Peter Hirschi

Clinical Practicum III

Final Project
October 14, 2015
Intracranial Stereotactic Radiosurgery for the Treatment of Brain Metastasis.

A Brief description of the area of disease, the stage of disease, and how the stage affected the
volume to be treated must be included.
A patient presented with malignant neoplasm of other and unspecified sites of male breast, Stage
IV, T3, N2a, M1, G2 and secondary malignant neoplasm of brain and spinal cord to include L45 and a solitary 1.3 cm enhancing metastatic mass in the right frontal lobe. Options to treat the
solitary brain lesion include whole brain irradiation and/or intracranial stereotactic radiosurgery
(SRS). SRS treatments combined with whole brain radiation (WBRT) have been found to
improve the mean survival time (MST) to 6.5 months from 4.9 months for patients receiving
WBRT alone. Also, patients receiving WBRT with SRS were more likely to have a stable or
improved performance status than those receiving WBRT alone. There was a significant
difference in local control as reported by treating institutions 82% for WBRT plus SRS patients
compared to 71% for WBRT only patients.1 For the purpose of this final project, a SRS
treatment of the brain lesion will be created and discussed.
The gross tumor volume (GTV) was contoured by a physician utilizing a T1 with flair MRI
scanned with 1mm slices that was previously fused with a planning CT scan. A 1mm margin was
added to the GTV to create the planned treatment volume (PTV).

A brief description of the simulation process and treatment setup along with treatment
prescription.
For simulation, the patient was placed in the supine position with a custom head and neck holder.
An open face mask was placed on the patient with two reinforcement strips placed over the
forehead and chin in order to make the mask more rigid. An open face mask is used in order to
expose facial landmarks to the VisionRT surface tracking cameras. VisionRT is utilized for
aligning the patient before treatment as well as monitoring intrafraction motion during treatment.
A blue foam pad is placed under the patient for comfort and a knee sponge is placed under the

knees. Images 1 and 2 show the CT simulation setup. The patient was scanned with 1.25mm
slices and included his entire cranium.

At Dixie Regional Medical Center, the following table is used as a general guideline for SRS
treatments of solitary lesions.
SRS Dose Guideline
Tumor Size
1cm or smaller
1-2cm
2-3cm
3-4cm
>4cm

Dose to 90% isodose line

24Gy
21Gy
18 Gy
15Gy
Not candidate for SRS

Because the lesion size is 1.3cm, the physician prescribed 21Gy in a single fraction to the PTV.

Provide an in depth description of the treatment planning process and the overall plan used for
treatment (did you try multiple beam arrangement, did you rotate the collimator or couch, or did
you modify your planning objectives? If so why?
For SRS treatments at Dixie Regional Medical Center, volumetric modulated arc therapy
(VMAT) is utilized. Because the brain lesion was located in the right frontal portion of the
cranium, I assumed I would want the arcs to approach anteriorly. For the first plan, I decided to
use the following beam arrangements.

The dose rate is 1,000 MU.

There were several factors influencing these parameters. One factor was rotating the collimator
at least 20 degrees to prevent MLC leakage radiation from being delivered on the same plane.
Also, the collimator was rotated as needed to avoid critical structures. Couch kicks were utilized
to spread dose through different planes. I tried to space the couch kicks evenly to help distribute
dose. Gantry stop and start angles were kept anteriorly to treat through the least amount of brain
as possible. Also, the angles were selected based on critical structure locations. Four arcs of 100
degrees are optimal when possible. The image below shows what the arcs look like.

After calculating the dose, the isodose coverage looked like this.

I noticed that the 30% and 50% isodose lines were not very conformal anteriorly. Also, one of
the arcs was very close to the right orbit.

I saved plan 1 and then changed some beam arrangements to see if I could make the dose
distribution more conformal to the PTV. I changed the beam parameters to the following:

The arcs look like this:

Notice that the biggest change was shifting the arcs to the right side of the patient. I drastically
shifted the arc that was treating from the left side of the cranium. I also adjusted a couple of arcs
making them more lateral and shifted them posteriorly.
Here is the isodose distribution.

