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Title: Comparison of doses received by the hippocampus in patients treated with single isocenter– vs multiple isocenter–based stereotactic radiation therapy to the brain for multiple brain metastases

Abstract

To investigate the doses received by the hippocampus and normal brain tissue during a course of stereotactic radiation therapy using a single isocenter (SI)–based or multiple isocenter (MI)–based treatment planning in patients with less than 4 brain metastases. In total, 10 patients with magnetic resonance imaging (MRI) demonstrating 2-3 brain metastases were included in this retrospective study, and 2 sets of stereotactic intensity-modulated radiation therapy (IMRT) treatment plans (SI vs MI) were generated. The hippocampus was contoured on SPGR sequences, and doses received by the hippocampus and the brain were calculated and compared between the 2 treatment techniques. A total of 23 lesions in 10 patients were evaluated. The median tumor volume, the right hippocampus volume, and the left hippocampus volume were 3.15, 3.24, and 2.63 mL, respectively. In comparing the 2 treatment plans, there was no difference in the planning target volume (PTV) coverage except in the tail for the dose-volume histogram (DVH) curve. The only statistically significant dosimetric parameter was the V{sub 100}. All of the other measured dosimetric parameters including the V{sub 95}, V{sub 99}, and D{sub 100} were not significantly different between the 2 treatment planning techniques. None of the dosimetric parameters evaluated for the hippocampusmore » revealed any statistically significant difference between the MI and SI plans. The total brain doses were slightly higher in the SI plans, especially in the lower dose region, although this difference was not statistically different. The use of SI-based treatment plan resulted in a 35% reduction in beam-on time. The use of SI treatments for patients with up to 3 brain metastases produces similar PTV coverage and similar normal tissue doses to the hippocampus and the brain when compared with MI plans. SI treatment planning should be considered in patients with multiple brain metastases undergoing stereotactic treatment.« less

Authors:
; ; ; ; ;
Publication Date:
OSTI Identifier:
22577842
Resource Type:
Journal Article
Resource Relation:
Journal Name: Medical Dosimetry; Journal Volume: 40; Journal Issue: 4; Other Information: Copyright (c) 2015 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved.; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
61 RADIATION PROTECTION AND DOSIMETRY; 62 RADIOLOGY AND NUCLEAR MEDICINE; ANIMAL TISSUES; COMPARATIVE EVALUATIONS; HIPPOCAMPUS; METASTASES; NEOPLASMS; NMR IMAGING; PATIENTS; PLANNING; RADIATION DOSES; RADIOTHERAPY; SURGERY

