Karen Krueger

Treatment Planning Project

October 23, 2015
Whole Brain Treatment with Hippocampal Sparing
History of Present Illness: Pt CU is a 30 year old African American female who was initially
diagnosed with cT4d cN1 cM0 invasive ductal carcinoma of the right breast in June of 2012. CU
underwent chemotherapy then radiation therapy. The patient completed radiation therapy in
March of 2013.
On June 3, 2015, during a follow-up appointment, CU told her oncology nurse that she had been
suffering from migraines. As a result an MRI was requested. Unfortunately, this revealed
metastatic involvement into the brain. The patient was referred to radiation oncology for
treatment of the brain.
The radiation oncologist prescribed treatment of the whole brain to 3000cGy with
250cGy/fraction for 12 treatments with hippocampal sparing per the Radiation Therapy
Oncology Group (RTOG) 0933 protocol.1 Brain metastasis is most commonly treated with whole
brain radiotherapy.1 The purpose of sparing the hippocampi during whole brain irradiation is to
allow the patient to maintain cognitive function for improved quality of life over traditional
whole brain treatment, after which most patients experience cognitive deterioration.
Patient Setup/Immobilization: CU underwent a CT simulation scan for treatment planning on
July 7, 2015. For the CT simulation CU laid supine on the simulation table. The patients head
was placed on a headrest and a small aquaplast mask was made. CUs arms were across her
abdomen holding a small ring with both hands. A knee sponge was placed for support. CUs feet
were banded together for further immobilization. The radiation therapist used the laser
coordinate system to approximate the location of isocenter, placed tape on the mask, and traced
the laser crosshairs onto the tape. The therapist then marked this location by placing three CTspot BBs on the mask. One BB was placed on each crosshair (one on each lateral side and one
anterior). The patient was scanned starting superior to the head and ending inferior to C6 using
1.25mm slices.
Anatomical Contouring: The RTOG 0933 protocol requires the patient to undergo a threedimensional spoiled gradient (SPGR), magnetization-prepared rapid gradient echo (MPRAGE),

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.

Figure 1. Isocenter placement.

When planning volumetric modulated arc therapy (VMAT), in order to create a more conformal
plan, it is necessary to make sure that for each arc different collimator angles are used. There
should be at least 15 between the collimator angles of each arc to ensure that the transmission
radiation between the multi-leaf collimator (MLC) leaves is different.
For this plan three arcs were created, two full rotation arcs and one partial rotation arc. Arc 1 was
designed to rotate counter clock wise (CCW) from gantry angle 1.0 to 359 with a collimator
rotation of 105 and a couch rotation of 180. The inferior border of Arc 1 was set just inferior to
the hippocampi. Arc 2 was designed to rotate clock wise (CW) from gantry angle 359 to 1with
a collimator rotation of 75 and a couch rotation of 180. The superior border of Arc 2 was
placed at the superior portion of the hippocampi.
Isocenter placement, collimator angles, and the partial collimator opening where two arcs
overlap in the hippocampal avoidance region are the keys to this technique.2 Treatment planning
of whole brain irradiation with hippocampal sparing with two partial arcs was developed by Jin
Shen, certified medical dosimetrist at the Montefiore Medical Center, and presented at the

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.

Figure 3. Beams Eye View of Arcs 1 and 2. Hippocampi shown in cyan.

Arc 3 was designed to rotate CCW from the gantry angle of 150 to 359 with a collimator
rotation of 180 and a couch rotation of 90. Arc 3 was used to create a conformal dose
distribution, by distributing dose between the left and right hippocampi as well as the anterior
portion of the brain, while blocking the hippocampi as necessary. The addition of the third arc
was derived from a Sun Nuclear webinar on whole brain irradiation with hippocampal sparing
presented by Brett Sloman, CMD, Justin Richards, CMD, David Preston, CMD, Shada WadiRamahi, Ph.D., DABR, Abriel Jenshus, BA, CMD, Genevieve Jarry, Ph.D., Greg Robinson M.S.,
CMD, RT (T), David Littlejohn RT (T), CMD, Thomas Constantino, CMD, Ahmad Nobah,
M.Sc., DABR, and Anthony Magliari, MS, CMD.3

Figure 4. Beams Eye View of Arc 3.

