1

Group 9
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)

Medical Dosimetry Program at the University of Wisconsin – La Crosse

I. Abstract
II. Introduction
A. PI Introduce neural structures: hippocampus and precentral gyrus. Explain their
location, function, and importance. Offer research for the cognitive preservation
of WBRT-HA that is a result of structural avoidance. Build on this research to
explain why we chose the precentral gyrus as our structure of interest. (Reference:
Teffer et al,1 Ribas,2 and Brown et al3)
B. PII: Discuss principles of radiation that is as low as reasonably achievable
(ALARA). Options for treatment in patients with multiple lesions or a high
treatment volume in the brain, their benefits and applications, as well as any
drawbacks for the methods. Include stereotactic radiotherapy (SRT), whole brain
radiation therapy (WBRT), and hippocampal avoidance whole brain radiation
therapy (WBRT-HA) (Reference: Brown et al,3 Hardy et al,4 and Pinkham et al5)
C. PIII: Discuss how SRT and WBRT-HA can spare neurological structures. Using
this information, lead into the question: what is the upper limit on metastatic
lesions being treated with SRT before the quality becomes equivalent to WBRT?
(Reference Brown et al3 and Pinkham et al5)
D. PIV: Revisit how current constraints of the brain do not consider structures like
the precentral gyrus. Discussion of patient details including pertinent medical
history, number of lesions, location of lesions, and why this patient was chosen.
1. Problem: 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.
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2. Purpose: 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.
3. Goals: The goal of this case study was to identify precentral gyrus dose
for SRT, WBRT-HA, and traditional WBRT.
III. Case Description
a. Patient Selection
i. PI: Patient Demographic
1. Retrospective
2. 15+ metastases
3. Potential for precentral gyrus involvement
b. Target Delineation
i. PI: Targets (PTV) and OAR (Brainstem, Eyes, Optic Chiasm, Optic
Nerves, Hippocampus)
1. PTV location and proximity to precentral gyrus (Figures 1 and 2)
ii. PII: Precentral gyrus location and extent of involvement
1. Description of structure, how it was contoured
2. Volume of structure, volume overlapping with PTVs (Table 1)
c. Treatment planning
i. PI: Description of WBRT field size, planning parameters, prescription
dose
ii. PII: Description of WBRT-HA field size, planning parameters,
prescription dose
iii. PIII: Description of SRT planning, fractions, and prescription dose
iv. PIV: OAR Constraints (Table 2)
1. Brainstem
a. Dmax = 54 Gy, V50<1% for WBRT and HA-WBRT
b. Dmax = 15 Gy, V10<0.5 cc for SRT
2. Eyes
a. Dmax = 50 Gy, Dmean ≤ 35 Gy for all modalities
3. Optic Chiasm
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a. Dmax ≤ 37.5 Gy Used for HA-WBRT

b. Dmax < 14.0 Gy Used for SRT
4. Optic nerves
a. Dmax ≤ 37.5 Gy Used for HA-WBRT
b. Dmax < 23 Gy for SRT
5. Bilateral hippocampi
a. D100% ≤ 9 Gy, Dmax ≤17 Gy Used for HA-WBRT
d. Plan analysis and evaluation
i. Precentral Gyrus Dose Analysis (Table 3)
1. PI: Comparison of absolute and relative minimum, maximum, and
mean dose for each planning technique.
a. SRT had the lowest relative minimum, maximum, and
mean dose. SRT had the lowest absolute minimum and
absolute mean dose.
b. WBRT-HA had the lowest absolute maximum dose.
ii. PTV Coverage
1. PI: Mean, minimum, and maximum dose to 18 PTVs superior to
the lateral sulcus (Table 4)
a. Mean PTV dose, standard deviation, and percentage of the
mean prescription dose reported.
2. PII: WBRT compared to SRT (Tables 5 and 6)
a. P<0.001, statistically significant difference between
methods.
b. WBRT delivered higher dose on average than SRT,
prescription dose was also higher.
3. PIII: WBRT-HA compared to SRT (Tables 5 and 6)
a. P=0.04 statistically significant difference between methods.
b. WBRT-HA delivered higher dose on average than SRT,
despite WBRT-HA having a lower prescription.
4. PIV: WBRT compared to WBRT-HA (Tables 5 and 6)
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a. P<0.001, statistically significant difference between

