1

Statements
Remember the problem, purpose and hypotheses statements that we worked so
hard on last semester? We will be using them again! They should be stated in
your paper (just as we worked on in your research proposal) but we are also
asking you to spell them out here as a reminder of the foundational basis for your
research.
Purpose Statement: The purpose of this study is to compare treatment planning techniques and
examine the precentral gyrus dose in an extreme SRT case of 36 metastatic brain lesions.

Problem Statement: The problem is that the precentral gyrus is rarely considered a dose
limiting treatment planning structure despite known motor and cognitive deficits associated with
irradiation.

Case Study Goals:

Goal 1: To compare the dose to precentral gyrus between SRT, WBRT-HA, and traditional
WBRT.
 2

Change Matrix
A change matrix is required with every milestone document submission.

A detailed change matrix simplifies the review process and indicates to the instructors and advisors that
the author has demonstrated a clear and thorough response to reviewer comments.

Reviewer comments are not intended as an exhaustive list. It is the Learner’s responsibility to correct
any additional errors that are not specifically noted by the reviewer and to address the requirements of
the capstone project. All instances where changes have been made should be clearly noted.

If, after discussion with the group, there are questions about a reviewer’s comments, it is the
responsibility of the group leader to reach out to the instructors and advisor via email for clarification.

If, after discussion with the instructors, the author chooses not to make a requested change, the
author must provide a brief rationale, and describe how they addressed reviewer concerns.

Failures to consider, address, and notate within the Change Matrix will result in the manuscript being
returned to the group without comment.

Copy and paste the instructor’s comment from your draft into the matrix.

You will continuously build on this change matrix so that any/all comments can be reviewed at any given
time in the projects progress.

Title of Capstone: A case study of precentral gyrus dose when controlling 36 metastatic brain
lesions with SRT, WBRT-HA and WBRT
Group: Jeremy Marshall, Erika Winn, Evangelia Andrews

Reviewer’s recommendation How addressed Page numbers where

change appears

Nishele- Studies can't suggest. Researchers Replaced “studies” with” researchers P 11

have suggested... Intro. paragraph 2

Matt - Do we need a reference for this
statement?
Nishele- I agree with Matt on the last revision
here that it seems you need a reference
citation here. I am certain you did not come
up with this and the next sentence on your
own and you are not anatomy experts.
Matt - Is this a complete sentence? It doesn't
read like it to me.
Reference for frontal lobe function added. P 11
Teffer K, Semendeferi K. Human prefrontal Intro. paragraph 1
cortex. Evolution of the Primate Brain.
2012:191-218. https://doi.org/10.1016/b978-
0-444-53860-4.00009-x
Reference for anatomic description of
precentral gyrus added.
Ribas GC. The cerebral sulci and gyri.
Neurosurgical Focus FOC. 2010;28(2):E2-.
https://doi.org/10.3171/2009.11.FOCUS09245
Sentence changed, “There are various...” was P 11
inserted at the beginning of the sentence. Intro. paragraph 1

Should this read something more like, "There

 3

are various neural structures which make us

the frontal lobe, each respo......."
Matt - I agree with this sentence but it feels Sentence was moved into following paragraph P 11
out of place here as I'm reading the following to improve the flow of the piece. Intro. paragraph 1-2
paragraph.
Ashley - Can’t begin sentence with WBRT has been spelled out “Whole brain P 11
abbreviation. radiotherapy” Intro. paragraph 2

Nishele - This sentence still does not read Sentence has been broken up into 2 sentences P 11
well. and rewritten Intro. Paragraph 2

Ashley - Remove extra space below Extra space between paragraphs removed P 11-12
paragraph Intro. paragraph 2-3

