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LOCALIZATION & TREATMENT PROCEDURES IN RADIATION THERAPY

CONTENTS

2.

WHOLE BRAIN & PRIMARY BRAIN

TUMORS

Patient Simulation: Whole Brain & Primary Brain

Tumors
The simulation procedure commonly used for fractionated primary brain tumors includes
a CT simulation and/or MR imaging with contrast. The patient’s position and immobiliza-
tion was provided in the Patient Simulation: CNS section. Scan parameters will extend
Previous: Overview: Central Nervous System
from vertex to mid-neck (or as specified by physician). Metastatic disease or whole brain
patients typically only require a CT sim without contrast. ANext:
MRICraniospinal
with contrast for each
Irradiation (CSI)
scan and will provide more insight into tumor vasculature, help differentiate edema from
tumor, and enhance soft tissue contrast improving the identification and localization of
critical structures. Frequently, CT scans of the brain use intravenous, iodinated, non-ionic,
contrast. Therapists should ensure the patient has not received contrast in the last 24
hours, has good kidney function through the verification of lab values (GFR, BUN,
Creatinine), and has had nothing to eat or drink (npo) for the last 4 hours. MR scans com-
monly use gadolinium “gad” contrast.

WHOLE BRAIN SIMULATION

Treatment Volume Localization: Whole Brain (WBRT)

WBRT will encompass all microscopic disease within the cranial contents. The beam ar-
rangement is a two-field technique using opposed laterals. Treatment field size is ap-
proximately 22cm x 17cm.

Treatment borders:

Posterior, Superior, & Anterior: 1-2cm flash/field falloff (verify with field light)
Inferior: Superior orbital ridge to 1-2cm below the mastoid tip (verify eye block)

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Next: Craniospinal Irradiation (CSI)

Left (g86) and Right (g274) lateral whole brain DRRs

Treatment Techniques: Whole Brain (WBRT)

Radiation therapy for brain metastasis is typically a palliative treatment. Treatment can
be given prophylactically for Small Cell Lung Cancers to a dose as low as 20-25 Gy. A
slightly lower dose will reduce deficits associated with whole brain radiation therapy and
allow for retreatment if metastasis occur later. Standard approach WBRT uses 3000-
3750 cGy in 10-15 fx (250 to 300 cGy per fraction). The most common fractionation
scheme is 30 Gy in 10 fractions. Other common fraction schemes include:

12 Gy: 6 Gy for 2 fractions given on consecutive days

20 Gy: 4 Gy/fx for 5 fractions daily

To avoid beam divergence into the opposite eye:

Option 1: Angle each beam posteriorly a few degrees until the beam divergence matches
the opposing sides outer canthus. The appropriate angle can be verified in the treatment
planning system. Notice, the beams match anteriorly just posterior to the lenses of the
eyes. Clinically, this divergence can be matched utilizing two metallic BBs, placed at each
eye’s outer canthus, and rotating the gantry using fluoroscopy until they are
superimposed.

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Next: Craniospinal
Option 2: Take advantage of the non-divergence of the central axis of theIrradiation
beam using (CSI)a
 ha
lf-
be
a
m
bl
oc
k.
Ro
tat
e
The red beam represents gantry 274 degrees
Depiction of a half-beam block to th
(Right lateral), the blue represents gantry 86
eliminate beam divergence anteriorly. e degrees (Left lateral). The anterior beams a
The blue circles represent the superior col parallel to the lens of the orbits.
orbital ridge and mastoid tip. The green li-
“+” represents the isocenter.
mator to match the inferior border (superior or-
bital ridge and mastoid tip). The isocenter will fall
near the EAM. Ensure adequate light field falloff in anterior, superior, and posterior
directions.

Emerging Technologies and Treatments: Whole Brain

(WBRT):

Hippocampal WBRT is a growing treatment that is focused on sparring the right and left
lobes of the hippocampus with the intent of avoiding radiation induced side effects. Like
WBRT the entire cranial contents are contoured, Hippocampal WBRT treatment utilizes
the Linac’s IMRT functions to limit dose to the hippocampus[1]. Avoidance sectors can
help reduce dose to critical structures, like the lenses of the eyes.