methods.
b. WBRT-HA delivered lower dose on average than WBRT,
prescription for WBRT-HA was also lower.
iii. Dose analysis and metrics
1. PI: 18 PTVs superior to the lateral sulcus
2. PII: Statistics: all pair-wise comparisons using the paired T-test
a. To determine if there was a difference between the 3
treatments
b. Significance level p=0.05
iv. PIV: Total Brain Dose and dose to OAR (Tables 7 and 8)
1. The lowest mean dose was SRT (30.6% prescription dose, 827
cGy)
2. Highest maximum dose was SRT (144.0 % prescription dose, 3888
cGy)
v. PV: Summary of Results
1. SRT yielded the lowest dose to the precentral gyrus
2. Statistically significant difference in dose between methods
a. WBRT-HA delivered higher dose on average than SRT
despite having a lower prescription
IV. Conclusion
a. PI: Summarize the purpose of the study
b. PII: Summarize results
c. PIII: Limitations and options for future research
i. Prescription dose and number of fractions were different for each method
ii. Limited to one patient
1. Results cannot be generalized for the whole population of patients
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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
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Tables
Table 1. Metastatic Lesion Volume, Proximity to Precentral Gyrus, and Any Overlap with
Precentral Gyrus.
Metastatic Distance From Volume of Percentage Overlap with
Lesion Precentral Lesion (cc) Precentral 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 Dmax = 54.0

Brainstem Same as WBRT
V10 < 0.5 cc V50 < 1%

Dmax = 50.0
Eyes Same as SRT Same as SRT
Dmean ≤ 35.0

Optic Chiasm Dmax < 14.0 N/A Dmax ≤ 37.5

Optic Nerves Dmax < 23 N/A Dmax ≤ 37.5

D100% ≤ 9.0
Bilateral Hippocampi N/A N/A
Dmax ≤ 17.0
*Gray (Gy)

Table 3. Dose to the Precentral Gyrus Observed for Each Treatment Method
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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)

Table 4. Dose to the 18 Planning Target Volume (PTVs) of Interest.

SRT WBRT WBRT-HA
max min mean max min mean max min mean
(cGy) (cGy) (cGy) (cGy) (cGy) (cGy) (cGy) (cGy) (cGy)
Average 2977 2125 2606 3089 3072 3079 2678 2618 2649
Std.
114 83 70 45 46 45 58 67 56
Deviation

Percent
110.3 78.7 96.5 103.0 102.4 103.6 99.2 104.7 106.0
Prescription
*Centigray (cGy)

Table 5. Descriptive Summary of the Mean (cGy) Data to 18 Planning Target Volumes (PTVs)
of Interest
Pair Mean Dose n Std. Deviation Std. Error
(cGy) (cGy) Mean (cGy)
1. WBRT 3078.8 18 44.9 10.6
SRT 2606.4 18 70.4 16.6
2.WBRT-HA 2648.7 18 56.1 13.2
SRT 2606.4 18 70.4 16.6
3.WBRT-HA 2648.7 18 56.1 13.2
WBRT 3078.8 18 44.9 10.6
*Centigray (cGy)

Table 6. Results of the Paired T-Test and Paired Confidence Intervals

Pair Paired Differences (cGy) t df Significance
Mean Std. Std. 95% Confidence One- Two-
Dev. Error Interval of the Sided Sided
Mean Difference p p
Lower Upper
1 472.4 95.29 22.46 425.06 519.83 21.04 17 <.001 <.001
2 42.3 80.62 19.00 2.24 82.42 2.23 17 .020 .040
3 -430.1 63.47 14.96 -461.67 -398.55 -28.75 17 <.001 <.001
*Centigray (cGy)
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Table 7. Total Brain Dose (cGy) Received for Each Treatment Method
Planning Max Dose Minimum Mean Dose
Technique (cGy) Dose (cGy) (cGy)
SRT 3888 85 827
WBRT 3256 2757 3076
WBRT-HA 3048 801 2654
*Centigray (cGy)

Table 8. Maximum, Minimum, and Mean Dose Received by the Organs at Risk (cGy)
Structure SRT WBRT WBRT-HA
Brainstem Maximum 2707 3079 2796
Minimum 223 2629 2499
Mean 795 2989 2645

Eye_L Maximum 371 3030 1301

Minimum 90 149 546
Mean 224 1156 968

Eye_R Maximum 859 2992 1278

Minimum 81 148 441
Mean 217 908 927

Optic Chiasm Maximum 681 2997 2773

Minimum 413 2902 2508
Mean 535 2969 2644

Optic Nerve_L Maximum 600 3021 2608

Minimum 259 2543 1227
Mean 436 2966 1921

Optic Nerve_R Maximum 528 3026 2607

Minimum 272 2557 1193
Mean 397 2962 1851

Bilateral Maximum 1101 3092 1534

Hippocampi Minimum 393 3000 802
Mean 524 3037 1234
*Centigray (cGy)