Ashley – Spell out first use. Replaced with “Quantitative Analysis of P 12

(QUANTEC) Normal Tissue Effects in the Clinic Intro. Paragraph 4
(QUANTEC)”
Ashley - Where is the mention of your The previous sentence was replaced with the P 12
problem statement? This is the fundamental approved problem statement from RPD. Intro. Paragraph 4
reason why you are doing this research.
Ashley - This is out of order. You should Sentence re-ordered; problem statement first P 12
mention your problem statement and your followed by purpose statement. Intro. Paragraph 4
purpose statement first.
Matt - Is this truly SRS (single fraction). Prescription and fractionation confirmed SRT. P 12
From what I've seen, as the number of lesions All instances of “SRS” have been replaced Intro. Paragraph 4
increases the number of fractions needed also with “SRT”. References for SRS have been
increases due to the volume of normal brain replaced with references for SRT. (SRS to SRT revision
being treated. As such, this is no longer occurs across the
considered SRS (single fraction) treatment, draft, from title to
but SRT (multi-fraction) brain treatment. conclusion.)
Please clarify.
Ashley - This is not the approved purpose The previous sentence was replaced with the P 12
statement from your RPD. approved purpose statement. Ensured Intro. Paragraph 4
sentence order per Ashley’s previous
comment.
Ashley - You have no hypothesis, only goals Sentences involving a hypothesis have been P 12
of the case study. Go back to the RPD and replaced with approved goals from RPD. Intro. Paragraph 4
review and then incorporate your goals into
the RPD.
Ashley - Remove . after each word Reference has been removed and replaced due P 14
to SRS to SRT change. References

Nishele - Is the next sentence after this part of Sentence in question was should have been a P 12
citation #1? If so I would combine the two part of citation #1. Sentences were combined Intro. Paragraph 3
sentences and cite it. Otherwise, I find it hard as suggested.
to believe you are the person who know there
is lesser risk of cognitive failure (no citation).
Matt – Please reword. I’m not exactly sure Sentence has been reworded and incorporates P 12.
what you’re trying to say here. SRT instead of SRS. Patient Demo.
paragraph 1.
Matt - These sections jump around a bit. First Section has been reorganized per Matt’s P 13.
you're talking about mets, then OAR recommendation. Section restructured as Structure Delineation
 4

structures, then 2 of the mets, then describing follows: Define OAR, define precentral gyrus
the location of the precentral gyrus, then location, number of mets, location and
talking about the location of mets to the proximity to gyrus
sulcus. I'd reorganize this some. Talk about
defining organs at risk...then about defining
the precentral gyrus...then about the number
of mets total and the number located in close
proximity of the gyrus.
Matt - As a reader trying to reproduce your Section has been expanded to include more P 13-14
technique, can I do it with the information specifics of the treatment planning. Arc Treatment planning
provided here. If the answer is no, which I angles, collimator rotation, couch rotation, paragraph 1-4
believe it is, then it needs to be explained blocking, energy used, and additional details
better. How many transverse arcs were there? were included.
Three of the beams apparently had two
different couch angles, 45 and315 degrees,
which I didn't know you could do with one
rapid arc beam, let alone 3.
Nishele - Technically you shouldn't be posing Sentence has been re-phrased as suggested to P 11
a question here. You should re-phrase such as avoid posing a question. Intro. Paragraph 3
...cognitive tissue; however researchers (or
clinicians) question whether there is an upper
limit...'
Nishele - use scholarly language. Sentence has been removed and replaced to P 11.
just say is not contoured ... improve clarity and readability. Intro. Paragraph 4

Nishele - Case study is not evaluating. The Replaced “case study” with “The researchers P 11
researchers are evaluating... seek to evaluate...” Intro. Paragraph 4

Nishele - Again - you are giving credit to a Replaced “This retrospective case study aims P 12
non-human thing. Researchers aim to to …" with “The researchers aim to Patient Demo.
evaluate... evaluate...” Paragraph 1
also use the greater than symbol

Nishele - And? So what if they were of Section reworded and expanded to provide a P 12
interest. better description of the targets which were Structure Delineation
I don't feel like you are actually listing out the delineated including GTV identification and paragraph 1-3
structures that were delineated. This section is expansion to for PTV.
to be specific in which structures were
delineated.