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Next: Craniospinal Irradiation (CSI)

 What is Whole Brain Radiation Therap…
Therap…

Treatment Volume Localization: Primary Brain

Tumors
Treatment volumes for fractionated radiotherapy to primary brain tumors can vary by
provider and institutional protocols. Historically, contours included the gross tumor vol-
ume (GTV) and surrounding edema (determined by pre-operative scans) with a 2-3 cm
margin. With advances in technology, treatment margins are much tighter. Today, treat-
ment volumes include the GTV, subclinical disease, and edema, comprising the CTV – clin-
ical tumor volume and a 5mm expansion to the PTV – prescribed tumor volume.

A patient with a GBM of the right frontal lobe. The PTV is demonstrated by the red outline and is
prescribed to receive a dose of 45 Gy with a boost to follow.

Treatment Techniques: Primary Brain Tumors

Historically, primary brain tumors were treated with a 2 or 3-field technique; two parallel
opposed lateral beams and perhaps a third (anterior, posterior, or vertex) beam. Wedges
were common to compensate for the round shape of the head to reduce hot spots and
improve dose
Previous: uniformity.
Overview: Beam weighting
Central Nervous System can also achieve help achieve an acceptable
dose distribution.
Next: Craniospinal Irradiation (CSI)
Modern photon treatments incorporate the use of 3D conformal planning using forward-
planning. IMRT and VMAT plans using dynamic MLC’s and treatment arcs can be accom-
plished with inverse-planning. Each type of treatment will have approximately 5 differ-
ent beams and couch positions. Therapists must take extra caution in the movement of
equipment to avoid any potential collisions. Dynamic treatment plans (Rapidarc/VMAT)
are more conformal and allow for increased normal tissues sparing and potentially dose
escalation.

The same GBM patient as the previous image with a 6-beam treatment plan at couch positions:
340, 305, 20, 55, and 90 degrees. The DRRs are color coordinated with their respective beams.
Patient is being treated with an SRT biteblock system.

Low-grade tumors are primarily treated with surgery, but if radiation is needed (due to
positive margins or remaining tumor), the dose is to approximately 45-54 Gy at 1.8-2.0
Gy/fx. High-grade tumors are treated to approximately 50 Gy with a 10 Gy boost at 1.8-
2.0 Gy/fx. Hypo-fractionation has been found to have similar efficacy; this could shape
treatments of the future. Hyper-fractionation and dose escalation have not demon-
strated a significant survival benefit.

Emerging Technologies & Treatments: Primary Brain

Tumors

Proton therapy can significantly reduce the dose to normal tissues and is especially
Previous: Overview: Central Nervous System
advantageous for pediatric patients and CSI treatments.
Next: Craniospinal Irradiation (CSI)
 MR Linac systems can provide enhanced imaging to detect changes daily and utilize
Adaptive Radiation Therapy, generating a new plan and treatment daily based on
the image resulting in greater normal tissue sparing and increased target dose.
Gamma Tiles – Surgically targeted Radiation therapy for patients with operational
brain tumors. Inserted by a surgeon at tumor site immediately after removal.
Delivers radiation to the targeted area and minimizes side effects.

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Media Attributions

Left and Right lateral whole brain DRRs © University of Iowa Hospitals and Clinics
Radiation Therapy Program is licensed under a CC BY (Attribution) license
Avoiding beam divergence © University of Iowa Hospitals and Clinics Radiation
Therapy Program is licensed under a CC BY (Attribution) license
half-beam block WBRT © Patrick J. Lynch, medical illustrator adapted by Jared Stiles
is licensed under a CC BY (Attribution) license
GBM Isodose lines © University of Iowa Hospitals and Clinics Radiation Therapy
Program is licensed under a CC BY (Attribution) license
GBM beams © University of Iowa Hospitals and Clinics Radiation Therapy Program
is licensed under a CC BY (Attribution) license

1. Pokhrel, D., Sood, S., McClinton, C., Shen, X., Lominska, C., Saleh, H., Badkul, R., Jiang,
H., Mitchell, M., & Wang, F. (2016). Treatment planning strategy for whole-brain ra-
diotherapy with hippocampal sparing and simultaneous integrated boost for multi-
ple brain metastases using intensity-modulated arc therapy. Medical Dosimetry,
41(4), 315–322. https://doi.org/10.1016/j.meddos.2016.08.001. ↵

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