Citation Formats

Algan, Ozer, E-mail: oalgan@ouhsc.edu, Giem, Jared, Young, Julie, Ali, Imad, Ahmad, Salahuddin, and Hossain, Sabbir. Comparison of doses received by the hippocampus in patients treated with single isocenter– vs multiple isocenter–based stereotactic radiation therapy to the brain for multiple brain metastases. United States: N. p., 2015. Web. doi:10.1016/J.MEDDOS.2015.04.001.
Algan, Ozer, E-mail: oalgan@ouhsc.edu, Giem, Jared, Young, Julie, Ali, Imad, Ahmad, Salahuddin, & Hossain, Sabbir. Comparison of doses received by the hippocampus in patients treated with single isocenter– vs multiple isocenter–based stereotactic radiation therapy to the brain for multiple brain metastases. United States. doi:10.1016/J.MEDDOS.2015.04.001.
Algan, Ozer, E-mail: oalgan@ouhsc.edu, Giem, Jared, Young, Julie, Ali, Imad, Ahmad, Salahuddin, and Hossain, Sabbir. Thu . "Comparison of doses received by the hippocampus in patients treated with single isocenter– vs multiple isocenter–based stereotactic radiation therapy to the brain for multiple brain metastases". United States. doi:10.1016/J.MEDDOS.2015.04.001.
@article{osti_22577842,
title = {Comparison of doses received by the hippocampus in patients treated with single isocenter– vs multiple isocenter–based stereotactic radiation therapy to the brain for multiple brain metastases},
author = {Algan, Ozer, E-mail: oalgan@ouhsc.edu and Giem, Jared and Young, Julie and Ali, Imad and Ahmad, Salahuddin and Hossain, Sabbir},
abstractNote = {To investigate the doses received by the hippocampus and normal brain tissue during a course of stereotactic radiation therapy using a single isocenter (SI)–based or multiple isocenter (MI)–based treatment planning in patients with less than 4 brain metastases. In total, 10 patients with magnetic resonance imaging (MRI) demonstrating 2-3 brain metastases were included in this retrospective study, and 2 sets of stereotactic intensity-modulated radiation therapy (IMRT) treatment plans (SI vs MI) were generated. The hippocampus was contoured on SPGR sequences, and doses received by the hippocampus and the brain were calculated and compared between the 2 treatment techniques. A total of 23 lesions in 10 patients were evaluated. The median tumor volume, the right hippocampus volume, and the left hippocampus volume were 3.15, 3.24, and 2.63 mL, respectively. In comparing the 2 treatment plans, there was no difference in the planning target volume (PTV) coverage except in the tail for the dose-volume histogram (DVH) curve. The only statistically significant dosimetric parameter was the V{sub 100}. All of the other measured dosimetric parameters including the V{sub 95}, V{sub 99}, and D{sub 100} were not significantly different between the 2 treatment planning techniques. None of the dosimetric parameters evaluated for the hippocampus revealed any statistically significant difference between the MI and SI plans. The total brain doses were slightly higher in the SI plans, especially in the lower dose region, although this difference was not statistically different. The use of SI-based treatment plan resulted in a 35% reduction in beam-on time. The use of SI treatments for patients with up to 3 brain metastases produces similar PTV coverage and similar normal tissue doses to the hippocampus and the brain when compared with MI plans. SI treatment planning should be considered in patients with multiple brain metastases undergoing stereotactic treatment.},
doi = {10.1016/J.MEDDOS.2015.04.001},
journal = {Medical Dosimetry},
number = 4,
volume = 40,
place = {United States},
year = {Thu Jan 01 00:00:00 EST 2015},
month = {Thu Jan 01 00:00:00 EST 2015}
}
  • Purpose: To investigate the doses received by the hippocampus and normal brain tissue during a course of stereotactic radiotherapy utilizing a single isocenter (SI) versus multiple isocenter (MI) in patients with multiple intracranial metastases. Methods: Seven patients imaged with MRI including SPGR sequence and diagnosed with 2–3 brain metastases were included in this retrospective study. Two sets of stereotactic IMRT treatment plans, (MI vs SI), were generated. The hippocampus was contoured on SPGR sequences and doses received by the hippocampus and whole brain were calculated. The prescribed dose was 25Gy in 5 fractions. The two groups were compared using t-testmore » analysis. Results: There were 17 lesions in 7 patients. The median tumor, right hippocampus, left hippocampus and brain volumes were: 3.37cc, 2.56cc, 3.28cc, and 1417cc respectively. In comparing the two treatment plans, there was no difference in the PTV coverage except in the tail of the DVH curve. All tumors had V95 > 99.5%. The only statistically significant parameter was the V100 (72% vs 45%, p=0.002, favoring MI). All other evaluated parameters including the V95 and V98 did not reveal any statistically significant differences. None of the evaluated dosimetric parameters for the hippocampus (V100, V80, V60, V40, V20, V10, D100, D90, D70, D50, D30, D10) revealed any statistically significant differences (all p-values > 0.31) between MI and SI plans. The total brain dose was slightly higher in the SI plans, especially in the lower dose regions, although this difference was not statistically significant. Utilizing brain-sub-PTV volumes did not change these results. Conclusion: The use of SI treatment planning for patients with up to 3 brain metastases produces similar PTV coverage and similar normal tissue doses to the hippocampus and the brain compared to MI plans. SI treatment planning should be considered in patients with multiple brain metastases undergoing stereotactic treatment.« less
  • Purpose: Single-isocenter, linac-based SRS for multiple brain metastases (multi-mets) can deliver highly conformal radiation doses and reduce overall patient treatment time compared to other therapy techniques. This study aims to quantify the dosimetric benefits of knowledge-based planning (KBP) for multi-met treatments. Methods: Using a previously-published KBP methodology (an artificial neural network (ANN) trained on single-target linac-based SRS plans), 3D dose distribution predictions for multi-met patients were obtained by treating each brain lesion as a solitary target and subsequently combining individual predictions into a single distribution using a dose-weighted geometric averaging to obtain the best results in the inter-target space. 