Nishele - This isn't planning section. This is Paragraph moved from structure delineation P 13
contouring. to treatment planning section Structure delineation
to treatment planning
Nishele - use degree symbol throughout the “Degrees” was taken out and replaced with P 13
paper degree symbol Tx planning paragraph
2&4
Nishele - in 10 what? Section has been rewritten to include more P 13-14
You need to write in scholarly language; not specifics of the treatment planning and Tx planning paragraph
slang. And write in completed sentences. include scholarly language. 1-4

Nishele - too short to be a stand-alone Section has been expanded to include more P 13-14
paragraph. i assume you'll be expanding this specifics of the treatment planning. Tx planning paragraph
section. 1-4
 5

AMA Referencing Quick Guide Checklist

Correctly using AMA formatting is one of the few aspects in the Capstone project that you have
complete control of whether it is your first outline submission or the final draft. Use this AMA quick
guide checklist to avoid common AMA formatting mistakes and receive the greatest number of points
possible. Not everyone has the ability to be an exceptional scholarly writer and researcher, however,
everyone has the capability of using AMA formatting correctly. Review this guide for EVERY submission
(discussion post, outline, draft) in the research courses and ask yourself the following questions:

Task Submiss Submissio Submissio Submissio Submissio Submissio Submissio

ion n Date: n Date: n Date: n Date: n Date: n Date:
Date:
8/5/22

Manuscript
Written in past ☒ ☐ ☐ ☐ ☐ ☐ ☐
tense?
Written in size 12,
☒ ☐ ☐ ☐ ☐ ☐ ☐
Times New Roman
font
Paragraphs include
☒ ☐ ☐ ☐ ☐ ☐ ☐
at least 3
sentences
Page numbers?

**The default font

for page numbers
is Calibri, size 11 ☒ ☐ ☐ ☐ ☐ ☐ ☐
even after you
have changed the
font in your paper
so make sure to
check
Spell out
abbreviation at
first use if not
recognized by
AMA

***Remember
that you may ☒ ☐ ☐ ☐ ☐ ☐ ☐
add/subtract
content with each
draft so something
that once spelled
out might be
removed and need
to spelled out
again
Spell out numbers ☒ ☐ ☐ ☐ ☐ ☐ ☐
 6

and abbreviations
that begin a
sentence?

**If an
abbreviation must
be spelled out to
begin a sentence,
do not include the
abbreviation in
parentheses after
words unless this
is the first use.
Numeric values
when referring to
☒ ☐ ☐ ☐ ☐ ☐ ☐
numbers in
sentence (“3”, not
“three”)
Reference
superscripts after ☒ ☐ ☐ ☐ ☐ ☐ ☐
each sentence I
used a reference?
OAR is properly
defined as organS
at risk.

**This is a
common mistake, ☒ ☐ ☐ ☐ ☐ ☐ ☐
even in journal
publications. By
saying OARs, you
are implying
organs at risks
which doesn’t
make sense
If I directly cited an
author, did I
immediately
include the ☒ ☐ ☐ ☐ ☐ ☐ ☐
reference
superscript
following the
author’s name?
Tables and figures
are referenced in-
text directly ☒ ☐ ☐ ☐ ☐ ☐ ☐
following the
sentence (….
(Figure 1).
All terms must be ☒ ☐ ☐ ☐ ☐ ☐ ☐
spelled out in the
abstract and
 7

manuscript at first
use

**So if you refer to

and spell out
VMAT in the
abstract, you must
also define the
term again in the
manuscript
Scholarly writing is
appropriate

**Do not use ☒ ☐ ☐ ☐ ☐ ☐ ☐

terms such as max,
cord, rad onc,
simmed etc. Spell
out these terms
and avoid slang
All reference of
our profession
should be written
as “medical
dosimetrist” not
☒ ☐ ☐ ☐ ☐ ☐ ☐
just “dosimetrist.”