Hippocampi shown in cyan.
Treatment Planning: The patient was planned for treatment on the Varian Trilogy with a 6MV
rapid arc plan. During the isocenter placement and beam arrangement, the arc angles, collimator
angles, and field size were entered into Eclipse version 11 treatment planning system. Before
treatment optimization, the prescription was entered into Eclipse. The prescription dose was
prescribed to the PTV.
The next step was the optimization process. Initially, the upper and lower constraints for each
PTV were entered as well as upper constraints for the hippocampi, optic chiasm, and lenses.
Lower constraints are used to maximize dose to areas during optimization while upper
constraints are used to minimize or limit dose. The priority of each constraint was entered. The
constraints and priorities were saved and the optimization was started. The optimization level
was then paused in the first phase in order to allow coverage of the PTVs and to observe the dose
per volume of critical structures via the dose volume histogram during optimization.
During the first phase, the priority for the hippocampi and hippocampi avoid were increased in
order to reduce dose to the hippocampi. Two upper objectives were used for the hippocampi
avoid and three upper objectives and a mean objective were used for the hippocampi. It appeared
that the optic nerve constraints would be met without constraint objectives and that the constraint
objective for the optic chiasm would be met. The first phase remained paused until the
hippocampi objectives were nearly met and was then unpaused to complete VMAT optimization.
Once optimization was complete, the plan was evaluated. This was done by viewing the DVH to

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

D2%>37.5Gy,<40Gy

Unacceptable
V30 < 90%

Hippocampi

D98% > 25Gy

D 100% < 9Gy

D 98% > 25Gy

D100% < 10Gy

D2% > 40Gy

D100% > 10Gy

Maximum dose <

Maximum dose < 17Gy

Maximum dose >

Optic Nerves

16Gy
Maximum dose <

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

D 98% > 25Gy

D2% > 40Gy

D98% = 23.8Gy

D98% > 25Gy

D 100% <

D100% < 10Gy

D100% > 10Gy

D100% = 8.5Gy

9Gy

Maximum dose <

Maximum dose

Maximum dose

Maximum

17Gy

> 17Gy

= 16.Gy

Optic

dose < 16Gy

Maximum

Maximum dose <

Maximum dose

Maximum dose

Chiasm
Left Optic

dose < 37.5Gy

Maximum

37.5Gy
Maximum dose <

< 37.5Gy
Maximum dose

= 39.2Gy
Maximum dose

Nerve
Right Optic

dose < 37.5Gy

Maximum

37.5Gy
Maximum dose <

< 37.5Gy
Maximum dose

= 33.1Gy
Maximum dose

Nerve

dose < 37.5Gy

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

D 98% > 25Gy

D2% > 40Gy

D98% = 25.5Gy

D98% > 25Gy

D 100% <

D100% < 10Gy

D100% > 10Gy

D100% = 8.5Gy

9Gy

Maximum dose <

Maximum dose

Maximum dose

Maximum

17Gy

> 17Gy

= 16.6Gy

Optic

dose < 16Gy

Maximum

Maximum dose <

Maximum dose

Maximum dose

Chiasm
Left Optic

dose < 37.5Gy

Maximum

37.5Gy
Maximum dose <

< 37.5Gy
Maximum dose

= 36.5Gy
Maximum dose

Nerve
Right Optic

dose < 37.5Gy

Maximum

37.5Gy
Maximum dose <

< 37.5Gy
Maximum dose

= 32.3Gy
Maximum dose

Nerve

dose < 37.5Gy

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

D 98% > 25Gy

D2% > 40Gy

D98% = 25.6Gy

D98% > 25Gy

D 100% <

D100% < 10Gy

D100% > 10Gy

D100% = 8.6Gy

9Gy

Maximum dose <

Maximum dose

Maximum dose

Maximum

17Gy

> 17Gy

= 15.6Gy

Optic

dose < 16Gy

Maximum

Maximum dose <

Maximum dose

Maximum dose

Chiasm
Left Optic

dose < 37.5Gy

Maximum

37.5Gy
Maximum dose <

< 37.5Gy
Maximum dose

= 36.5Gy
Maximum dose

Nerve
Right Optic

dose < 37.5Gy

Maximum

37.5Gy
Maximum dose <

< 37.5Gy
Maximum dose

= 32.1Gy
Maximum dose

Nerve

dose < 37.5Gy

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.

Figure 8. Dose Volume Histogram of final plan.

Conclusion:
I learned several things from this treatment planning project. I learned Jin Shens method of
dividing the brain into four separate PTVs for plan optimization. This method allowed me to
reduce the dose to the hippocampi during VMAT optimization by allowing some parts of the
PTV to receive higher doses. From Shens presentation, I also learned how proper isocenter
placement and collimator angles along with a partial collimator opening enables the hippocampi
to be blocked while the rest of the brain is treated without compromising coverage. During the
Sun Nuclear webinar I learned that it is not always ideal to use the normal tissue objective
(NTO). The NTO is used to define the fall off from a specific PTV.3 When planning whole brain
treatment with hippocampal sparing you are more concerned with dose fall off inside of the
hippocampi, than outside of the brain. Dose fall off outside of the brain is relatively easy to
achieve. I also learned that with some protocols, such as this one, the plan is allowed to be really
hot as long as the D2% is < 37.5Gy. In full discloser, I ran approximately 20 plans for this
project. After about 15 I had an acceptable plan. However as I started gathering data for the
project I realized that I could make an adjustment that might improve coverage for the plan.
Originally I had limited my Y field size to the smallest size which encompassed the brain during

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.