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• Anthony Magliari

Hippocampal sparing whole brain RT

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Conflict of Interest disclosure

• Anthony Magliari

• Employed by Varian Medical Systems

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Overview

• What is HCSWB-RT?

• Why do it?

• What protocols exist?

• Beam arrangements

• Optimization strategies

• Additional resources

• 2015 AAMD / Sun Nuclear Plan Challenge

• 2016 AAMD Hippocampal Sparing presentation by Timothy Oh

• Knowledge Based Planning solution (RapidPlan) on Oncopeer

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What is Hippocampal Sparing WBRT?

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Why HCSWB-RT?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997490/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3462659/

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Protocols: RTOG 0933 / NRG-CC001

• RTOG 0933 superseded by…

• NRG-CC001 (30Gy in 10Fx)

“treatment-planning

priorities should be

followed:

1. OpticChiasm

2. OpticNerve_L

OpticNerve_R

3. Hippocampus

4. PTV_3000

5. Lens_L or

Lens_R”

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Other Protocols / planning guides

• NRG-CC003 (Prophylactic Cranial Irradiation) • 25Gy in 10 Fx

• Scaled down version of NRG-CC001

• Prokic V, et al (Whole Brain Irradiation With Hippocampal

Sparing and Dose Escalation on Multiple Brain Metastases:

A Planning Study on Treatment Concepts) • 30Gy in 12Fx with SIB for metastasis to 51Gy

• http://www.redjournal.org/article/S0360-3016(12)00302-1/pdf

• 2015 AAMD / Sun Nuclear Plan Challenge • Combined Rx from Prokic V with RTOG 0933 contraints, and more

• http://planchallenge.sunnuclear.com/

• Oncopeer Rapidplan Solution and Description Document • 30Gy in 10 Fx with 7Gy HCS goal and constraints from all the above

• Posted by Rob Foster http://www.oncopeer.com • menu > my groups > RapidPlan – Model Sharing > activity

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Beam arrangements

• Preferred: 3 or 4 arcs (6X or 6X FFF) • 2 non-coplanar arcs 315*/45* collimator and 1 or 2 vertex ½ arcs

• Vertex ½ arc 90* couch and MLCs parallel to arc direction (0*) or

• Vertex ½ arcs 90* couch and 315*/45* collimator

• Check jaws to ensure arcs open to entire brain throughout rotations

• 2 non coplanar arcs, same as above no vertex

• Non coplanar partial arcs with “sub PTVs” • Shen J, et al Medical Dosimetry journal

• Referenced in Timothy Oh’s 2016 AAMD presentation

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Beam arrangements

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Optimization

• General tips

• Ask for reasonable goals (don’t drastically overshoot)

• Never create conflicts in the optimizer

• Use and tune with NTO (“rings” normally unnecessary in Eclipse)

• Let the total cost function line get completely flat

• Pause VMAT optimizer at each step

• Increase max seconds for static field IMRT

• Specific tips

• Understand the lower you push dose to the Hippocampus the more

heterogeneous (hot spots), 115-120% Dmax not abnormal and OK

• Use a “PTVopt” with an expansion from the hippocampus of 7-8mm

when shooting for ~7Gy min dose

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Optimization

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Other resources: 2015 plan challenge

• Includes video interviews with top performers from all TPS • http://planchallenge.sunnuclear.com/webinars

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Other resources: 2016 AAMD meeting http://atlanta2016.medicaldosimetry.org/2016AnnualConference/assets/File/Wednesday/Oh.pdf

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Other resources: RapidPlan on Oncopeer

https://varian.app.box.com/v/HCSWB

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Questions?

• Anthony Magliari