**Remember that
there are other
types of
dosimetrists
Is my paper
formatted
according the ☐ ☐
☒ ☐ ☐ ☐ ☐
instructions? Case
study vs. Research
Paper

Reference Page
Page break
before this ☒ ☐ ☐ ☐ ☐ ☐ ☐
section?
Capitalize the
first letter of
☒ ☐ ☐ ☐ ☐ ☐ ☐
the first word
in the title only
Abbreviate
and italicize ☒ ☐ ☐ ☐ ☐ ☐ ☐
the journal?
Year, volume, ☒ ☐ ☐ ☐ ☐ ☐ ☐
issue and page
number
 8

written
without any
spaces?

**If you didn’t

find one listed,
consider
completing
another
literature
search review.
If you cannot
find one, reach
out to
instructor for
help
Doi?

**Remember
that most
publications
have doi
numbers now
so if you do
☒ ☐ ☐ ☐ ☐ ☐ ☐
not locate one
on the original
article,
complete
another
literature
search to find
it.
Format dois
like this:
http://doi.org..
.
☐
☒ ☐ ☐ ☐ ☐ ☐
**Remember
this has
changed from
last semester
Listed in
chronological
order as they ☒ ☐ ☐ ☐ ☐ ☐ ☐
are referenced
in text
Figures and Tables
 9

Page break
before each ☒ ☐ ☐ ☐ ☐ ☐ ☐
section?
Each heading
is bolded and
☒ ☐ ☐ ☐ ☐ ☐ ☐
centered for
each section
If 2 figures are
related, they
are to be ☒ ☐ ☐ ☐ ☐ ☐ ☐
labeled as A
and B.
Captions are
written in
complete
sentences and ☒ ☐ ☐ ☐ ☐ ☐ ☐
single spaced
starting with
“Figure 1”
Figure
captions
☒ ☐ ☐ ☐ ☐ ☐ ☐
appear after
the figure
Table captions
appear before ☒ ☐ ☐ ☐ ☐ ☐ ☐
the figure
All patient
identifying
information is
☒ ☐ ☐ ☐ ☐ ☐ ☐
blocked and
fused with the
original image
All table axis,
labels and
legends are in
☒ ☐ ☐ ☐ ☐ ☐ ☐
Times New
Roman, size 12
font
Any DVHs
include
structure ☒ ☐ ☐ ☐ ☐ ☐ ☐
labels directly
on the DVH
Vertical lines
are removed ☒ ☐ ☐ ☐ ☐ ☐ ☐
from tables
Single line ☒ ☐ ☐ ☐ ☐ ☐ ☐
 10

spacing used
for figure and
table
descriptions
 11

A case study of precentral gyrus dose when controlling 36 metastatic brain lesions with
SRT, WBRT-HA and WBRT

Authors: Jeremy Marshall, R.T.(T), Evangelia Andrews, Erika Winn, Nishele

Lenards, Ph.D., CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, M.S., CMD, Matt Tobler, CMD,
R.T.(T), FAAMD

Medical Dosimetry Program at the University of Wisconsin – La Crosse

Abstract
Introduction
The hippocampus is a sensitive neural structure located deep in the temporal lobe which
plays an instrumental role in learning and memory. While the hippocampi are present in all
vertebrates, the human brain is set apart by its relatively large frontal lobe, which allows for
high-level cognitive abilities such as consciousness, communication, and advanced problem
solving.1 There are various neural structures that make up the frontal lobe, each responsible for a
different higher-order task. One of these structures is the precentral gyrus. Often referred to as
the primary motor cortex, the precentral gyrus is found anterior to the central sulcus, expands
laterally on each frontal lobe, and is responsible for voluntary motor control.2 Despite the
importance of the precentral gyrus, it is very rarely considered a dose limiting structure in
radiation treatment planning.
A fundamental pillar of radiation oncology is to keep dose to healthy tissue as low as
reasonably achievable (ALARA). For cranial irradiation, whole brain radiotherapy (WBRT) is
often employed for prophylactic treatments and control of metastatic disease, as it has been
shown to effectively control metastases while reducing chance of death due to neurologic
causes.3 Unfortunately, with the nature of WBRT, an excessive amount of healthy tissue is
exposed to radiation, leading to cognitive deficits. Whole brain radiotherapy has been associated
with declines in memory, attention, and processing in up to 75% of patients during treatment.4
Specific to radiation therapy, researchers have suggested that low levels of radiation exposure to
the hippocampus may contribute to radiotherapy-induced cognitive toxicity, and subsequently,
treatment techniques have been adapted to avoid this structure.3 Stereotactic radiotherapy (SRT)
and whole brain radiotherapy- hippocampal avoidance (WBRT-HA) are 2 methods that were
adapted for cranial irradiation.
 12