17more » previously-treated multi-met plans, with target numbers ranging from N=2–5, were used to validate the ANN predictions and subsequent KBP auto-planning routine. The fully-deliverable KBP plans were developed by converting dose distribution predictions into patient-specific optimization objectives while maintaining identical target normalizations (typically PTV V100%=D98%). Plan quality improvements were quantified by the difference between SRS quality metrics (QMs): δdQM=QM(clinical)-QM(KBP). QMs of interest were: gradient measure (GM), conformity index (CI), brain V10 and V5, brainstem D0.1cc and heterogeneity index (HI). Finally, overall plan quality was judged via blinded plan comparison by SRS-specializing physicians. Results: Two clinical plans were found to be significant outliers wherein plan quality was dramatically worse than KBP. Despite indicating KBP superiority, these were removed from the QM analysis to prevent skewing the results. In the remaining cases, clinical and KBP QMs were nearly identical with modest improvements in the KBP sample: δGM=0.12±0.56mm, δCI=−0.01±0.04, Brain δV10=0.8±2.6cc, brain δV5=6.3 ±10.7cc, brainstem δD0.1cc=0.06±1.19Gy and δHI= −0.04±0.05. Ultimately, 13/17 KBP plans were deemed superior to the manual plans in blinded physician review. Conclusion: The results demonstrate that KBP-driven automated planning in linac-based single-isocenter treatments for multiple brain metastases is indistinguishable from, or even better than, traditional manual planning. J. Hattangadi: Research Grant; Varian Medical Systems; K.L. Moore: Research Grant: Varian Medical Systems.« less
  • Purpose: To describe our clinical experience using a unique single-isocenter technique for frameless intensity-modulated stereotactic radiosurgery (IM-SRS) to treat multiple brain metastases. Methods and Materials: Twenty-six patients with a median of 5 metastases (range, 2-13) underwent optically guided frameless IM-SRS using a single, centrally located isocenter. Median prescription dose was 18 Gy (range, 14-25). Follow-up magnetic resonance imaging (MRI) and clinical examination occurred every 2-4 months. Results: Median follow-up for all patients was 3.3 months (range, 0.2-21.3), with 20 of 26 patients (77%) followed up until their death. For the remaining 6 patients alive at the time of analysis, medianmore » follow-up was 14.6 months (range, 9.3-18.0). Total treatment time ranged from 9.0 to 38.9 minutes (median, 21.0). Actuarial 6- and 12-month overall survivals were 50% (95% confidence interval [C.I.], 31-70%) and 38% (95% C.I., 19-56%), respectively. Actuarial 6- and 12-month local control (LC) rates were 97% (95% C.I., 93-100%) and 83% (95% C.I., 71-96%), respectively. Tumors {<=}1.5 cm had a better 6-month LC than those >1.5 cm (98% vs. 90%, p = 0.008). New intracranial metastatic disease occurring outside of the treatment volume was observed in 7 patients. Grade {>=}3 toxicity occurred in 2 patients (8%). Conclusion: Frameless IM-SRS using a single-isocenter approach for treating multiple intracranial metastases can produce clinical outcomes that compare favorably with those of conventional SRS in a much shorter treatment time (<40 minutes). Given its faster treatment time, this technique is appealing to both patients and personnel in busy clinics.« less
  • Purpose: This study evaluates a novel algorithm that can be used with any treatment planning system for simple and rapid generation of stereotactic radiosurgery (SRS) plans for treating multiple brain metastases using a single isocenter dynamic conformal arc (DCA) approach. This technique is compared with a single isocenter volumetric modulated arc therapy (VMAT) technique in terms of delivery time, conformity, low dose spread and delivery accuracy. Methods: Five patients, with a total of 37 (5 – 11) targets were planned using a previously published method for generating optimal VMAT plans and using the proposed DCA algorithm. All planning target volumesmore » (PTVs) were planned to 20 Gy, meeting a minimum 99% coverage and maximum 135 % hot spot for both techniques. Quality assurance was performed using radiochromic film, with films placed in the high dose regions of each PTV. Normal tissue volumes receiving 12 Gy and 6 Gy (V12 and V6) were computed for each plan. Conformity index (CI) and gamma evaluations (95% of points passing 4%/0.5mm) were computed for each PTV. Results: Delivery times, including beam on and table rotation times, were comparable: 17 – 22 minutes for all deliveries. V12s for DCA plans were (18.5±15.2 cc) vs. VMAT (19.7±14.4 cc). V6s were significantly lower for DCA (69.0±52.0 cc) compared with VMAT (154.0±91.0 cc) (p <<0.05). CIs for VMAT targets were (1.38±0.50) vs. DCA (1.61±0.41). 36 of 37 DCA planned targets passed gamma tests, while 29 of 37 VMAT planned targets passed. Conclusion: Single isocenter DCA plans were easily achieved. The evaluation suggests that DCA may represent a favorable technique compared with VMAT for multiple target SRS by reducing dose to normal tissue and more accurately depicting deliverable dose.« less
  • Purpose: Radiation Therapy Oncology Group (RTOG) 9508 showed a survival advantage for patients with 1 but not 2 or 3 brain metastasis (BM) treated with whole-brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS) versus WBRT alone. An improved prognostic index, the graded prognostic assessment (GPA) has been developed. Our hypothesis was that if the data from RTOG 9508 were poststratified by the GPA, the conclusions may vary. Methods and Materials: In this analysis, 252 of the 331 patients were evaluable by GPA. Of those, 211 had lung cancer. Breast cancer patients were excluded because the components of the breast GPAmore » are not in the RTOG database. Multiple Cox regression was used to compare survival between treatment groups, adjusting for GPA. Treatment comparisons within subgroups were performed with the log-rank test. A free online tool ( (brainmetgpa.com)) simplified GPA use. Results: The fundamental conclusions of the primary analysis were confirmed in that there was no survival benefit overall for patients with 1 to 3 metastases; however, there was a benefit for the subset of patients with GPA 3.5 to 4.0 (median survival time [MST] for WBRT + SRS vs WBRT alone was 21.0 versus 10.3 months, P=.05) regardless of the number of metastases. Among patients with GPA 3.5 to 4.0 treated with WBRT and SRS, the MST for patients with 1 versus 2 to 3 metastases was 21 and 14.1 months, respectively. Conclusions: This secondary analysis of predominantly lung cancer patients, consistent with the original analysis, shows no survival advantage for the group overall when treated with WBRT and SRS; however, in patients with high GPA (3.5-4), there is a survival advantage regardless of whether they have 1, 2, or 3 BM. This benefit did not extend to patients with lower GPA. Prospective validation of this survival benefit for patients with multiple BM and high GPA when treated with WBRT and SRS is warranted.« less