology. NRG-CC001: a randomized phase III trial of memantine and whole-
brain radiotherapy with or without hippocampal avoidance in patients with brain
metastases. September 26, 2017. Accessed July 6, 2023.
https://classic.clinicaltrials.gov/ProvidedDocs/15/NCT02360215/Prot_SAP_000.pdf
12. Brown PD, Gondi V, Pugh S, et al. Hippocampal avoidance during whole-brain
radiotherapy plus memantine for patients with brain metastases: phase III trial NRG
oncology CC001. J Clin Oncol. 2020;38(10):1019-1029.
https://doi.org/10.1200/JCO.19.02767
 7

Figures

Figure 1A. Planning technique “A” field designs showing an example of the field for the CW
and CCW full arcs (left picture) and the sagittal arcs using split-x technique that separates the
brain into left and right sides (right picture).

Figure 1B. Planning technique “B” field designs showing an example of the fields for the CW
and CCW arcs with split-x technique separating the brain into superior and inferior portions (left
picture) and the sagittal arcs with split-x technique separating the brain into left and right sides
(right picture).

Figure 1C. Planning technique “C” field designs showing an example of the fields for the CW
and CW arcs with the couch at 355 degrees (left picture), the CW and CCW arcs with the couch
at 5 degrees (middle picture), and the sagittal arc (right picture).
 8

Tables
Table 1A. Planning technique “A” arc arrangements. Showing 2 full arcs and 2 sagittal arcs.
Field ID Energy MLC Gantry Rtn Colli Rtn [deg] Couch Rtn
[deg] [deg]
CW 6X-FFF VMAT 181-179 30 0
CCW 6X-FFF VMAT 179-181 330 0
Sag Arc CW 6X-FFF VMAT 181-340 90 270
Sage Arc CCW 6X-FFF VMAT 340-181 90 270

Table 1B. Planning technique “B” arc arrangements. Showing 2 full arcs and 2 sagittal arcs with
the couch at 270 and 275 degrees.
Field ID Energy MLC Gantry Rtn Colli Rtn [deg] Couch Rtn
[deg] [deg]
CCW 6X-FFF VMAT 179-181 95 0
CW 6X-FFF VMAT 181-179 85 0
Sag Arc CCW 6X-FFF VMAT 179-25 80 270
Sage Arc CW 6X-FFF VMAT 25-179 100 275

Table 1C. Planning technique “C” arc arrangements. Showing 4 full arcs with the couch at 355
and 5 degrees and the sagittal arc.
Field ID Energy MLC Gantry Rtn Colli Rtn [deg] Couch Rtn
[deg] [deg]
CCW T355 6X-FFF VMAT 179-181 330 355
CW T355 6X-FFF VMAT 181-179 30 355
CCW T5 6X-FFF VMAT 179-181 330 5
CW T5 6X-FFF VMAT 181-179 30 5
CCW T90 6X-FFF VMAT 179-20 330 90
9