To keep dose to healthy tissue minimized, SRT and WBRT-HA techniques are often
utilized clinically for primary and metastatic brain lesions. Compared to WBRT, SRT is
associated with a reduced risk of neurocognitive side effects in patients with 1- 3 brain
metastases.5 With WBRT-HA techniques, the hippocampi are avoided while prescription dose is
delivered to the rest of the brain, resulting in a lesser risk of cognitive failure compared to
WBRT.3 The effectiveness of SRT and WBRT-HA stems from the ability to avoid and preserve
cognitive tissue, however, the researchers of this case study question if there is an upper limit on
the number of metastatic lesions treated before the cognitive tissue preservation becomes
equivalent to WBRT.
The brain, unlike most organs, is an elaborate system with fundamentally and
functionally different areas. Current Quantitative Analysis of Normal Tissue Effects in the Clinic
(QUANTEC) data for the brain is limited, indicating dose constraints for the whole brain,
brainstem, and hippocampus, even though there are many critical areas and neural structures
within the brain that are unaccounted for. The problem is that the precentral gyrus is rarely
considered a dose limiting treatment planning structure despite known motor and cognitive
deficits associated with irradiation. The researchers seek to evaluate the precentral gyrus dose in
an extreme case where 36 metastatic brain lesions were treated with SRT compared to traditional
WBRT or WBRT-HA. The first goal of this case study is to identify the precentral gyrus dose for
SRT, WBRT-HA, and traditional WBRT. The second goal of the case study is to evaluate the
necessity for SRT according to precentral gyrus dose.

Case Description
Patient Demographics and Setup
Treatment with SRT is associated with a reduction in neurocognitive side effects in
patients with 1-3 brain lesions compared to patients treated with WBRT.5 The researchers of this
case study aimed to evaluate precentral gyrus sparing for an SRT patient who greatly exceeded 3
metastatic lesions. Distribution of lesions within the frontal lobe and their proximity to the
precentral gyrus was also considered. Ultimately, an SRT patient with 36 metastatic brain lesions
was chosen; 18 of those 36 lesions were housed within the frontal lobe with varying distance to
the precentral gyrus.
For simulation, the patient was positioned headfirst supine with arms down and at their
sides and knees elevated slightly with a cushion for comfort. Immobilization utilized for
 13

simulation included a CDR board with custom mask and cranial mold. A Philips Brilliance big
bore computed tomography (CT) scanner was used to scan the patient with a slice thickness of
1.0 mm. Three radiopaque localization markers were placed on the patient’s mask, 2 laterally
and 1 anteriorly. These radiopaque markers would be utilized for treatment planning and
treatment setup.
Structure Delineation
The CT images obtained in simulation were fused with a magnetic resonance image
(MRI) of the patient’s brain which aided in structure delineation. Eclipse version 16.1 was
utilized for structure contouring. Organs at risk (OAR) were contoured by the medical
dosimetrist and consisted of the brainstem, eyes, optic chiasm, and optic nerves. Additional
contours were created by the radiation oncologist and included the hippocampi, precentral gyrus,
and gross tumor volumes (GTVs) for each of the 36 metastatic lesions. A 0.2 cm expansion was
added to the GTVs which established the planning treatment volumes (PTVs).
The precentral gyrus is found on the lateral surface of the brain. It runs parallel to the
central sulcus on the frontal lobe, ends at the anterior sulcus, and extends inferiorly to the
lateral sulcus.2 Of the 36 total metastases treated, 18 were of particular interest as they
were located superior to the lateral sulcus (Figure 1). The total volume and distance from the
precentral gyrus for each of the 18 PTVs of interest were recorded (Table 1). Two of the 18
targets overlapped with the precentral gyrus and 2 additional metastases were less than 1.0 cm
away.
Treatment Planning
Treatment planning was also performed using Eclipse version 16.1. The treatment
planning constraints used for planning were based on department standards as well as constraints
outlined by Brown et al3 (Table 2). All OAR constraints were met for their respective treatment
modality, and any constraint not specified by department standards was below QUANTEC
limits.
The 2 isocenter SRT plan was designed in a way which divided the brain into anterior
and posterior halves; one isocenter was placed in the anterior portion and the other was placed in
the posterior portion. The treatment plan consisted of 18 stereotactic radiosurgery (SRS) rapid
arc beams which used various couch angles and collimator rotations to ensure OAR sparing and
acceptable PTV coverage (Table 3). The energy utilized for this plan was 6 MV flattening filter-
 14