Notice that the 50% and 30% lines are much more conformal to PTV. The maximum dose
location is located within the PTV. I was satisfied with the isodose distribution at this point, so
the next step was to find the isodose line that completely encompasses the PTV. I did this by
using the DVH shown below. I found the point at the top of the DVH that shows when the entire
PTV is covered by the relative dose, and that point is 88.1904%.

Using this information I changed the dose prescription prescribed percentage from 100% to 88%.
This will ensure that 100% of the PTV structure will receive at least 21Gy. By increasing the

prescription by 12% the hotspot dose increases dramatically from 2194cGy to 2494cGy. The
overall dose to the PTV also increases dramatically, however because this treatment is delivering
an obliteration dose to the PTV it is not a concern. As Ive heard a physicist put it so eloquently;
dead is dead.

Include all structures contoured with the rationale for contouring all organs at risk contoured, tell
what their tolerance doses are and whether these tolerances were met or not (this can be
presented in a table format).
Structures Contoured
Structures Contoured and dose Constraints for Single Fraction 21Gy Intracranial SRS (TG101 &
Quantec)2,3
Structure

Dose Limit

Dose Achieved

Constraint
Met? Y/N

Right Eye

Arrange beam angles & arcs to avoid

8 cGy

5.2 cGy

6.8 cGy

3.8 cGy

30.2 cGy

15.9 cGy

148.5 cGy

177.2 cGy

9.84cc

treating through critical structure.

Left Eye

Arrange beam angles & arcs to avoid

treating through critical structure.

Right Lens

Arrange beam angles & arcs to avoid

treating through critical structure.

Left Lens

Arrange beam angles & arcs to avoid

treating through critical structure.

Left Optic

<0.2cc 800cGy

Nerve

Max dose 1,000 cGy

Right Optic

<0.2cc 800cGy

Nerve

Max dose 1,000 cGy

Optic

<0.2cc 800cGy

Chiasm

Max dose 1,000 cGy

Brainstem

<0.5cc 1,250cGy
Max dose 1,500cGy

Brain

<10cc 1,200cGy

Provide a DVH with the GTV, PTV and all surrounding critical structures.

The brain lesion location is a good distance away from all of the critical structures which is
evident in the DVH above. All critical structure dose constraints were easily met. The biggest
factors I was looking at while creating this plan was dose uniformity across the PTV and overall
dose compaction. The brain DVH is a good indicator of dose compaction. However, the size of
the PTV must also be taken into account when looking at the brain DVH.

Summarize what you learned from this clinical project.

While I still only have a basic understanding of SRS planning, this project really increased my
knowledge of concepts used to treat brain lesions with obliteration doses. I still struggle
visualizing all the arcs and where they are traveling. I gained some experience altering arc fields
in order to avoid critical structures. I also learned how the prescription line dose is used to ensure
100% coverage of the PTV.

References
1. Andrews DW, Scott CB, Sperdutu PW, Et al. Whole brain radiation therapy with or
without stereotactic radiosurgery boost for patients with one to three brain metastases:
phase III results of the RTOG 9508 randomized trial. The Lancet. 2004;363(9422):1665
1672. DOI: http://dx.doi.org/10.1016/S0140-6736(04)16250-8
2. Benedict et al: Stereotactic body radiation therapy: The report of TG101. Med Phys.
2010;76(8): 4078-4101. http://dx.doi.org/10.1118/1.3438081
3. Bentzen SM, Constine LS, Deasy JO, et al. Quantitative analyses of normal tissue effects
in the clinic (QUANTEC): an introduction to the scientific issues. Int J Radiat Oncol Biol
Phys. 2010;76(3):S3-9. http://dx.doi.org/10.1016/j.ijrobp.2009.09.040