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Background  Although whole brain radiation therapy (WBRT) provides palliation and prophylaxis, reduces local recurrence probability and improves overall survival, it is evident that WBRT is associated with neurocognitive deficits due to radiation induced damage of the hippocampus. Therefore, minimizing hippocampal dose to the least possible level is of high clinical relevance. In dual-arc conventional volumetric modulated arc therapy (dac-VMAT), the large irradiation field for whole brain planned target volume (PTV) requires a wide jaw opening in which substantial low dose volume to the hippocampus may be produced due to suboptimal multi-leaf collimator (MLC) movements. The present study investigates the potential of a radiation therapy technique with split-arc and reduced field size, namely split-arc partial-field volumetric modulated arc therapy (sapf-VMAT) to spare the hippocampus during WBRT.    Methods  Computed tomography and magnetic resonance images of 20 patients with brain metastases were retrieved in this retrospective planning study. The hippocampus was manually delineated by single radiation oncologist strictly following the RTOG 0933 atlas definition. Plans delivering 30 Gy in 10 fractions were generated for each patient using dac-VMAT and sapf-VMAT. Dosimetric parameters from both techniques were compared by paired t-test.    Results  The results demonstrated that radiation dose to the hippocampus was significantly reduced using sapf-VMAT relative to dac-VMAT plans. sapf-VMAT (7.86Gy,  p  = 0.001) had significantly lowered average D 100%  compared to dac-VMAT (9.23 Gy). Decrease in hippocampus D max  using sapf-VMAT (13.23 Gy,  p  = 0.001) was statistically significant when compared to dac-VMAT (16.33 Gy). The resulting mean dose to the hippocampus was 9.16 Gy for the for sapf-VMAT. Mean dose of sapf-VMAT was significantly lower than dac-VMAT (10.85 Gy,  p  < 0.05). In both eyes, sapf-VMAT demonstrated significantly lower D mean  compared to dac-VMAT ( p  < 0.05). Whole brain PTV coverage was not compromised in both techniques.    Conclusion  sapf-VMAT has demonstrated significant dose reduction to the hippocampus and both eyes compared to dac-VMAT.

radiation oncology

Volumetric modulated arc therapy (VMAT) for hippocampal-avoidance whole brain radiation therapy: planning comparison with Dual-arc and Split-arc partial-field techniques