free (FFF) photons and an overall plan normalization of 98% was set. Treatments occurred once
every other day and the prescription dose, delivered by a Varian TrueBeam linear accelerator,
was 27 Gy in 3 fractions.
Two plans were generated retrospectively for comparison of precentral gyrus dose
against that which was received by SRT. To create the most accurate comparison across
treatment techniques, the plans were created using 6 MV photons to be delivered on a Varian
TrueBeam linear accelerator. For the WBRT, beam arrangement consisted of the traditional
parallel opposed static fields at 90° and 270°. A single isocenter was placed in the center of the
brain with equal field weighting, distributing uniform coverage across the brain. The radiation
oncologist utilized a multileaf collimator (MLC) to ensure adequate blocking around optic
structures, oral cavity, and base of skull. The flash margin around the anterior, posterior, and
superior portion of the skull was set to 2.0 cm. The dose was normalized to the midplane of the
brain. Treatments occurred once daily, 5 days a week with the prescription dose being 30 Gy in
10 fractions.
The second plan was a WBRT-HA plan which consisted of 6 coplanar static beams,
spaced out for adequate coverage. The isocenter was placed in the center of the brain and the
PTV was defined as the whole brain excluding the hippocampi. Each treatment field utilized
MLC blocks fit to the PTV with a 0.5 cm margin. Critical structures were blocked to ensure
OAR constraints would be met. The gantry angles used were 355°, 50°, 110°, 185°, 225°, and
300°. There were no couch rotations or collimator rotations for this treatment technique. The
plan was normalized for 98% of the prescription dose to cover 98% of the PTV. Treatments
occurred once daily, 5 days a week, with the prescription dose being 25 Gy in 10 fractions.
Plan Analysis and Evaluation
Given the differences in dose and fractionation for the different techniques, both relative
and absolute maximum, mean, and minimum dose to the precentral gyrus were recorded (Table
4). Stereotactic radiotherapy yielded the lowest relative minimum, maximum, and mean dose to
the precentral gyrus at 19.4%, 102.7%, and 31.6% respectively. The lowest mean dose to the
precentral gyrus was a result of SRT at 853 cGy. By comparison, WBRT-HA had the lowest
absolute maximum dose to the precentral gyrus of 2477 cGy and the highest relative maximum
dose to the precentral gyrus of 109.8% prescription dose.
 15

When creating the retrospective studies, the researchers aimed to create a plan which
would meet dose constraints and could be treated clinically; the precentral gyrus was not
intentionally spared in any of the treatment methods. The lowest average dose to the 18 PTVs
came from SRT (2606 cGy, SD = 70 cGy) which also had the lowest relative target dose of
96.5%. The most homogenous PTV coverage came from WBRT (average 3907 cGy SD = 45
cGy). The hottest treatment plan was WBRT-HA with a mean relative dose of 106.0% (2649
cGy SD = 56 cGy).

Conclusion
a. PI: Summarize the purpose of the study
b. PII: Summarize results
c. PIII: Limitations and options for future research
 16

References

1. Teffer K, Semendeferi K. Human prefrontal cortex. Evolution of the Primate Brain.

2012:191-218. https://doi.org/10.1016/b978-0-444-53860-4.00009-x
2. Ribas GC. The cerebral sulci and gyri. Neurosurgical Focus FOC. 2010;28(2):E2-.
https://doi.org/10.3171/2009.11.FOCUS09245
3. 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. Clin Onc. 2020;38(10):1019-1029.
https://doi.org/10.1200/jco.19.02767
4. Hardy SJ, Krull KR, Wefel JS, Janelsins M. Cognitive changes in cancer survivors.
ASCO Educational Book. 2018;(38):795-806. https://doi.org/10.1200/edbk_201179
5. Pinkham MB, Whitfield GA, Brada M. New developments in intracranial stereotactic
radiotherapy for metastases. Clin Oncol (R Coll Radiol). 2015;27(5):316-323.
https://doi.org/10.1016/j.clon.2015.01.007
6.
 17

Figures

Figure 1. 3D model of the patient shows the precentral gyrus (peach, Left) and the target
volumes (Right).
 18

Tables

Table 1. Metastatic Lesion Volume, Proximity to Precentral Gyrus, and Any Overlap with
Precentral Gyrus.
Metastatic Distance From Volume of Percentage Overlap with Precentral
Lesion Precentral Lesion (cc) Gyrus
Gyrus (cm)
1 3 0.07 0
2 0.62 0.04 0
3 1.5 0.08 0
4 3.38 0.03 0
5 2.41 0.05 0
6 0 0.03 0.33
7 3.81 0.02 0
8 0.76 0.33 0
9 3.28 0.21 0
10 5.37 0.16 0
11 2.78 0.03 0
12 1.78 0.13 0
13 4.96 0.08 0
14 3.84 0.03 0
15 5.72 0.06 0
16 7.19 0.01 0
17 4.23 0.05 0
18 0 0.06 0.5

Table 2. Dose Constraints for the Organs at Risk Utilized During Treatment Planning.
Structure SRT (Gy) WBRT (Gy) WBRT-HA (Gy)

Dmax = 15.0
Brainstem N/A N/A
V10 < 0.5 cc

Eyes Dmax = 2.0 Dmax < 33 Dmax < 33

Dmax < 33
Optic Chiasm Dmax < 15.3 Dmax ≤ 25

Dmax < 33
Optic Nerves Dmax < 15.3 Dmax ≤ 25

D100% ≤ 7.5
Bilateral Hippocampi N/A N/A
Dmax ≤ 13.5
 19

*Gray (Gy)

Table 3. Arc Beams, Couch Rotations, and Collimator Angles Used for Planning Stereotactic
Treatment.
Arc Gantry Angles Collimator Couch
Number Angles Rotation
1 25 CW 178 160° 0°
2 178 CCW 30 0° 0°
3 30 CW 178 90° 0°
4 315 CCW 182 135° 0°
5 182 CW 178 160° 0°
6 178 CCW 182 0° 0°
7 40 CW 178 160° 45°
8 178 CCW 40 160° 45°
9 40 CW 178 160° 0°
10 320 CCW 182 135° 0°
11 40 CW 178 15° 0°
12 178 CCW 40 15° 0°
13 182 CW 310 90° 0°
14 310 CCW 182 135° 0°
15 178 CCW 60 135° 0°
16 182 CW 320 135° 0°
17 315 CCW 182 0° 315°
18 182 CW 330 15° 0°

*Clockwise (CW); counterclockwise (CCW)

Table 4. Dose to the Precentral Gyrus Observed for Each Treatment Method
Max Dose Minimum Dose Mean Dose (cGy)
Planning cGy Percent cGy Percent cGy Percent
Technique Prescription Prescription Prescription
Dose Dose Dose
SRT 2773 102.7% 523 19.4% 853 31.6%
WBRT 3209 106.9% 3032 101.0% 3082 102.7%
WBRT-HA 2744 109.8% 2551 102.0% 2663 106.5%
*Centigray (cGy)